肝硬化门脉高压合并肺动脉高压患者的临床特征及危险因素分析

目的 分析肝硬化患者门脉性肺动脉高压（PoPH）的发生率、临床特征及危险因素。方法 收集2021年3月至2022年3月于中国医科大学附属第一医院住院的115例肝硬化门静脉高压患者的一般临床资料、实验室化验及检查结果，根据超声心动图结果是否合并肺动脉高压为标准分为PoPH组和非PoPH组。分析两组患者的一般临床特征及多因素logistic回归分析肝硬化发生PoPH的独立危险因素。结果 （1）肝硬化患者PoPH的发生率为8.7%(10/115)。（2）PoPH组10例，平均年龄（54.5±14.3）岁，平均肺动脉压力（44.0±4.3）mmHg。非PoPH组105例，平均年龄（56.9±10.7）岁。PoPH组患者血红蛋白（Hb）、血清白蛋白（ALB）显著低于非PoPH组（P<0.05）;PoPH组平均红细胞容积（MCV）、平均红细胞血红蛋白含量（MCH）、Child-Pugh评分及终末期肝病模型（MELD）评分显著高于非PoPH组（P<0.05）。（3）多因素logistic回归分析结果显示：低Hb(OR 0.95,95%CI 0.90～1.00,P=0.034)是肝硬化门脉...     

门肺高压的治疗现状

门肺高压(portopulmonary hypertension,PoPH)是指源于门脉高压的肺动脉高压(PAH),最早由Mantz等在1951年首次描述,是少见却可危及生命的门脉高压并发症。由于与其他形式的PAH病理生理学机制类似,WHO将     

门静脉高压相关性肺动脉高压治疗现状

门静脉高压相关性肺动脉高压(PoPH)是门静脉高压的一种严重并发症, 常引起肺血管收缩、重构, 其特征为毛细血管前肺动脉高压, 是动脉性肺动脉高压(PAH)的重要类型之一, PoPH的发生可能与雌激素代谢有关。PoPH患者生存时间短, 预后差。目前PoPH治疗手段有限, 主要包括原发病治疗、肺动脉高压靶向药物治疗, 肝移植可作为一项治疗手段。本文就PoPH的流行病学、发病机制、临床特征、治疗现状作一综述, 旨在提高临床医生对PoPH的认识。     

肺动脉高压患者心功能的变化

为了探讨肺动脉高压与右心功能的关系，2001年12月至2003年1月，我们利用彩色多普勒超声诊断仪，对40例肺动脉高压患者的右心功能各项指标进行了检测。现分析如下。     

