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Salatini R, Amaral J, Raimundo RD, Rocha F, de Abreu LC, Morais M, Tannuri U, Tannuri AC. Cardiac autonomic modulation in children with severe liver disease, before and after liver transplantation. Transl Pediatr 2022; 11:438-447. [PMID: 35558982 PMCID: PMC9085941 DOI: 10.21037/tp-21-273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 11/04/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The cardiovascular system is directly influenced by the autonomic nervous system (ANS); its changes affect heart rate variability (HRV) and are sensitive indicators of physiological changes. Autonomic dysfunction (AD) is manifested in up to 60% of patients with cirrhosis. Therefore, we aim to analyze the indexes of HRV pre- and post-surgery of children submitted for liver transplantation (LT). METHODS HRV, in children of both genders from 6 months of age to 10 years, that attended at the pediatric surgery clinic in the queue for LT at the Children's Institute were analyzed. To access HRV we analyzed indexes such as standard deviation of the RR intervals (SDNN), root-mean-square of the successive normal sinus RR interval difference (RMSSD), low frequency (LF), high frequency (HF), and LF/HF. RESULTS The analysis of the behavior of cardiac autonomic modulation, in the period prior to LT and after surgery, showed an increase in HRV linear parameters SDNN, TINN (triangular interpolation of NN interval histogram), HFms2. In the time domain, there was also an increase in the HFms2 index. CONCLUSIONS The analysis of the period preceding LT and two months after surgery showed an increase in the HRV linear parameters representing a global HRV improvement. In the time domain, there was also an increase in the HFms2 index, parasympathetic tone of the HRV.
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Affiliation(s)
- Renata Salatini
- Department of Clinical Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Joice Amaral
- Department of Pediatrics, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | | | - Fernando Rocha
- Design of Studies and Scientific Writing Laboratory, Centro Universitario FMABC, Sao Paulo, Brazil
| | - Luiz Carlos de Abreu
- Design of Studies and Scientific Writing Laboratory, Centro Universitario FMABC, Sao Paulo, Brazil.,Department of Integrated Health Education, Federal University of Espírito Santo (UFES), Vitória, Espírito Santo, Brazil
| | - Mauro Morais
- Design of Studies and Scientific Writing Laboratory, Federal University of Acre, Acre, Brazil
| | - Uenis Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Ana Cristina Tannuri
- Department of Pediatrics, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
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Arya S, Deshpande H, Belwal S, Sharma P, Sadana P, Chandrakant, Rahman F, Gupta M, Uniyal B. Association between cardiac dysfunction, arrhythmias and chronic liver diseases: A narrative review. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2020. [DOI: 10.1016/j.tacc.2020.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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3
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Neong SF, Billington EO, Congly SE. Sexual Dysfunction and Sex Hormone Abnormalities in Patients With Cirrhosis: Review of Pathogenesis and Management. Hepatology 2019; 69:2683-2695. [PMID: 30468515 DOI: 10.1002/hep.30359] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 11/06/2018] [Indexed: 02/06/2023]
Abstract
Healthy sexual function is important to maintain a good quality of life but is frequently impaired in patients with cirrhosis. The degree of sexual dysfunction appears to be linked with the degree of hepatic dysfunction. In men, sexual dysfunction can be related to the hyperestrogenism of portal hypertension and/or to decreased testosterone resulting from testicular dysfunction. In women, suppression of the hypothalamic-pituitary-gonadal axis appears to be a principal contributor, with no significant effect of portal hypertension. There is also a huge psychological barrier to break through as there is a component of depression in many patients with cirrhosis. Sexual dysfunction is often underdiagnosed in the cohort with cirrhosis. Management of sexual disorders in patients with cirrhosis can be challenging as they are often multifactorial. A multidisciplinary approach is key in managing these patients. We review the current literature on the pathogenesis of sexual dysfunction in patients with cirrhosis and propose a stepwise algorithm to better manage these patients.
