Splanchnic Blood Flow Research Articles

Mesenteric blood flow and muscle sympathetic nerve activity during vasovagal syncope.

Vasovagal syncope is thought to be mediated by a progressive fall in cardiac output secondary to venous pooling of blood in the splanchnic circulation. How and when this occurs before syncope has not been determined. A total of 20 patients who became hypotensive during head-up tilt (age 40.9 ± 3.4 years; 10 females) were divided into two groups-the glyceryl trinitrate (GTN) group (n = 12) and the vasovagal syncope (VVS) group (n = 8) - on the basis of whether or not nitroglycerine provocation was required. They were compared with a control group (age 38.6 ± 3.3; 8 females; n = 13). Hemodynamics, including superior mesenteric artery blood flow (SMABF) and muscle sympathetic nerve activity (MSNA) were recorded continuously during early tilt, presyncope and recovery. We used pixel-weighting to calculate average velocity from the pulsed Doppler velocity envelope. During baseline and early tilt, resistance to mesenteric blood flow was lower in the VVS group: 0.30 ± 0.02 to 0.30 ± 0.02mmHg/ml/min versus controls 0.30 ± 0.03 to 0.38 ± 0.04mmHg/ml/min (p = 0.05). During presyncope, as blood pressure and stroke volume gradually fell, SMABF was higher in the VVS group, falling from 370 ± 46 to 248 ± 35ml/min, versus controls, falling from 342 ± 51 to 233 ± 19 (p = 0.03). At this time, MSNA was lower in the VVS group than controls: 39 ± 4 to 34 ± 3 bursts/min versus 45 ± 2 to 48 ± 3 (p = 0.001). During presyncope, increased splanchnic blood flow may pool more blood in capacitance vessels resulting in decreased venous return and cardiac output. This may be secondary to decreased vasoconstrictor sympathetic activity.

Ultrasound criteria for assessing the correction of metabolic-associated fatty liver disease and liver blood flow disorders using arginine in patients with coronary artery disease in combination with COVID-19

Background. Coronavirus disease 2019 (COVID-19) remains one of the most urgent global health problems today. In the conditions of its spread around the world, the global scientific community is trying to study not only respiratory, but also extrapulmonary manifestations of this infection. It is known that with COVID-19, the endothelium, the hemostasis system, and the liver are affected with the occurrence of such a complication as metabolic dysfunction-associated steatotic liver disease (MASLD). The most vulnerable group of patients in terms of coronavirus disease and its complications (including MASLD) are those with coronary heart disease (CAD), therefore the search for effective drugs and optimal ultrasound criteria to evaluate liver steatosis in the dynamics of treatment is the main task of modern medicine. Goal: to determine the ultrasound criteria for assessing the correction of MASLD and liver blood flow disorders using arginine in patients with CAD associated with COVID-19. Materials and methods. A prospective study was conducted in 52 patients with CAD combined with PCR-positive COVID-19. The study was carried out upon admission to the hospital and 6 months after discharge. Group I (n = 27) consisted of CAD + COVID-19 patients who, in addition to standard therapy for MASLD, received arginine for 6 months after discharge from the hospital; group II (comparison group, n = 25) included participants who received standard therapy wi­thout arginine. Results. Splanchnic artery duplex scanning at baseline showed that 21 (78.0 %) patients in group I and 19 (76.0 %) in group II had a decrease in peak systolic velocity (PSV) in the proper hepatic artery (PHA), an increase in portal vein blood flow at the beginning of treatment, as well as increased liver size in 20 (74.0 %) patients in group I and 17 (68.0 %) in group II. An increase in the attenuation coefficient was detected in all patients of groups I and II. There were no differences between the groups at the time of inclusion in the study in terms of splanchnic blood flow and atte­nuation coefficient. After 6 months of arginine treatment, an improvement in the portal vein blood flow and a decrease in blood flow velocity in the PHA, a decrease in the diameter of the portal vein, a decrease in the size of the right and left liver lobes were found in group I, with no improvement in group II. A repeated study revealed a decrease in the attenuation coefficient in group I and no changes in group II. At the beginning of the study, a direct correlation was found between fibrinogen and the attenuation coefficient in group I (r = 0.54; p < 0.05), as well as in group II (r = 0.51; p < 0.05). After 6 months, C-reactive protein decreased in both groups. Conclusions. In patients with CAD combined with COVID-19 in the presence of MASLD, a decrease in the portal vein blood flow and an increase in PSV in the PHA were found. When arginine was used for 6 months in combination with standard therapy, according to the European Society of Cardiology protocols, there was a significant decrease in the attenuation coefficient, PSV in the PHA, and an increase in the portal vein blood flow. This indicates the possibility of using the attenuation coefficient as the main marker, and PSV in the PHA and the portal vein blood flow as additional criteria for ultrasound assessment of MASLD correction with arginine in patients with CAD combined with COVID-19.