改良英国医学研究委员会呼吸困难量表评分、慢性阻塞性肺疾病评估测试评分与慢性阻塞性肺疾病患者肺功能的相关性及其对肺动脉高压的预测价值

目的分析改良英国医学研究委员会呼吸困难量表(mMRC)评分、慢性阻塞性肺疾病评估测试(CAT)评分与慢性阻塞性肺疾病(COPD)患者肺功能的相关性,并比较二者对肺动脉高压的预测价值。方法选取2016年1月—2018年1月廊坊市人民医院收治的COPD患者163例,其中肺功能分级Ⅰ级26例,Ⅱ级47例,Ⅲ级56例,Ⅳ级34例。比较不同肺功能分级患者性别、年龄、肺动脉高压发生情况、第1秒用力呼气容积(FEV_1)/用力肺活量(FVC)、m MRC评分、CAT评分;mMRC评分、CAT评分与COPD患者肺功能分级的相关性分析采用Spearman秩相关分析;m MRC评分、CAT评分与COPD患者肺功能指标的相关性分析采用Pearson相关分析;绘制ROC曲线以评价mMRC评分、CAT评分对COPD患者肺动脉高压的预测价值。结果 (1)不同肺功能分级患者中男性所占比例、年龄比较,差异无统计学意义(P0.05);肺功能分级Ⅲ级、Ⅳ级患者肺动脉高压发生率高于肺功能分级Ⅰ级、Ⅱ级患者,肺功能分级Ⅱ级患者肺动脉高压发生率高于肺功能分级Ⅰ级患者(P0.05);肺功能分级Ⅳ级患者FEV_1/FVC、mMRC评分、CAT评分高于肺功能分级Ⅰ级、Ⅱ级、Ⅲ级患者,肺功能分级Ⅲ级患者FEV_1/FVC、m MRC评分、CAT评分高于肺功能分级Ⅰ级、Ⅱ级患者,肺功能分级Ⅱ级患者FEV_1/FVC、mMRC评分、CAT评分高于肺功能分级Ⅰ级患者(P0.05)。(2)Spearman秩相关分析结果显示,mMRC评分(r_s=0.906)、CAT评分(r_s=0.847)与COPD患者肺功能分级呈正相关(P0.05);Pearson相关分析结果显示,mMRC评分与COPD患者FEV_1/FVC(r=-0.712)、第1秒用力呼气容积占预计值的百分比(FEV_1%pred)(r=-0.813)呈负相关(P0.05),CAT评分亦与COPD患者FEV_1/FVC(r=-0.801)、FEV_1%pred(r=-0.894)呈负相关(P0.05)。(3)ROC曲线显示,mMRC评分、CAT评分预测COPD患者肺动脉高压的曲线下面积(AUC)分别为0.545[95%CI(0.278,0.803)]、0.870[95%CI(0.000,1.000)],最佳截断值分别为3.00分、21.00分,CAT评分预测COPD患者肺动脉高压的AUC大于mMRC(P0.05)。结论 m MRC、CAT评分与COPD患者肺功能分级呈正相关,与肺功能指标呈负相关,且对肺动脉高压具有一定预测价值;与mMRC评分相比,CAT评分可更准确地反映COPD患者肺功能,且对肺动脉高压的预测价值较高,更适用于患者整体病情评估。     

肝硬化门静脉性肺动脉高压患者的临床特点及危险因素分析

目的:分析肝硬化门静脉性肺动脉高压(PoPH)患者的临床特点及危险因素.方法:回顾性地初步筛选了2016年1月至2018年12月在重庆医科大学附属第二医院住院的1381例肝硬化患者,二次筛选出合并门静脉高压的患者428例,根据是否合并肺动脉压力升高分为PoPH组和非PoPH组,通过分析临床资料采用Logistic回归分...     

肝硬化门脉高压症患者心脏功能影响因素及其状况评价*

目的 研究肝硬化门脉高压症患者心脏功能状态,探讨其与肝功能的关系,并分析影响左心室舒张功能不全的相关危险因素。方法 我院消化科住院的肝硬化门脉高压症患者126例,其中 Child-Pugh A级76例、B级41例、C级9例,MELD分级≤9分64例和>9分62例。行心电图和超声心动图（包括脉搏波多普勒和组织多普勒成像）检测。采用回归分析影响舒张功能不全的相关因素。结果 在126例患者中,有1例（0.8%）被诊断为左心收缩功能不全,77例（61%）被诊断为左心室舒张功能不全,心电图异常率为65%,其中QTc延长发生率为41%;不同Child-Pugh分级和MELD评分患者左心室舒张功能不全、心电图异常率和QTc延长发生率差异无统计学意义（P>0.05）;Logistic回归分析发现年龄（OR=1.163,95%CI：1.086~1.244）和心率（OR=1.106,95%CI：1.018~1.201）是影响舒张功能不全的相关危险因素。结论 肝硬化门脉高压症患者心功能改变主要以舒张功能减退和电生理异常为主,而与肝病严重程度和大量腹水并无显著相关性。对于年长和心率增快的肝硬化门脉高压症患者,要加强心脏舒张功能的评估,尽早诊断和及时干预可能能改善肝硬化患者的预后。     