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Affiliation(s)
- Shuet Fong Neong
- Multiorgan Transplant, University Health Network, Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Emma O Billington
- Division of Endocrinology & Metabolism, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
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Izzy M, Oh J, Watt KD. Cirrhotic Cardiomyopathy After Transplantation: Neither the Transient Nor Innocent Bystander. Hepatology 2018; 68:2008-2015. [PMID: 29672903 DOI: 10.1002/hep.30040] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/27/2018] [Accepted: 04/16/2018] [Indexed: 12/24/2022]
Abstract
Cirrhotic cardiomyopathy in end-stage liver disease is currently characterized by blunted contractile systolic response to stress with or without diastolic dysfunction in the absence of known heart disease. Since the establishment of the diagnostic criteria of cirrhotic cardiomyopathy in 2005, there have been multiple studies regarding its pathophysiology and pretransplant clinical course. The data regarding the post-transplant course of this entity are sparse. This review addresses the course and prognosis of the elements of cirrhotic cardiomyopathy after liver transplantation (LT). To this end, there is limited compelling evidence demonstrating the reversibility of this entity post-LT. Cirrhotic cardiomyopathy may, in fact, increase the risk of post-transplant complications. This review reveals a need to refine the diagnostic criteria of cirrhotic cardiomyopathy in view of the remarkable progress in the sphere of echocardiographic evaluation of systolic and diastolic dysfunction. The post-transplant course and outcomes related to cirrhotic cardiomyopathy may be better evaluated in the setting of updated diagnostic criteria.
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Affiliation(s)
- Manhal Izzy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Jae Oh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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Di Stefano C, Milazzo V, Milan A, Veglio F, Maule S. The role of autonomic dysfunction in cirrhotic patients before and after liver transplantation. Review of the literature. Liver Int 2016; 36:1081-9. [PMID: 27003923 DOI: 10.1111/liv.13126] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/15/2016] [Indexed: 02/13/2023]
Abstract
In patients affected by hepatic cirrhosis, autonomic dysfunction is a common finding; usually it is asymptomatic but it may correlate with increased mortality and morbidity before, during and after liver transplant, due to hemodynamic instability in the course of stressful events like sepsis, gastrointestinal bleeding and reperfusion after transplantation surgery. Hyperdynamic circulation and hepatic dysfunction seem to play a role in the pathogenesis of autonomic dysfunction, even if pathophysiological mechanisms are not completely known. We present a revision of previous literature about prevalence, pathophysiological mechanisms, clinical features, and mortality and morbidity of autonomic dysfunction secondary to hepatic cirrhosis.
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Affiliation(s)
- Cristina Di Stefano
- Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Valeria Milazzo
- Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Alberto Milan
- Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Franco Veglio
- Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Simona Maule
- Autonomic Unit and Hypertension Unit, Department of Medical Sciences, University of Turin, Turin, Italy
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Abstract
BACKGROUND Plasma catecholamine influences autonomic function and control, but there are few reports correlating them. In this study, 47 individuals (mean age, 38 years) were studied: 19 diabetes mellitus (DM) patients with gastroparesis, 16 with liver disease and 12 control subjects. METHODS Noninvasive autonomic function was assessed for sympathetic adrenergic functions as peripheral vasoconstriction in response to cold stress test and postural adjustment ratio (PAR) and cholinergic function as Valsalva ratio, represented by change in R-R intervals. Measurements were compared by analysis of variance and Spearman's correlation, and results were reported as mean ± standard error. RESULTS Plasma norepinephrine (1902.7 ± 263.3; P = 0.001) and epinephrine (224.5 ± 66.5; P = 0.008) levels, as well as plasma dopamine levels (861.3 ± 381.7), and total plasma catecholamine levels were highest for patients with liver disease, who also had significant negative correlation between norepinephrine level and vasoconstriction (P = 0.01; r = -0.5), PAR1 (P = 0.01; r = -0.5), sympathetic adrenergic functions (P = 0.005; r = -0.6), total autonomic index (P = 0.01-0.5) and total autonomic function (P = 0.01; r = -0.2) and also negative correlation between epinephrine plasma level and total autonomic function (P = 0.04; r = 0.4). DM patients were next highest in norepinephrine level (133.26 ± 7.43), but lowest for plasma catecholamine; a positive correlation between dopamine level and PAR1 (P = 0.008; r = 0.6) was also seen in this group. Plasma dopamine levels and spider score correlated negatively (P = 0.04; r = -0.5) and total plasma catecholamine positively with encephalopathy (P = 0.04; r = 0.5) in patients with liver disease. CONCLUSIONS Plasma catecholamine levels correlated with adrenergic functions in control subjects and patients with DM and liver disease, with no significant correlation seen for cholinergic function.