The effect of fluid replacement during 60 minutes of moderate-intensity running on splanchnic blood flow.

The effect of fluid replacement during 60 minutes of moderate-intensity running on splanchnic blood flow.

Dynamic volume status assessment with the VExUS score after heart valve surgery complicated by acute kidney injury: a case series

Background: Fluid overload is an independent risk factor for acute kidney injury after cardiac surgery. An objective volume status assessment remains an unsolved clinical problem.Objective: To analyze the relationship between the dynamic changes in splanchnic blood flow patterns (portal, hepatic, and interlobar renal veins), reflecting the venous congestion severity, and severity of renal dysfunction in the studied patients.Methods: From February to May 2023, 3 patients after open heart surgery developed acute kidney injury in the postoperative period: 2 of them required renal replacement therapy. In the perioperative period, all patients underwent Doppler ultrasonographic assessment of the splanchnic blood flow according to the venous excess ultrasound (VExUS) score.Results: The most distinct changes in blood flow patterns were observed in portal and interlobar renal veins. Two anuric patients requiring renal replacement therapy had a pulsatile portal venous flow with systolic flow reversal that indicated severe venous congestion and biphasic renal venous flow. After restoration of urine output in 1 patient, the blood flow pattern in the portal vein returned to the normal pattern. In another patient, the blood flow remained pulsatile, which manifested itself by persisting clinical signs of overhydration. In the third patient, the portal blood flow also was pulsatile but had no systolic flow reversal. The renal blood flow was biphasic, although it was initially continuous. After restoration of urine output and overhydration improvement, the blood flow pattern returned to the preoperative pattern.Conclusion: In the studied patients, the dynamic assessment of splanchnic blood flow using the VExUS score allowed to objectively assess the venous congestion severity and served as an additional criterion for initiating renal replacement therapy in case of acute kidney injury progression. Further research could validate this type of monitoring because its interpretation requires a comprehensive assessment due to moderate specificity. Received 21 June 2023. Revised 17 July 2023. Accepted 24 July 2023. Informed consent: The patients’ informed consent to use the records for medical purposes is obtained. Funding: The study did not have sponsorship. Conflict of interest: The authors declare no conflicts of interests. Contribution of the authors: The authors contributed equally to this article.

Sex Differences In Splanchnic Blood Flow During Mild-intensity Dynamic Exercise

Sex Differences In Splanchnic Blood Flow During Mild-intensity Dynamic Exercise

Role of prior feeding status in mediating the effects of exercise on blood glucose kinetics.

Changes in blood glucose concentrations are underpinned by blood glucose kinetics (endogenous and exogenous glucose appearance rates and glucose disappearance rates). Exercise potently alters blood glucose kinetics and can thereby be used as a tool to control blood glucose concentration. However, most studies of exercise-induced changes in glucose kinetics are conducted in a fasted state, and therefore less is known about the effects of exercise on glucose kinetics when exercise is conducted in a postprandial state. Emerging evidence suggests that food intake prior to exercise can increase postprandial blood glucose flux compared with when meals are consumed after exercise, whereby both glucose appearance rates and disappearance rates are increased. The mechanisms underlying the mediating effect of exercise conducted in the fed versus the fasted state are yet to be fully elucidated. Current evidence demonstrates that exercise in the postprandial state increased glucose appearance rates due to both increased exogenous and endogenous appearance and may be due to changes in splanchnic blood flow, intestinal permeability, and/or hepatic glucose extraction. On the other hand, increased glucose disappearance rates after exercise in the fed state have been shown to be associated with increased intramuscular AMPK signaling via a mismatch between carbohydrate utilization and delivery. Due to differences in blood glucose kinetics and other physiological differences, studies conducted in the fasted state cannot be immediately translated to the fed state. Therefore, conducting studies in the fed state could improve the external validity of data pertaining to glucose kinetics and intramuscular signaling in response to nutrition and exercise.