门静脉闭锁致门脉高压相关性肺动脉高压1例并文献复习

目的:复习罕见门静脉解剖异常导致门脉高压性肺动脉高压(PPHTN)的相关文献,了解这类患者临床特点。方法:回顾分析1例成人门静脉闭锁导致PPHTN患者的临床经过和特点,并以"门静脉闭锁"、"门脉高压性肺动脉高压"为检索词,在万方数据库和中国全文期刊数据库中进行检索,以"atresia of portal vein"、"pulmonary hypertension"为检索词在pubmed全文数据库中进行检索。结果:患者女性,71岁,3年前因反复"肝性脑病"发现门静脉主干闭锁,脾静脉纤细;肠系膜上静脉-左肾静脉门体分流形成。胃底周围见静脉曲张,门腔静脉自发分流形成可能。2年6个月前出现双下肢水肿,1月前活动耐力明显下降,伴夜间阵发性呼吸困难,伴腹胀。UCG示下腔静脉增宽,心室呈"D"型影,s PAP84mm Hg(1mm Hg=0.133kPa)。因患者入院后出现院内感染及急性肾损伤,未能行右心导管检查,结合病史及检查结果,除外肺实质疾病、肺血栓栓塞症、结缔组织疾病及其他可能导致肺动脉高压(PAH)的药物使用或毒物接触史,同时确定患者存在门脉高压导致的胃底静脉曲张,诊断患者为非肝病性门静脉解剖异常导致的PPHTN。共检索中文文献2篇,外文文献24篇,保留较为详细病例资料文献15篇,涉及病例25例。结论:非肝病性门脉高压所形成的门体分流可以导致高动力性PAH,先天性门体分流者多见,继发于成人门静脉闭锁者罕见,早期识别随访,及时针对PAH进行干预治疗,维护右心功能,可能会延迟右心衰竭发生的时间,改善预后。     

肝硬化门脉高压症患者心脏功能影响因素及其状况评价

目的研究肝硬化门脉高压症患者心脏功能状态,探讨其与肝功能的关系,并分析影响左心室舒张功能不全的相关危险因素。方法我院消化科住院的肝硬化门脉高压症患者126例,其中Child-Pugh A级76例、B级41例、C级9例,MELD分级≤9分64例和9分62例。行心电图和超声心动图(包括脉搏波多普勒和组织多普勒成像)检测。采用回归分析影响舒张功能不全的相关因素。结果在126例患者中,有1例(0.8%)被诊断为左心收缩功能不全,77例(61%)被诊断为左心室舒张功能不全,心电图异常率为65%,其中QTc延长发生率为41%;不同Child-Pugh分级和MELD评分患者左心室舒张功能不全、心电图异常率和QTc延长发生率差异无统计学意义(P0.05);Logistic回归分析发现年龄(OR=1.163,95%CI:1.086～1.244)和心率(OR=1.106,95%CI:1.018～1.201)是影响舒张功能不全的相关危险因素。结论肝硬化门脉高压症患者心功能改变主要以舒张功能减退和电生理异常为主,而与肝病严重程度和大量腹水并无显著相关性。对于年长和心率增快的肝硬化门脉高压症患者,要加强心脏舒张功能的评估,尽早诊断和及时干预可能能改善肝硬化患者的预后。     

西地那非治疗COPD肺动脉高压疗效观察

目的研究西地那非对肺动脉高压的疗效及安全性。方法采用西地那非治疗30例COPD肺动脉高压患者,比较治疗前后心功能、血流动力学、动脉血气和生存质量的差异。结果 COPD肺动脉高压患者治疗后6min步行距离、心输出量、心指数、PaO2、SaO2和生存质量显著高于治疗前(均P<0.001),Borg呼吸困难积分、右室收缩压、平均肺动脉压、肺血管阻力、三尖瓣返流速率和PaCO2显著低于治疗前(均P<0.001)。不良反应有头痛4例(13.3%),面部潮红4例(13.3%),头昏2例(6.7%),耳鸣1例(3.3%)。结论西地那非可显著提高COPD肺动脉高压患者心功能及生存质量,是一种安全有效的治疗方法。     

Portopulmonary hypertension

Portopulmonary hypertension (PoPH) refers to the condition that pulmonary arterial hypertension (PAH) occur in the stetting of portal hypertension. The development of PoPH is thought to be independent of the severity of portal hypertension or the etiology or severity of liver disease. PoPH results from excessive vasoconstriction, vascular remodeling, and proliferative and thrombotic events within the pulmonary circulation that lead to progressive right ventricular failure and ultimately to death. Untreated PoPH is associated with a poor prognosis. As PoPH is frequently asymptomatic or symptoms are generally non-specific, patients should be actively screened for the presence of PoPH. Two-dimensional transthoracic echocardiography is a useful non-invasive screening tool, but a definitive diagnosis requires invasive hemodynamic confirmation by right heart catheterization. Despite a dearth of randomized, prospective data, an ever-expanding clinical experience shows that patients with PoPH benefit from therapy with PAH-specific medications including with endothelin receptor antagonists, phosphodiesterase-5 inhibitors, and/or prostanoids. Due to high perioperative mortality, transplantation should be avoided in those patients who have severe PoPH that is refractory to medical therapy.     