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7
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Sun W, Zhang D, Sun J, Xu B, Sun K, Wang T, Ren C, Li J, Chen Y, Xu M, Bi Y, Xu Q, Wang W, Gu Y, Ning G. Association between non-alcoholic fatty liver disease and autonomic dysfunction in a Chinese population. QJM 2015; 108:617-24. [PMID: 25614616 DOI: 10.1093/qjmed/hcv006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Autonomic dysfunction (AD) accompanying with chronic liver disorders led to an increased risk of mortality. However, researches that investigated the association between non-alcoholic fatty liver disease (NAFLD) and AD were insufficient. AIMS To study the association of NAFLD with AD in middle-aged and elderly Chinese adults. DESIGN Four thousand nine hundred seventy-four adults aged 40 years or older were enrolled in this cross-sectional study. NAFLD was diagnosed by hepatic B-mode ultrasonography. Autonomic function was assessed using a simple EZSCAN test by measuring sudomotor function, with an AD index > 50% defined as a manifestation of AD. METHODS Pearson correlation, multiple stepwise linear regression, univariate and multivariate logistic regression was employed to examine the relationship between NAFLD and AD, controlling for potential confounders. RESULTS The prevalence of AD was significantly higher in participants with NAFLD than those without (40.75 vs. 26.86%, P < 0.0001). Age, body mass index, status of diabetes, sex, diastolic blood pressure and prevalent NAFLD, were positively correlated with AD index in multiple stepwise linear regression analysis (all P < 0.05), whereas total cholesterol was negatively related to it (P = 0.0043). Compared with the participants without NAFLD, those with NAFLD had an increased odds of the prevalent AD (odds ratio 1.38; 95% confidence interval 1.15-1.64; P = 0.0004) after controlling for multiple confounders. CONCLUSIONS The presence of NAFLD was significantly associated with AD, as indicated by abnormal sudomotor function. The association was independent from various conventional risk factors.
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Affiliation(s)
- W Sun
- From the Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, Ruijin Hospital, E-Institute of Shanghai Universities, Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Ruijin Hospital, and
| | - D Zhang
- From the Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, Ruijin Hospital, E-Institute of Shanghai Universities, Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Ruijin Hospital, and
| | - J Sun
- From the Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, Ruijin Hospital, E-Institute of Shanghai Universities, Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Ruijin Hospital, and
| | - B Xu
- From the Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, Ruijin Hospital, E-Institute of Shanghai Universities, Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Ruijin Hospital, and
| | - K Sun
- From the Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, Ruijin Hospital, E-Institute of Shanghai Universities, Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Ruijin Hospital, and
| | - T Wang
- From the Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, Ruijin Hospital, E-Institute of Shanghai Universities, Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Ruijin Hospital, and
| | - C Ren
- From the Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, Ruijin Hospital, E-Institute of Shanghai Universities, Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Ruijin Hospital, and
| | - J Li
- From the Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, Ruijin Hospital, E-Institute of Shanghai Universities, Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Ruijin Hospital, and
| | - Y Chen
- From the Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, Ruijin Hospital, E-Institute of Shanghai Universities, Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Ruijin Hospital, and
| | - M Xu
- From the Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, Ruijin Hospital, E-Institute of Shanghai Universities, Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Ruijin Hospital, and
