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Cardiopulmonary hemodynamics and c-reactive protein as prognostic indicators in compensated and decompensated cirrhosis
Journal of Hepatology ( IF 26.8 ) Pub Date : 2018-05-01 , DOI: 10.1016/j.jhep.2017.12.027 Laura Turco 1 , Guadalupe Garcia-Tsao 2 , Ilenia Magnani 3 , Marcello Bianchini 1 , Martina Costetti 1 , Cristian Caporali 4 , Stefano Colopi 4 , Emilio Simonini 4 , Nicola De Maria 1 , Federico Banchelli 5 , Rosario Rossi 3 , Erica Villa 1 , Filippo Schepis 1
Journal of Hepatology ( IF 26.8 ) Pub Date : 2018-05-01 , DOI: 10.1016/j.jhep.2017.12.027 Laura Turco 1 , Guadalupe Garcia-Tsao 2 , Ilenia Magnani 3 , Marcello Bianchini 1 , Martina Costetti 1 , Cristian Caporali 4 , Stefano Colopi 4 , Emilio Simonini 4 , Nicola De Maria 1 , Federico Banchelli 5 , Rosario Rossi 3 , Erica Villa 1 , Filippo Schepis 1
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BACKGROUND & AIMS
The main stages of cirrhosis (compensated and decompensated) have been sub-staged based on clinical, endoscopic, and portal pressure (determined by the hepatic venous pressure gradient [HVPG]) features. Vasodilation leading to a hyperdynamic circulatory state is central in the development of a late decompensated stage, with inflammation currently considered a key driver. We aimed to assess hepatic/systemic hemodynamics and inflammation (by C-reactive protein [CRP]) among the different sub-stages of cirrhosis and to investigate their interrelationship and prognostic relevance. METHODS
A single center, prospective cohort of patients with cirrhosis undergoing per protocol hepatic and right-heart catheterization and CRP measurement, were classified into recently defined prognostic stages (PS) of compensated (PS1: HVPG ≥6 mmHg but <10 mmHg; PS2: HVPG ≥10 mmHg without gastroesophageal varices; PS3: patients with gastroesophageal varices) and decompensated (PS4: diuretic-responsive ascites; PS5: refractory ascites) disease. Cardiodynamic states based on cardiac index (L/min/m2) were created: relatively hypodynamic (<3.2), normodynamic (3.2-4.2) and hyperdynamic (>4.2). RESULTS
Of 238 patients, 151 were compensated (PS1 = 25; PS2 = 36; PS3 = 90) and 87 were decompensated (PS4 = 48; PS5 = 39). Mean arterial pressure decreased progressively from PS1 to PS5, cardiac index increased progressively from PS1-to-PS4 but decreased in PS5. HVPG, model for end-stage liver disease (MELD), and CRP increased progressively from PS1-to-PS5. Among compensated patients, age, HVPG, relatively hypodynamic/hyperdynamic state and CRP were predictive of decompensation. Among patients with ascites, MELD, relatively hypodynamic/hyperdynamic state, post-capillary pulmonary hypertension, and CRP were independent predictors of death/liver transplant. CONCLUSIONS
Our study demonstrates that, in addition to known parameters, cardiopulmonary hemodynamics and CRP are predictive of relevant outcomes, both in patients with compensated and decompensated cirrhosis. LAY SUMMARY
There are two main stages in cirrhosis, compensated and decompensated, each with a main relevant outcome. In compensated cirrhosis the main relevant outcome is the development of ascites, while in decompensated cirrhosis it is death. Major roles of cardiac dysfunction and systemic inflammation have been hypothesized in the evolution of the disease in decompensated patients. In this study, we have shown that these factors were also involved in the progression from compensated to decompensated stage.