肝硬化合并急性上消化道出血的预后评分系统对比

目的 对比现行的肝硬化合并急性上消化道出血的预后评分系统.方法 回顾性分析2019年1～12月西安交通大学第一附属医院因肝硬化上消化道出血住院的患者资料,对比Child-Pugh评分、CAGIB评分、MELD评分及NLR评分系统的曲线下面积(area under curve,AUC).结果 共有328例肝硬化伴急性消化...     

Indocyanine green retention is a potential prog-nostic indicator after splenectomy and pericar-dial devascularization for cirrhotic patients

BACKGROUND: Splenectomy and pericardial devasculariza-tion (SPD) is an effective treatment of upper gastrointestinal bleeding and hypersplenism in cirrhotic patients with portal hypertension. Indocyanine green retention at 15 minutes (ICGR15) was reported to offer better sensitivity and speciifc-ity than the Child-Pugh classiifcation in hepatectomy, but few reports describe ICGR15 in SPD. The present study was to evaluate the prognostic value of ICGR15 for cirrhotic patients with portal hypertension who underwent SPD.
METHODS: From January 2012 to January 2015, 43 patients with portal hypertension and hypersplenism caused by liver cirrhosis were admitted in our center and received SPD. The ICGR15, Child-Pugh classiifcation, model for end-stage liver disease (MELD) score, and perioperative characteristics were analyzed retrospectively.
RESULTS: Preoperative liver function assessment revealed that 34 patients were Child-Pugh class A with ICGR15 of 13.6%-43.0% and MELD score of 7-20; 8 patients were class B with ICGR15 of 22.8%-40.7% and MELD score of 7-17; 1 patient was class C with ICGR15 of 39.7% and MELD score of 22. The optimal ICGR15 threshold for liver function com-pensation was 31.2%, which offered a sensitivity of 68.4% and a speciifcity of 70.8%. Univariate analysis showed preopera-tive ICGR15, MELD score, surgical procedure, intraoperative blood loss, and autologous blood transfusion were signiifcant-ly different between postoperative liver function compensated and decompensated groups. Multivariate regression analysis revealed that ICGR15 was an independent risk factor of post-operative liver function recovery (P=0.020).
CONCLUSIONS: ICGR15 has outperformed the Child-Pugh classiifcation for assessing liver function in cirrhotic patients with portal hypertension. ICGR15 may be a suitable prognos-tic indicator for cirrhotic patients after SPD.     

伴门静脉栓子的食管胃静脉曲张破裂出血急诊胃镜下硬化术联合组织胶注射术止血失败的危险因素分析

目的探讨急诊胃镜下硬化术(EIS)序贯联合组织胶注射术(HI)在合并门静脉栓子(PVE)的肝硬化食管胃静脉曲张破裂出血(EGVB)治疗中失败的危险因素。方法选取2018年1月—2019年12月首都医科大学附属北京世纪坛医院和解放军总医院第五医学中心急诊胃镜治疗的合并PVE的EGVB患者共109例,按照急诊胃镜下止血疗效分为止血失败组(n=28)和止血成功组(n=81),比较两组间的一般资料、胃镜下静脉曲张及出血表现、血液生化指标、Child-Pugh分级及MELD评分,分析其止血失败的危险因素。计量资料两组间比较采用t检验或Mann-Whitney U秩和检验,计数资料两组间比较采用χ2检验,多因素分析采用logisitc回归分析。结果止血失败组外周血WBC、TBil、Child-Pugh分级、MELD评分均显著高于止血成功组(统计值分别为Z=3.794、Z=4.751、χ2=40.104、Z=6.412,P值均<0.001),而PTA、Alb、CHE均显著低于止血成功组(统计值分别为t=9.653、Z=3.093、Z=4.092,P值分别为<0.001、0.002、<0.001);其中WBC、PTA、TBil、Alb、Child-Pugh分级为其止血治疗失败的独立危险因素[OR(95%CI)分别为:28.543(1.285~634.113)、0.194(0.045~0.835)、2.197(1.004~4.810)、0.448(0.209~0.961)、5.164(1.307~20.406),P值均<0.05]。结论WBC、PTA、TBil、Alb、Child-Pugh分级为急诊EIS序贯联合HI治疗合并PVE的EGVB失败的独立危险因素,术前充分评估并纠正有助于提高止血成功率。     