Study of Propranolol in Cirrhosis Patients with Portal Hypertension: Research at Sidoarjo General Hospital

Cirrhosis is the final stage of chronic liver disease caused by fibrosis which decreases the function and changes the shape and structure of the liver. Portal hypertension is an essential pathophysiology of cirrhosis, which can lead to an increased risk of death in patients resulting in very detrimental complications originating from portal obstruction of blood flow, such as cirrhosis or blockage of blood vessels. According to the EASL guidelines, non-selective β-blocker therapy such as propranolol can reduce portal pressure by reducing the portal venous flow through two mechanisms: decreased cardiac output and decreased splanchnic blood flow. This study aimed to determine the pattern of using propranolol in patients with liver cirrhosis in Sidoarjo Hospital. This was an observational study with a retrospective approach in cirrhosis patients with portal hypertension from 1st January 2021 until 31st December 2021. The Patient Medication Records (PMR) data was obtained from 15 male patients (68%), with the most age ranging from 56 to 65 years old (37%). The pattern of using single therapy was in 22 patients (100%). The highest use of single treatment was Propranolol (3×10 mg) with 12 patients (52%), Propranolol (2x10 mg) with ten patients (43%), and Propranolol (2x40 mg) with only one patient (5%). Interm of switching therapy, only one medication which is Propranolol (2x10 mg switch toPropranolol (2x40 mg).
 Keywords: Propranolol, Portal Hypertention, Cirrhosis

A case of successful comprehensive treatment of necrotizing enterocolitis in a newborn child

Necrotizing enterocolitis is an inflammatory disease caused by infection and hypoxic–ischemic damage of the intestinal mucosa, which leads to generalization with the development of a systemic inflammatory response. The pathogenetic mechanisms leading to intestinal wall damage are ischemia and pain. Therefore, the use of central neuraxial blocks, which provide the analgesic effect and preganglionic blockade of the sympathetic nervous system, is pathogenetically justified.
 The aim of the work is to acquaint practitioners with the case of successful comprehensive treatment using neuraxial blocks in a newborn with necrotizing enterocolitis.
 Materials and methods. The child was treated at the Department of Anesthesiology and Intensive Care for Newborns of Zaporizhzhia City Pediatric Hospital No. 5. He underwent clinical and biochemical blood tests, microbiological, radiological and ultrasound examinations using hospital equipment.
 Results. A child was operated due to suspected intestinal perforation and pneumoperitoneum. It was found that throughout the small and large intestines had multiple hemorrhages and air bubbles in the subserosa, but no perforation sites were found. Subsequently, the child underwent conservative treatment with antibacterial therapy according to the de-escalation principle, antifungal therapy, intravenous immunoglobulins, total parenteral nutrition. In addition to this standard treatment, the child underwent caudal-epidural blocks twice a day for a week in the postoperative period for effective analgesia, improvement of microcirculation and splanchnic blood flow.
 Conclusions. Surgical intervention performed on a newborn child with the second stage of necrotizing enterocolitis (intestinal pneumatosis), when its perforation could not be excluded, did not significantly affect the course of the disease, so the positive outcome can be considered the result of successful comprehensive intensive care. In our opinion, the decisive factor that influenced the positive treatment outcomes (prevention of perforation and peritonitis) was the effect of neuraxial caudal epidural blocks, which contributed to the improvement of microcirculation in the splanchnic area, elimination of intestinal ischemia and effective anesthesia.