| | - Y Bi
- From the Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, Ruijin Hospital, E-Institute of Shanghai Universities, Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Ruijin Hospital, and
| | - Q Xu
- Department of Research and Development, Ruijin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai 200025, China
| | - W Wang
- From the Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, Ruijin Hospital, E-Institute of Shanghai Universities, Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Ruijin Hospital, and
| | - Y Gu
- From the Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, Ruijin Hospital, E-Institute of Shanghai Universities, Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Ruijin Hospital, and
| | - G Ning
- From the Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, Ruijin Hospital, E-Institute of Shanghai Universities, Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Ruijin Hospital, and
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8
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de Lima DC, Ribeiro HS, Cristina R, Oliveira M, de Vasconcelos Generoso S, Lima AS, Toulson Davisson Correia MI. Functional status and heart rate variability in end-stage liver disease patients: Association with nutritional status. Nutrition 2015; 31:971-4. [DOI: 10.1016/j.nut.2015.01.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 01/28/2015] [Accepted: 01/31/2015] [Indexed: 12/28/2022]
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Mozos I. Arrhythmia risk in liver cirrhosis. World J Hepatol 2015; 7:662-672. [PMID: 25866603 PMCID: PMC4388994 DOI: 10.4254/wjh.v7.i4.662] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 12/04/2014] [Accepted: 01/19/2015] [Indexed: 02/06/2023] Open
Abstract
Interactions between the functioning of the heart and the liver have been described, with heart diseases affecting the liver, liver diseases affecting the heart, and conditions that simultaneously affect both. The heart is one of the most adversely affected organs in patients with liver cirrhosis. For example, arrhythmias and electrocardiographic changes are observed in patients with liver cirrhosis. The risk for arrhythmia is influenced by factors such as cirrhotic cardiomyopathy, cardiac ion channel remodeling, electrolyte imbalances, impaired autonomic function, hepatorenal syndrome, metabolic abnormalities, advanced age, inflammatory syndrome, stressful events, impaired drug metabolism and comorbidities. Close monitoring of cirrhotic patients is needed for arrhythmias, particularly when QT interval-prolonging drugs are given, or if electrolyte imbalances or hepatorenal syndrome appear. Arrhythmia risk may persist after liver transplantation due to possible QT interval prolongation, persistence of the parasympathetic impairment, post-transplant reperfusion and chronic immunosuppression, as well as consideration of the fact that the transplant itself is a stressful event for the cardiovascular system. The aims of the present article were to provide a review of the most important data regarding the epidemiology, pathophysiology, and biomarkers of arrhythmia risk in patients with liver cirrhosis, to elucidate the association with long-term outcome, and to propose future research directions.
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10
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Abstract
Inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, is a chronic immune-mediated intestinal disorder, and its etiology and pathogenesis are not well clarified. The pathogenesis of IBD is multifactorial, and the nerve system may participate in the development of IBD by modulating immune responses. Recently, autonomic dysfunction in IBD patients has been intensively studied. It has been reported that IBD patients suffer from autonomic dysfunction, and the severity of autonomic dysfunction correlates with disease activity of IBD, suggesting that autonomic dysfunction is a potential marker for IBD disease activity and also a potential target for IBD treatment. In this paper, we review the recent advances in understanding the relationship between autonomic dysfunction and IBD.