Hyperuricaemia in patients with right or left heart failure.

Based on the clinical observation that patients with right or left heart failure often present with hyperuricaemia, the relation between serum urate values and haemodynamic variables was studied in patients with primary pulmonary hypertension (PPH) as well as in patients with advanced ischaemic heart disease or dilated cardiomyopathy. The study was a retrospective analysis of 39 patients with PPH and 36 patients with left heart disease, examining serum urate levels in association with haemodynamic variables. Elevated urate concentrations were found in 79% of the PPH patients. There was no association between serum urate levels and mean pulmonary artery pressures, but a significant correlation was found between urate levels and the cardiac index (r=0.48; p=0.0021) and an even stronger correlation between serum urate levels and mean right atrial pressures (r=0.83; p<0.0001). A similar association was found in a subgroup of 21 PPH patients not receiving diuretics. In 36 patients with ischaemic heart disease or dilated cardiomyopathy, hyperuricaemia was present in 78% and was significantly associated with elevated right atrial pressures (r=0.40; p=0.031) and even more so with elevated left atrial pressures (r=0.55; p=0.0005) but not with the cardiac index (r=0.034; p=0.86). The data show that hyperuricaemia in patients with cardiac dysfunction is closely related to elevated right or left atrial filling pressures.     

Role of liver function and portal vein congestion index on rebleeding in cirrhotics after distal splenorenal shunt

BACKGROUND: Bleeding from esophagogastric varices is the worst and most lethal complication of cirrhotic portal hypertension. Distal splenorenal shunt (Warrens surgery) is used in the therapeutic of this patients, Child A and B, with rebleeding after clinical endoscopic therapy. The portal vein congestion index is elevated in cirrhotic portal hypertension and could predict rebleeding after Warrens surgery in these patients. AIM: To verify if the portal vein congestion index or liver function (Child-Pugh) at preoperative are predictive factors of rebleeding after Warrens surgery. METHODS: Sixty-two cirrhotic patients were submitted to Warrens surgery at "Santa Casa" Medical School and Hospital - Liver and Portal Hypertension Unit, S?o Paulo, SP, Brazil. Fifty-eight were analyzed for Child-Pugh class and 36 for portal vein congestion index, divided in two groups: with or without rebleeding and statistical analysis was performed. RESULTS: In the rebleeding group, 69% were Child B, with portal vein congestion index = 0.09. The group without rebleeding show us 62% patients Child A with portal vein congestion index = 0.076. The difference was significant for Child-Pugh class but not to portal vein congestion index. CONCLUSION: Portal vein congestion index was not predictive of rebleeding after Warrens surgery, but cirrhotics Child B have more chance to rebleed after this surgery than Child A.     

Right Heart Catheterization (RHC): A Comprehensive Review of Provocation Tests and Hepatic Hemodynamics in Patients With Pulmonary Hypertension (PH)

The classic definition of pulmonary arterial hypertension (PAH) is a mean pulmonary artery pressure (mPAP) of 20 mmHg. The gold standard for assessing pulmonary hemodynamics is right heart catheterization (RHC), which is necessary to confirm the diagnosis of PH. In some instances, RHC evaluates the degree of hemodynamic dysfunction and performs vasoreactivity tests. Measurement of the hepatic venous pressure gradient remains the gold standard diagnostic for identifying portal hypertension. This review aims to describe the procedure of RHC and the hemodynamic measurement in patients with PAH and Portopulmonary hypertension (PoPH). The RHC remains the gold standard for diagnosing PAH and PoPH.     