The Right Time for Certification

The Right Time for Certification

Effect of terlipressin on systemic and hepatic hemodynamics in patients undergoing liver transplantation

ABSTRACT Background and Aims Liver transplantation is associated with hemodynamic instability. Systemic and Splanchnic circulations interact closely. Portal hypertension is linked to vasodilatory molecules resulting in arterial vasodilatation. Terlipressin, is a synthetic vasopressin analogue causes selective vasoconstriction of splanchnic arteriols, thus decreasing splanchnic blood flow and shifting blood from the splanchnic to the systemic circulation resulting in enhanced systemic hemodynamics. This study aimed to assess the impact of intraoperative terlipressin on systemic and hepatic hemodynamics in recipients of living donor liver transplantation (LDLT). Methods The present longitudinal observational study was carried out at Ain Shams Center for Organ Transplant on 30 cases suffering from portal hypertension and chronic liver disease undergoing LDLT. Subjects were equally categorized into two groups: Group 1(control): patients did not receive intraoperative terlipressin, Group 2 (terlipressin): patients received terlipressin (1 mg intravenously over 10 min) just after exposure of the portal vein to maintain mean arterial blood pressure over 65 mmHg. Results Systolic and diastolic blood pressure were better preserved in the terlipressin group, with reduced norepinephrine requirements as well as a substantial decline in the heart rate during the anhepatic and reperfusion phases (P < 0.05). Terlipressin significantly decreases portal venous pressure with (P = 0.03) and portal vein flow (P < 0.001) without altering the hepatic artery resistivity index (HARI) (P = 0.219). Conclusion Intraoperative terlipressin during liver transplantation surgery was associated with improved systemic hemodynamics despite decreased portal venous pressure and blood flow, without affecting HARI.

Elevation of the head of bed reduces splanchnic blood flow in patients with intra-abdominal hypertension

BackgroundElevation of the head of bed (HOB) increases intra-abdominal pressure (IAP), but the effect of body position on abdominal splanchnic perfusion is not clear. The current study aimed to evaluate the effect of body position on the superior mesenteric artery (SMA) and the celiac artery (CA) blood flow by Doppler ultrasound in mechanically ventilated patients with intra-abdominal hypertension (IAH).MethodsThis prospective cohort study included 53 mechanically ventilated patients with IAH. IAP, hemodynamic variables, and Doppler parameters of the SMA and CA were measured in the supine position. The measurements were repeated after the HOB angle was raised to 15° for 5 min and similarly at HOB angles of 30° and 45°. Finally, the patient was returned to the supine and these variables were re-measured.ResultsThe median (interquartile range, IQR) superior mesenteric artery blood flow (SMABF) decreased from 269 (244–322) to 204 (183–234) mL/min and the median (IQR) celiac artery blood flow (CABF) from 424 (368–483) to 376 (332–472) mL/min (both p<0.0001) while median (IQR) IAP increased from 14(13–16) to 16(14–18) mmHg (p<0.0001) when the HOB angle was changed from 0° to 15°. However, SMABF and CABF were maintained at similar levels from 15° to 30°, despite median (IQR) IAP increased to 17(15–18) mmHg (p = 0.0002). Elevation from 30° to 45° further reduced median (IQR) SMABF from 200(169–244) to 164(139–212) mL/min and CABF from 389(310–438) to 291(241–383) mL/min (both p<0.0001), Meanwhile, median (IQR) IAP increased to 19(18–21) mmHg (p<0.0001).ConclusionsIn mechanically ventilated patients with IAH, progressive elevation of the HOB from a supine to semi-recumbent position was associated with a gradual reduction in splanchnic blood flow. However, the results indicate that splanchnic blood flow is not further reduced when the HOB is elevated from 15° to 30°.This study confirms the influence of head-up angle on blood flow of the splanchnic organs and may contribute to the selection of the optimal position in patients with abdominal hypertension.