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11
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Beirão M, Matos E, Beirão I, Pinho-Costa P, Torres P. No ocular involvement in familial amyloidotic polyneuropathy ATTR V30M domino liver recipients. Transpl Int 2012; 25:646-51. [PMID: 22443165 DOI: 10.1111/j.1432-2277.2012.01467.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In many transplantation centers domino liver transplantation is an established procedure, increasing the number of available liver grafts. Increasingly, grafts from familial amyloidotic polyneuropathy (FAP) patients are used. Ocular involvement is a well known manifestation of FAP, and can be vision-threatening. The aim of this study was to evaluate the risk of development of familial amyloidotic polyneuropathy ocular manifestations in domino liver recipients. Forty-four cirrhotic patients submitted to liver transplantation were studied, with an average of 6 years of follow up after the procedure. Twenty two patients had received a liver from a FAP donor (Group 1) and 22 had received a liver from a non-FAP cadaveric donor (Group 2). Both groups were similar for mean age and gender. Routine ophthalmological examinations with particular attention to amyloid deposition in the anterior segment and vitreous, peripheral retina state, lacrimal functions tests (Schirmer and tear break-up time) and pupillometry (dynamic and static) were performed. No statistically significant differences were observed in all studied ophthalmic parameters between the two groups. No FAP related ophthalmic manifestations were detected after 6 years of domino liver transplantation, but further prospective regular ophthalmological examinations are necessary to detect the eventual development of late ocular manifestations.
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Affiliation(s)
- Melo Beirão
- Ophthalmology, Hospital de Santo António, Porto, Portugal.
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12
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Abstract
It is becoming increasingly clear that quality of life (QOL) is impaired in those with chronic liver disease (CLD). One of the most important contributors to impaired QOL is the symptomatic burden which can range from slight to debilitating. Autonomic dysfunction accounts for a significant proportion of these symptoms, which can be common, non-specific and challenging to treat. Investigating the autonomic nervous system can be straight forward and can assist the clinician to diagnose and treat specific symptoms. Evidence-based treatment options for autonomic symptoms, specifically in CLD, can be lacking and must be extrapolated from other studies and expert opinion. For those with severely impaired quality of life, liver transplantation may offer an improvement; however, more research is needed to confirm this.
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Affiliation(s)
- James Frith
- NIHR Biomedical Research Centre in Ageing, Institute for Ageing and Health, Newcastle University, Newcastle UK
| | - Julia L Newton
- NIHR Biomedical Research Centre in Ageing, Institute for Ageing and Health, Newcastle University, Newcastle UK
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Møller S, Henriksen JH. Cirrhotic cardiomyopathy. J Hepatol 2010; 53:179-90. [PMID: 20462649 DOI: 10.1016/j.jhep.2010.02.023] [Citation(s) in RCA: 229] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Revised: 01/26/2010] [Accepted: 02/04/2010] [Indexed: 12/13/2022]
Abstract
Increased cardiac output was first described in patients with cirrhosis more than fifty years ago. Later, various observations have indicated the presence of a latent cardiac dysfunction, which includes a combination of reduced cardiac contractility with systolic and diastolic dysfunction and electrophysiological abnormalities. This syndrome is termed cirrhotic cardiomyopathy. Results of experimental studies indicate the involvement of several mechanisms in the pathophysiology, such as reduced beta-adrenergic receptor signal transduction, altered transmembrane currents and electromechanical coupling, nitric oxide overproduction, and cannabinoid receptor activation. Systolic incompetence in patients can be revealed by pharmacological or physical strain and during stressful procedures, such as transjugular intrahepatic portosystemic shunt insertion and liver transplantation. Systolic dysfunction has recently been implicated in development of renal failure in advanced disease. Diastolic dysfunction reflects delayed left ventricular filling and is partly attributed to ventricular hypertrophy, subendocardial oedema, and altered collagen structure. The QT interval is prolonged in about half of the cirrhotic patients and it may be normalised by beta-blockers. No specific therapy for cirrhotic cardiomyopathy can be recommended, but treatment should be supportive and directed against the cardiac dysfunction. Future research should better describe the prevalence, impact on morbidity and survival, and look for potential treatments.
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Affiliation(s)
- Søren Møller
- Department of Clinical Physiology and Nuclear Medicine, Hvidovre Hospital, Faculty of Health Sciences, University of Copenhagen, Denmark.