中文翻译：
心肺血流动力学和 c 反应蛋白作为代偿期和失代偿期肝硬化的预后指标
背景和目的 肝硬化的主要阶段（代偿期和失代偿期）已根据临床、内窥镜和门静脉压力（由肝静脉压力梯度 [HVPG] 决定）特征进行了细分。导致高动力循环状态的血管舒张是晚期失代偿期发展的核心，炎症目前被认为是一个关键驱动因素。我们旨在评估肝硬化不同亚阶段的肝脏/全身血流动力学和炎症（通过 C 反应蛋白 [CRP]），并研究它们的相互关系和预后相关性。方法 一个单中心、前瞻性的肝硬化患者队列，按照协议进行肝和右心导管插入术和 CRP 测量，被分类为最近定义的代偿预后阶段 (PS) (PS1: HVPG ≥6 mmHg 但<10 mmHg；PS2：HVPG ≥10 mmHg 无胃食管静脉曲张；PS3：胃食管静脉曲张患者）和失代偿（PS4：利尿剂反应性腹水；PS5：顽固性腹水）疾病。创建基于心脏指数 (L/min/m2) 的心脏动力学状态：相对低动力 (<3.2)、正常动力 (3.2-4.2) 和高动力 (>4.2)。结果 在 238 名患者中，151 名代偿（PS1 = 25；PS2 = 36；PS3 = 90）和 87 名失代偿（PS4 = 48；PS5 = 39）。平均动脉压从 PS1 到 PS5 逐渐降低，心脏指数从 PS1 到 PS4 逐渐增加，但在 PS5 中降低。HVPG、终末期肝病 (MELD) 模型和 CRP 从 PS1 到 PS5 逐渐增加。在代偿患者中，年龄、HVPG、相对低动力/高动力状态和 CRP 是失代偿的预测因素。在腹水患者中，MELD、相对低动力/高动力状态、毛细血管后肺动脉高压和CRP是死亡/肝移植的独立预测因子。结论 我们的研究表明，除了已知参数外，心肺血流动力学和 CRP 可以预测代偿期和失代偿期肝硬化患者的相关结果。概述 肝硬化有两个主要阶段，代偿期和失代偿期，每个阶段都有一个主要的相关结果。在代偿性肝硬化中，主要的相关结果是腹水的发展，而在失代偿性肝硬化中，主要相关结果是死亡。已经假设心功能障碍和全身炎症在失代偿患者疾病发展中的主要作用。在这项研究中，
更新日期：2018-05-01
中文翻译：
心肺血流动力学和 c 反应蛋白作为代偿期和失代偿期肝硬化的预后指标
背景和目的 肝硬化的主要阶段（代偿期和失代偿期）已根据临床、内窥镜和门静脉压力（由肝静脉压力梯度 [HVPG] 决定）特征进行了细分。导致高动力循环状态的血管舒张是晚期失代偿期发展的核心，炎症目前被认为是一个关键驱动因素。我们旨在评估肝硬化不同亚阶段的肝脏/全身血流动力学和炎症（通过 C 反应蛋白 [CRP]），并研究它们的相互关系和预后相关性。方法 一个单中心、前瞻性的肝硬化患者队列，按照协议进行肝和右心导管插入术和 CRP 测量，被分类为最近定义的代偿预后阶段 (PS) (PS1: HVPG ≥6 mmHg 但<10 mmHg；PS2：HVPG ≥10 mmHg 无胃食管静脉曲张；PS3：胃食管静脉曲张患者）和失代偿（PS4：利尿剂反应性腹水；PS5：顽固性腹水）疾病。创建基于心脏指数 (L/min/m2) 的心脏动力学状态：相对低动力 (<3.2)、正常动力 (3.2-4.2) 和高动力 (>4.2)。结果 在 238 名患者中，151 名代偿（PS1 = 25；PS2 = 36；PS3 = 90）和 87 名失代偿（PS4 = 48；PS5 = 39）。平均动脉压从 PS1 到 PS5 逐渐降低，心脏指数从 PS1 到 PS4 逐渐增加，但在 PS5 中降低。HVPG、终末期肝病 (MELD) 模型和 CRP 从 PS1 到 PS5 逐渐增加。在代偿患者中，年龄、HVPG、相对低动力/高动力状态和 CRP 是失代偿的预测因素。在腹水患者中，MELD、相对低动力/高动力状态、毛细血管后肺动脉高压和CRP是死亡/肝移植的独立预测因子。结论 我们的研究表明，除了已知参数外，心肺血流动力学和 CRP 可以预测代偿期和失代偿期肝硬化患者的相关结果。概述 肝硬化有两个主要阶段，代偿期和失代偿期，每个阶段都有一个主要的相关结果。在代偿性肝硬化中，主要的相关结果是腹水的发展，而在失代偿性肝硬化中，主要相关结果是死亡。已经假设心功能障碍和全身炎症在失代偿患者疾病发展中的主要作用。在这项研究中，
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