Interventional Treatment of Budd–Chiari Syndrome

Medical treatment is regarded as the primary course of action in patients with Budd-Chiari syndrome (BCS). Its efficacy, however, is limited, and most patients require interventional treatment during follow-up. Short-segment stenosis or the occlusion (the so-called web) of hepatic veins or the inferior vena cava are frequent in Asian countries. An angioplasty with or without stent implantation is the treatment of choice to restore hepatic and splanchnic blood flow. The long-segment thrombotic occlusion of hepatic veins, common in Western countries, is more severe and may require a portocaval shunting procedure to relieve hepatic and splanchnic congestion. Since it was first proposed in a publication in 1993, the transjugular intrahepatic portosystemic shunt (TIPS) has gained more and more attention, and in fact it has been so successful that previously utilized surgical shunts are only used for few patients for whom it does not work. Both interventional treatment options can be performed successfully in about 95% of patients even after the complete obliteration of the hepatic veins. The long-term patency of the TIPS, a considerable problem in its early years, has been improved with PTFE-covered stents. The complication rates of these interventions are low and the survival rate is excellent with five- and ten-year survival rates of 90% and 80%, respectively. Present treatment guidelines recommend a step-up approach indicating interventional treatment after the failure of medical treatment. However, this widely accepted algorithm has several points of contention, and early interventional treatment is proposed instead.

Hepatorenal Syndrome: Current Concepts and Future Perspectives.

Hepatorenal syndrome (HRS), a progressive but potentially reversible deterioration of kidney function, remains a major complication in patients with advanced cirrhosis, often leading to death before liver transplantation (LT). Recent updates in the pathophysiology, definition, and classification of HRS have led to a complete revision of the nomenclature and diagnostic criteria for HRS type 1, which was renamed HRS-acute kidney injury (AKI). HRS is characterized by severe impairment of kidney function due to increased splanchnic blood flow, activation of several vasoconstriction factors, severe vasoconstriction of the renal arteries in the absence of kidney histologic abnormalities, nitric oxide dysfunction, and systemic inflammation. Diagnosis of HRS remains a challenge because of the lack of specific diagnostic biomarkers that accurately distinguishes structural from functional AKI, and mainly involves the differential diagnosis from other forms of AKI, particularly acute tubular necrosis (ATN). The optimal treatment of HRS is LT. While awaiting LT, treatment options include vasoconstrictor drugs to counteract splanchnic arterial vasodilation and plasma volume expansion by intravenous albumin infusion. In patients with HRS unresponsive to pharmacological treatment and with conventional indications for kidney replacement therapy (KRT), such as volume overload, uremia, or electrolyte imbalances, KRT may be applied as a bridging therapy to transplantation. Other interventions, such as transjugular intrahepatic portosystemic shunt, and artificial liver support systems have a very limited role in improving outcomes in HRS. Although recently developed novel therapies have potential to improve outcomes of patients with HRS, further studies are warranted to validate the efficacy of these novel agents.

An Individualized Low-Pneumoperitoneum-Pressure Strategy May Prevent a Reduction in Liver Perfusion during Colorectal Laparoscopic Surgery.

High intra-abdominal pressure (IAP) during laparoscopic surgery is associated with reduced splanchnic blood flow. It is uncertain whether a low IAP prevents this reduction. We assessed the effect of an individualized low-pneumoperitoneum-pressure strategy on liver perfusion. This was a single-center substudy of the multicenter 'Individualized Pneumoperitoneum Pressure in Colorectal Laparoscopic Surgery versus Standard Therapy II study' (IPPCollapse-II), a randomized clinical trial in which patients received an individualized low-pneumoperitoneum strategy (IPP) or a standard pneumoperitoneum strategy (SPP). Liver perfusion was indirectly assessed by the indocyanine green plasma disappearance rate (ICG-PDR) and the secondary endpoint was ICG retention rate after 15 min (R15) using pulse spectrophotometry. Multivariable beta regression was used to assess the association between group assignment and ICG-PDR and ICG-R15. All 29 patients from the participating center were included. Median IAP was 8 (25th-75th percentile: 8-10) versus 12 (12,12) mmHg, in IPP and SPP patients, respectively (p < 0.001). ICG-PDR was higher (OR 1.42, 95%-CI 1.10-1.82; p = 0.006) and PDR-R15 was lower in IPP patients compared with SPP patients (OR 0.46, 95%-CI 0.29-0.73; p = 0.001). During laparoscopic colorectal surgery, an individualized low pneumoperitoneum may prevent a reduction in liver perfusion.

Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis

Complex portal vein thrombosis (PVT) is a challenge in liver transplantation (LT). Extra-anatomical approaches to portal revascularization, including renoportal (RPA), left gastric vein (LGA), pericholedochal vein (PCA), and cavoportal (CPA) anastomoses, have been described in case reports and series. The RP4LT Collaborative was created to record cases of alternative portal revascularization performed for complex PVT. An international, observational web registry was launched in 2020. Cases of complex PVT undergoing first LT performed with RPA, LGA, PCA, or CPA were recorded and updated through 12/2021. A total of 140 cases were available for analysis: 74 RPA, 18 LGA, 20 PCA, and 28 CPA. Transplants were primarily performed with whole livers (98%) in recipients with median (IQR) age 58 (49-63) years, model for end-stage liver disease score 17 (14-24), and cold ischemia 431 (360-505) minutes. Post-operatively, 49% of recipients developed acute kidney injury, 16% diuretic-responsive ascites, 9% refractory ascites (29% with CPA, p <0.001), and 10% variceal hemorrhage (25% with CPA, p= 0.002). After a median follow-up of 22 (4-67) months, patient and graft 1-/3-/5-year survival rates were 71/67/61% and 69/63/57%, respectively. On multivariate Cox proportional hazards analysis, the only factor significantly and independently associated with all-cause graft loss was non-physiological portal vein reconstruction in which all graft portal inflow arose from recipient systemic circulation (hazard ratio 6.639, 95% CI 2.159-20.422, p= 0.001). Alternative forms of portal vein anastomosis achieving physiological portal inflow (i.e., at least some recipient splanchnic blood flow reaching transplant graft) offer acceptable post-transplant results in LT candidates with complex PVT. On the contrary, non-physiological portal vein anastomoses fail to resolve portal hypertension and should not be performed. Complex portal vein thrombosis (PVT) is a challenge in liver transplantation. Results of this international, multicenter analysis may be used to guide clinical decisions in transplant candidates with complex PVT. Extra-anatomical portal vein anastomoses that allow for at least some recipient splanchnic blood flow to the transplant allograft offer acceptable results. On the other hand, anastomoses that deliver only systemic blood flow to the allograft fail to resolve portal hypertension and should not be performed.

Abernethy Syndrome Type 1B in a Young Male presenting with acute gastrointestinal bleeding: A Case report

Abernethy syndrome is a rare congenital extrahepatic portosystemic shunt (CEPS) in which splanchnic blood flows straightly into the inferior vena cava (IVC). Compared to type 1, in which the intra hepatic portal tree is not developed, in type 2 the portal vein is intact, but forms an anastomosis with the IVC. In the subtype 1a, superior mesenteric and splenic veins do not merge into the portal vein, while in type 1b they anatomically form the portal vein. CEPS can cause a wide spectrum of clinical manifestations including hepatic, pulmonary, metabolic and neurological symptoms and is usually diagnosed before adulthood. The diagnosis is established using the radiological imaging methods. Whileliver transplantation is the treatment of choice for type 1, surgical or minimally invasive endovascular shunt closure are treatment options for type 2 Abernethy syndome.

α-Adrenergic blockade prevented environmental temperature reduction-induced transient portal pressure surge in cirrhotic and portal hypertensive rats.