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14
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Long-term effect of liver transplantation on cirrhotic autonomic cardiac dysfunction. Dig Liver Dis 2010; 42:131-6. [PMID: 19540819 DOI: 10.1016/j.dld.2009.05.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 04/30/2009] [Accepted: 05/15/2009] [Indexed: 12/11/2022]
Abstract
There is little information on the long-term effect of liver transplantation (LT) on cardiac autonomic dysfunction in cirrhotic patients. We compared cardiac autonomic function before and in the long-term after LT. In a transversal study, we investigated 30 cirrhotics awaiting LT, 15 clinically stable patients 2-6 years after LT and 27 healthy controls. Seven cirrhotic patients were studied before LT, and 6, 12 and 33 months after LT, in a prospective fashion. Cardiac autonomic function was measured by heart rate variability (HRV) analysis during 24-h electrocardiogram recording. In the transversal study, patients with cirrhosis as compared to healthy controls had significantly reduced standard deviation of normal-to-normal RR intervals (SDNN) (p<0.001) and of the square root of the mean of squared differences between adjacent NN intervals (RMS-SD) (p<0.01), while the ratio between low frequency (LF) and high frequency (HF) at night was significantly (p<0.05) increased. Liver transplanted patients had significantly (p<0.001) higher SDNN values than cirrhotics, while RMS-SD and LF/HF at night did not differ. In the prospective study, SDNN progressively increased after LT and was significantly (p<0.05) higher at 12 and 33 months, compared to the pre-operative value. RMS-SD and LF/HF at night did not change after LT. In conclusion, the overall HRV decrease present in cirrhosis, measured by SDNN values, is partially corrected in the long-term after LT. However, parasympathetic impairment, measured by RMS-SD and LF/HF at night, is not affected even in the long-term after operation.
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15
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Abstract
Autonomic dysfunction (AD) is common in chronic liver disease (CLD) of all aetiologies and even more so in those awaiting transplantation. As yet, the pathophysiology is not completely understood but the clinical effects are dramatic for the patient, who has a heavy symptomatic burden. There are several considerations, specific to liver disease, which complicate AD. Outlined here is a practical guide for clinicians detailing the common presentations and consequences of AD, investigation techniques and treatment options. As morbidity and mortality is increased in CLD patients with AD its recognition, investigation and management is important to all who encounter such patients.
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Affiliation(s)
- James Frith
- Biomedical Research Centre in Ageing-Liver theme & Institute of Cellular Medicine, Newcastle University, Newcastle, UK.
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16
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Abstract
Cardiac failure affects the liver and liver dysfunction affects the heart. Chronic and acute heart failure can lead to cardiac cirrhosis and cardiogenic ischemic hepatitis. These conditions may impair liver function and treatment should be directed towards the primary heart disease and seek to secure perfusion of vital organs. In patients with advanced cirrhosis, physical and/or pharmacological stress may reveal a reduced cardiac performance with systolic and diastolic dysfunction and electrophysical abnormalities, termed cirrhotic cardiomyopathy. Pathophysiological mechanisms include reduced beta-adrenergic receptor signal transduction and defective cardiac electromechanical coupling. However, the QT interval is prolonged in approximately half of patients with cirrhosis and it may be improved by beta-blockers. No specific therapy can be recommended but it should be supportive and directed against the heart failure. Transjugular intrahepatic portosystemic shunt insertion and liver transplantation affect cardiac function in portal hypertensive patients and cause stress to the cirrhotic heart, with a risk of perioperative heart failure. The risk and prevalence of coronary artery disease are increasing in cirrhotic patients and since perioperative mortality is high, careful evaluation of such patients with dobutamine stress echocardiography, coronary angiography and myocardial perfusion imaging is required prior to liver transplantation. Future research should focus on beneficial effects of treatment on cardiac function and mortality.
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Affiliation(s)
- Søren Møller
- Department of Clinical Physiology and Nuclear Medicine, 239, Hvidovre Hospital, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark.
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