Comparative study of indocyanine green-R15, Child-Pugh score,and model for end-stage liver disease score for prediction of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt

BACKGROUNDHepatic encephalopathy (HE) remains an enormous challenge in patients who undergo transjugular intrahepatic portosystemic shunt (TIPS) implantation. The preoperative indocyanine green retention rate at 15 min (ICG-R15), as one of the liver function assessment tools, has been developed as a prognostic indicator in patients undergoing surgery, but there are limited data on its role in TIPS.AIMTo determine whether the ICG-R15 can be used for prediction of post-TIPS HE in decompensated cirrhosis patients with portal hypertension (PHT) and compare the clinical value of ICG-R15, Child-Pugh score (CPS), and model for end-stage liver disease (MELD) score in predicting post-TIPS HE with PHT.METHODSThis retrospective study included 195 patients with PHT who underwent elective TIPS at Beijing Shijitan Hospital from January 2018 to June 2019. All patients underwent the ICG-R15 test, CPS evaluation, and MELD scoring 1 wk before TIPS. According to whether they developed HE or not, the patients were divided into two groups: HE group and non-HE group. The prediction of one-year post-TIPS HE by ICG-R15, CPS and MELD score was evaluated by the areas under the receiver operating characteristic curves (AUCs).RESULTSA total of 195 patients with portal hypertension were included and 23% (45/195) of the patients developed post-TIPS HE. The ICG-R15 was identified as an independent predictor of post-TIPS HE. The AUCs for the ICG-R15, CPS, and MELD score for predicting post-TIPS HE were 0.664 (95% confidence interval [CI]: 0.557-0.743, P = 0.0046), 0.596 (95%CI: 0.508-0.679, P = 0.087), and 0.641 (95%CI: 0.554-0.721, P = 0.021), respectively. The non-parametric approach (Delong-Delong & Clarke-Pearson) showed that there was statistical significance in pairwise comparison between AUCs of ICG-R15 and MELD score (P = 0.0229).CONCLUSIONThe ICG-R15 has appreciated clinical value for predicting the occurrence of post-TIPS HE and is a choice for evaluating the prognosis of patients undergoing TIPS.     

心房颤动合并肺动脉高压的临床特征与危险因素

目的 探讨肺动脉高压(pulmonary arterial hypertension,PAH)在心房颤动(atrial fibrillation,AF)患者中的临床特征与危险因素.方法 纳入于2016年11月～2019年11月连续入院的292名确诊AF的患者,根据临床分类分为两组:①阵发性AF组167例(发作后在7天内...     

Model for end-stage liver disease score to serum sodium ratio index as a prognostic predictor and its correlation with portal pressure in patients with liver cirrhosis.

BACKGROUND: The models for end-stage liver disease (MELD) and serum sodium (SNa) are important prognostic markers in cirrhosis. A novel index, MELD to SNa ratio (MESO), was developed to amplify the opposing effect of MELD and SNa on outcome prediction. METHODS: A total of 213 cirrhotic patients undergoing hepatic venous pressure gradient (HVPG) measurement were retrospectively analyzed. RESULTS: The MESO index correlated with HVPG (r=0.258, P<0.001) and Child-Pugh score (rho=0.749, P<0.001). Using mortality as the end point, the area under receiver operating characteristic curve (AUC) was 0.860 for SNa, 0.795 for the MESO index and 0.789 for MELD (P values all >0.3) at 3 months. Among patients with Child-Pugh class A or B, the MESO index had a significantly higher AUC compared with MELD (0.80 vs. 0.766, P<0.001). A MESO index <1.6 identified 97% of patients who survived at 3 months and the predicted survival rate was 96.5%. In survival analysis, MESO index >1.6 independently predicted a higher mortality rate (relative risk: 3.32, P<0001) using the Cox model. CONCLUSIONS: The MESO index, which takes into account the predictive power of both MELD and SNa, is a useful prognostic predictor for both short- and long-term survival in cirrhotic patients.