Exposure to low temperatures has been associated with increased gastroesophageal variceal bleeding in patients with cirrhosis and portal hypertension; however, the mechanism remains unclear. Therefore, the aim of the present study was to evaluate the impact of environmental temperature reduction on portal hypertension and the role of adrenergic signaling pathways in this phenomenon. Male Sprague-Dawley rats underwent common bile duct ligation or partial portal vein ligation to induce liver cirrhosis and/or portal hypertension. The impacts of acute or chronic changes in environmental temperature were surveyed. The results showed that acute cooling from 25 to 15°C and 5°C increased the portal pressure by 10.6% and 15.5% in cirrhotic rats, and by 22.2% and 36.1% in portal hypertensive rats, respectively. The transient portal pressure surge started shortly after cooling, reached a peak within 5 min and returned to baseline after 10 min. Systemic vascular resistance, mean arterial pressure and splanchnic blood flow increased significantly at the same time. Plasma epinephrine and norepinephrine concentrations, phospholipase C, protein kinase C activity and myosin phosphorylation of peripheral arteries increased significantly in response to cooling. Phentolamine (an α-blocker) but not propranolol (a non-selective β-blocker) dose-dependently inhibited the transient portal pressure surge and aforementioned molecular changes. In conclusion, environmental temperature reduction induced peripheral vasoconstriction via α-adrenergic pathways, and redistribution of blood flow to the splanchnic system led to a surge in transient portal pressure. Treatment with α-adrenergic receptor antagonists may exert additional benefits in controlling portal hypertension, especially on exposure to low temperatures.

Improvement of the splanchnic blood flow and hepatic vein oxygenation following revascularization in patients with chronic mesenteric ischaemia.

Chronic mesenteric ischaemia (CMI) is an underdiagnosed but severe condition. Access to functional testing is often limited and the diagnosis is usually based primarily on symptoms and imaging. One of the functional tests available is measurement of the splanchnic blood flow (SBF). The purpose of the present investigation was to evaluate if changes in the splanchnic perfusion after revascularization can be detected by measuring the SBF and hepatic vein oxygenation. The SBF was measured in 10patients before and after revascularization of the mesenteric arteries by either percutaneous transluminal angioplasty (n = 9) or open revascularization (n = 1). The SBF was measured indirectly using Fick's principle and using the tracer Tc-99m Mebrofenin along with assessment of hepatic blood oxygenation, before and after a standard meal, following catheterization of a hepatic vein and the femoral artery. Nine of 10patients (90%) achieved a profound increase in SBF after revascularization (mean increase in postprandial response to meal stimulation from 71 ± 95to 531 ± 295 ml/min, p = 0.001), and an increase in postprandial hepatic vein oxygen saturation (from 52 ± 14% to 59 ± 13%, p = 0.006). The symptoms of the patients diminished accordingly. One patient had no symptom relief, and no increase in postprandial SBF, but an angiographic result with no significant stenosis postrevascularization. Revascularization increased the SBF and hepatic vein oxygen saturation significantly concurrent with symptom relief and according with the angiographic successful result in the vast majority of patients. A satisfying angiographic result post vascular intervention does not rule out CMI.

PULMONARY HYPERTENSION FOLLOWING TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) PLACEMENT DUE TO NEUROHORMONAL VASOACTIVE CAUSES

PULMONARY HYPERTENSION FOLLOWING TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) PLACEMENT DUE TO NEUROHORMONAL VASOACTIVE CAUSES

S1247 Progress in Drug Therapy for Hepatorenal Syndrome: A Systematic Review of Clinical Studies in the Last 3 Years

