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Hepatopulmonary syndrome: prevalence and predictive value of various cut offs for arterial oxygenation and their clinical consequences

¹ Department of Internal Medicine IV, Intensive Care Unit, University of Vienna, Allgemeines Krankenhaus, Waehringer Guertel 18-20, A-1090 Vienna, Austria
² Department of Medical Statistics, University of Vienna, Schwarzspanierstrasse 17, A-1090 Vienna, Austria
³ Department of Transplantation Surgery, University of Vienna, Allgemeines Krankenhaus, Waehringer Guertel 18-20, A-1090 Vienna, Austria
⁴ Department of Internal Medicine IV, Division of Gastroenterology, University of Vienna, Allgemeines Krankenhaus, Waehringer Guertel 18-20, A-1090 Vienna, Austria

Correspondence to:
Correspondence to:
Dr P Schenk, Department of Internal Medicine IV, Intensive Care Unit 13 H1, University of Vienna, Allgemeines Krankenhaus, Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria;
Peter.Schenk{at}akh-wien.ac.at

Background: The hepatopulmonary syndrome (HPS) is defined as the triad of liver disease, arterial deoxygenation, and pulmonary vascular dilatation. The reported prevalence of HPS in cirrhotic patients varies between 4% and 19%, and various threshold values defining arterial deoxygenation have been used and recommended previously. However, it is not known how the prevalence of HPS differs using different cut off values for arterial deoxygenation.

Methods: We studied 127 patients for the presence of HPS using transthoracic contrast echocardiography for detection of pulmonary vasodilation, pulmonary function tests, and blood gas analysis.

Results: Ninety eight patients were included in the study, of whom 33 (34%) had a positive contrast echocardiography. Using an increased alveolar-arterial difference for the partial pressure of oxygen (AaDO₂) as an indication of hypoxaemia, the prevalence of HPS was considerably higher (>15 mm Hg, 32%; >20 mm Hg, 31%; and >age related threshold, 28%) than using reduced partial pressure of arterial oxygen (PaO₂) as a threshold (<80 mm Hg, 19%; <70 mm Hg, 15%; and <age related threshold, 15%). For AaDO₂ as the cut off, the positive predictive value for a diagnosis of HPS was low (34%, 37%, and 53%, respectively). In contrast, PaO₂ as a cut off had considerably higher positive predictive values (44%, 93%, and 94%, respectively). Introducing PaO₂ <65 mm Hg as the cut off, the positive predictive value increased to 100%. Dyspnoea was more often present in patients with "clinically significant" HPS (57%) compared with "subclinical HPS" (8%), and patients without HPS (6%). The Child-Pugh score correlated significantly with the severity of HPS. Two of five liver transplanted patients with "subclinical HPS" had embolic brain infarcts, possibly induced by venous emboli passing through dilated intrapulmonary vessels.

Conclusions: Defining arterial hypoxaemia in HPS by different, previously used, cut off values for arterial oxygenation leads to a wide variation in the prevalence of HPS in the same sample of cirrhotic patients.

Keywords: liver cirrhosis; portal hypertension; hypoxaemia; pulmonary vasodilation; contrast echocardiography

Abbreviations: HPS, hepatopulmonary syndrome; PaO₂, partial pressure of arterial oxygen; AaDO₂, alveolar-arterial difference for the partial pressure of oxygen; PaCO₂, partial pressure of arterial carbon dioxide; FEV₁, forced expiratory volume in one second; TLC, total lung capacity; OLT, orthotopic liver transplantation

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