Published online Oct 27, 2023. doi: 10.4254/wjh.v15.i10.1140
Peer-review started: August 17, 2023
First decision: September 5, 2023
Revised: September 14, 2023
Accepted: October 8, 2023
Article in press: October 8, 2023
Published online: October 27, 2023
The lymphatic system is crucial in maintaining the body fluid homeostasis. A dysfunctional lymphatic system may contribute to the refractoriness of ascites and edema in cirrhosis patients. Therefore, assessment of lymphatic dysfunction in cirrhosis patients with refractory ascites (RA) can be crucial as it would call for using different strategies for fluid mobilization.
To assessing the magnitude, spectrum, and clinical associations of lymphatic dysfunction in liver cirrhosis patients with RA.
This observational study included 155 consecutive cirrhosis patients with RA. The presence of clinical signs of lymphedema, such as peau d’orange appearance and positive Stemmer sign, intestinal lymphangiectasia (IL) on duodenal biopsy seen as dilated vessels in the lamina propria with strong D2-40 immunohistochemistry, and chylous ascites were used to diagnose the overt lymphatic dysfunctions.
A total of 69 (44.5%) patients out of 155 had evidence of lymphatic dysfunction. Peripheral lymphedema, found in 52 (33.5%) patients, was the most common manifestation, followed by IL in 42 (27.0%) patients, and chylous ascites in 2 (1.9%) patients. Compared to patients without lymphedema, those with lymphedema had higher mean age, median model for end-stage liver disease scores, mean body mass index, mean ascitic fluid triglyceride levels, and proportion of patients with hypoproteinemia (serum total protein < 5 g/dL) and lymphocytopenia (< 15% of total leukocyte count). Patients with IL also had a higher prevalence of lymphocytopenia and hypoproteinemia (28.6% vs. 9.1%, P = 0.004). Seven (13%) patients with lymphedema had lower limb cellulitis compared to none in those without it. On multivariate regression analysis, factors independently associated with lymphatic dysfunction included obesity [odds ratio (OR): 4.2, 95% confidence intervals (95%CI): 1.1–15.2, P = 0.027], lymphocytopenia [OR: 6.2, 95%CI: 2.9–13.2, P < 0.001], and hypoproteinemia [OR: 3.7, 95%CI: 1.5–8.82, P = 0.003].
Lymphatic dysfunction is common in cirrhosis patients with RA. Significant indicators of its presence include hypoproteinemia and lymphocytopenia, which are likely due to the loss of lymphatic fluid from the circulation. Future efforts to mobilize fluid in these patients should focus on methods to improve lymphatic drainage.
Core Tip: Lymphatic dysfunction is often underappreciated in advanced cirrhosis patients. Our study evaluated the magnitude, spectrum, and associations of lymphatic dysfunction in cirrhosis patients with refractory ascites (RA). Nearly half (44.5%) of the studied population (n = 155) revealed evidence of overt lymphatic dysfunction in the forms of peripheral lymphedema (33.5%), intestinal lymphangiectasia (27.0%), and chylous ascites (1.9%). Obesity, hypoproteinemia, and lymphocytopenia were independently associated with lymphatic dysfunction in said patients. From a therapeutic standpoint, it can be extremely important to evaluate lymphatic dysfunction in cirrhosis patients with RA since it would call for using different strategies for fluid mobilization.