Introduction: Rapid deterioration of kidneys in patients with severe liver injury i-e., cirrhosis is termed a hepatorenal syndrome (HRS). Hemodynamic instability due to increased splanchnic blood flow, systemic vasodilation, and renal vasoconstriction might cause HRS, and the goal of the drug therapies is to improve systematic circulation. This article aims to review the efficacy and safety of drug therapies tested in the last 3 years in HRS patients. Methods: We searched PubMed, Embase, Cochrane, and WOS from 1/1/2019 till 05/15/2022. We screened 520 articles and included 3 clinical trials (N=462) and 5 observational studies (N=1,034) with >5 patients providing data about the safety and efficacy of drugs. All case reports, case series, review articles, meta-analyses, and clinical studies with irrelevant populations were excluded. Results: In 8 studies, 708 patients were treated with terlipressin +albumin, 73 with noradrenaline, 22 with midodrine + albumin, 28 with midodrine+ albumin+ octreotide, 82 with other vasoconstrictors, and 121 with albumin only. In two clinical studies (N=416), HRS patients treated with terlipressin + albumin had a reversal in 32%-39.7%, liver transplant (LT) in 12.5%-23%, and death in 51% (11% with respiratory failure) of the patients, versus a reversal in 17%, LT in 29% and death in 45% (2% with respiratory failure) with albumin. In three clinical studies (N=382), HRS patients with terlipressin + albumin had a reversal in 40%-50.2%, overall response (OR) in 41.7%-72.9%, and death in 51% versus a reversal in 16.7%-22.7%, OR in 20%-23% and death in 82% with noradrenaline/other vasoconstrictors. In a retrospective study (N=88), HRS patients treated with midodrine+ octreotide+ albumin had a reversal, LT, and death in 25%, 3.6%, and 39.2%, respectively, versus reversal, LT, and death in 10%, 23%, and 43%, respectively, with non-standard treatment. In a pilot study (N=42), recurrence of HRS was 18% with midodrine vs. 50% with albumin only. (Table) Conclusion: Terlipressin with albumin significantly improved the reversal of HRS and transplants. However, mortality wasn’t improved due to treatment-related adverse effects. Terlipressin with albumin significantly improved the outcomes in HRS patients as compared to noradrenaline with albumin. Standardized albumin + midodrine + octreotide was more effective than non-standardized treatment of HRS. Midodrine with albumin reduced the recurrence of HRS in HRS recovered patients as compared to albumin. More RCTs are needed to confirm these results. Table 1. - Study Phase Treatment therapy N Outcomes Trials Wong et al. 2021 III (RCT) Terlipressin + Albumin (90 days) 199 Reversal of HRS (SCr < 1.5mg/dl) =32%, Renal transplant=29% Liver transplant=23%, Death=51% (11% with respiratory failure) Placebo 101 Reversal of HRS (SCr < 1.5mg/dl) =17%, Renal transplant=39%, Liver transplant=29%, Death=45% (2% with respiratory failure) Sharma et al. 2021 Pilot study (on patients recovered with terlipressin + albumin) Midodrine + albumin 22 Recurrence of HRS=18%, Mean ascitic tap in 2 months=1.9 Albumin 20 Recurrence of HRS=50%, Mean ascitic tap in 2 months=2.6 Arora et al. 2020 RCT Terlipressin + albumin 60 Reversal of HRS (SCr within 0.3mg/dl of baseline) = 40%, Any response (7-days) = 41.7% Survived patients=49% Noradrenaline+ albumin 60 Reversal of HRS (SCr within 0.3mg/dl of baseline) = 16.7%, Any response (7-days)=20%, Survived patients=18% Observational studies Kulkarni et al. 2022 Prospective Terlipressin + Albumin 116 Adverse effects leading to discontinuation=21%, Complete response (SCr within 0.3mg/dl of baseline) = 39.7%, Transplant free patient -at 90 days=57.8%, liver transplant=12.5% Hiruy et al. 2021 Retrospective Albumin+ midodrine+ octreotide (standardized) 28 Full response (SCr within 0.3mg/dl of baseline) =25%, renal replacement=21%, liver transplant=3.6%, 30-day mortality=39.2% Non-standardized treatment 60 Full response (SCr within 0.3mg/dl of baseline) = 10%, renal replacement=45%, liver transplant=23%, 30-day mortality=43% Moore et al. 2020 Retrospective Terlipressin+ albumin 203 Complete response (SCr < 1.5mg/dl) =50.2%, overall response=72.9% Renal transplant=12%, liver transplant=2%, Other vasoconstrictors 22 Complete response (SCr < 1.5mg/dl) =22.7%, overall response=59.1% Giovo et al. 2020 Retrospective Terlipressin+ albumin 24 Response to treatment=67% Noradrenaline+ albumin 13 Response to treatment=23% Nguyen-Tat et al. 2019 Retrospective Terlipressin + albumin for HRS-1 patients 54 HRS reversal=48%, relapse=8%, median OS=89±53 Terlipressin + albumin for HRS-2 patients 52 HRS reversal=46%, relapse=50%, mortality=20%, median OS=239±174 RCT= randomized clinical trial, HRS=Hepatorenal syndrome, SCr=serum creatinine.