Juan Gonzalez-Abraldes | University of Alberta (original) (raw)
Papers by Juan Gonzalez-Abraldes
The present article aims to provide answers to questions frequently asked by physicians attending... more The present article aims to provide answers to questions frequently asked by physicians attending patients with Wilson's disease (WD) or those with a suspected diagnosis of WD. The article is divided into 2 parts: a first part with answers to questions relating to the diagnosis of this entity and a second with answers to questions concerning treatment. A brief appendix is included with responses to questions not falling into either of these 2 categories.
Hepatology (Baltimore, Md.), Jan 4, 2015
Non-selective beta-blockers (NSBB) are widely used since they have been proved effective in the p... more Non-selective beta-blockers (NSBB) are widely used since they have been proved effective in the prophylaxis of acute variceal bleeding (AVB). However, still a significant proportion of patients experience AVB whilst on treatment with NSBB and their impact on prognosis of AVB is unknown. The present study aimed at assessing the effect of being on prophylactic therapy with NSBB on 5-day failure and 6-week mortality of cirrhotic patients admitted with AVB. 142 patients were included: 49 patients were receiving prophylactic therapy with NSBB (NSBB group) and 93 patients were not (control group). There were some differences in the baseline characteristics between the groups: higher proportion of alcoholic etiology and active alcoholism (37% vs. 10%), higher platelets count and lower hematocrit at admission in the control group. However, the severity of AVB and initial treatment were similar. 5-day failure occurred in 20% of patients (14% in NSBB vs. 24% in controls; p = 0.27). The adjust...
Clinical Gastroenterology and Hepatology, 2015
Hepatic venous pressure gradient (HVPG) is associated with risk of liver events in patients with ... more Hepatic venous pressure gradient (HVPG) is associated with risk of liver events in patients with chronic hepatitis C. Antiviral therapies that lead to a sustained virologic response (SVR) reduce portal pressure and prevent liver disease progression. However, it is not clear to what extent the progression of hepatitis C is modified once patients develop cirrhosis with severe portal hypertension (CSPH, HVPG≥10 mmHg). We assessed the effects of HVPG and SVR on the risk of liver decompensation, hepatocellular carcinoma, and/or death in patients with hepatitis C-related cirrhosis. We collected data from 100 patients with hepatitis C and compensated cirrhosis who underwent HVPG measurement ≤3 months before (baseline) and 24 weeks after therapy with pegylated interferon alfa-2a and ribavirin at 4 hospitals in Spain, from 2001 through 2009. SVR was defined as undetectable serum HCV RNA 24 weeks after treatment ended. Clinical data were collected until death, liver transplantation, or December 2012 (median 5 y; interquartile range, 1.4-7 y). Seventy-four patients had CSPH at baseline and 35% of patients achieved an SVR. During the follow-up period, 19 patients developed liver decompensation (ascites, variceal bleeding, or encephalopathy). The actuarial probability values for liver decompensation at 1, 5, and 7 years were 3%, 19% and 22%, respectively. Baseline level of HVPG, but not SVR, was independently associated to the risk of liver decompensation. Patients with CSPH, regardless of an SVR to therapy for hepatitis C, remain at risk for liver decompensation within the 5 y after treatment; they should be closely monitored.
World journal of gastroenterology : WJG, Jan 7, 2006
Animal models have allowed detailed study of hemodynamic alterations typical of portal hypertensi... more Animal models have allowed detailed study of hemodynamic alterations typical of portal hypertension and the molecular mechanisms involved in abnormalities in splanchnic and systemic circulation associated with this syndrome. Models of prehepatic portal hypertension can be used to study alterations in the splanchnic circulation and the pathophysiology of the hyperdynamic circulation. Models of cirrhosis allow study of the alterations in intrahepatic microcirculation that lead to increased resistance to portal flow. This review summarizes the currently available literature on animal models of portal hypertension and analyzes their relative utility. The criteria for choosing a particular model, depending on the specific objectives of the study, are also discussed.
Hepatology (Baltimore, Md.), Jan 11, 2015
Alcoholic hepatitis (AH) frequently progresses to multiple organ failure (MOF) and death. However... more Alcoholic hepatitis (AH) frequently progresses to multiple organ failure (MOF) and death. However, the driving factors are largely unknown. At admission, patients with AH often show criteria of systemic inflammatory response syndrome (SIRS) even in the absence of an infection. We hypothesize that the presence of SIRS may predispose to MOF and death. To test this hypothesis, we studied a cohort including 162 patients with biopsy-proven AH. The presence of SIRS and infections was assessed in all patients and multivariate analyses identified variables independently associated with MOF and 90-day mortality. At admission, 32 (19.8%) patients were diagnosed with a bacterial infection, while 75 (46.3%) fulfilled SIRS criteria. 58 patients (35.8%) developed MOF during hospitalization. Short-term mortality was significantly higher among patients who developed MOF (62.1% vs. 3.8%, p<.001). The presence of SIRS was a major predictor of MOF (odds ratio 2.69, p=.025) and strongly correlated w...
Gut, 2014
In the liver, the transcription factor, Kruppel-like factor 2 (KLF2), is induced early during pro... more In the liver, the transcription factor, Kruppel-like factor 2 (KLF2), is induced early during progression of cirrhosis to lessen the development of vascular dysfunction; nevertheless, its endogenous expression results insufficient to attenuate establishment of portal hypertension and aggravation of cirrhosis. Herein, we aimed to explore the effects and the underlying mechanisms of hepatic KLF2 overexpression in in vitro and in vivo models of liver cirrhosis. Activation phenotype was evaluated in human and rat cirrhotic hepatic stellate cells (HSC) treated with the pharmacological inductor of KLF2 simvastatin, with adenovirus codifying for this transcription factor (Ad-KLF2), or vehicle, in presence/absence of inhibitors of KLF2. Possible paracrine interactions between parenchymal and non-parenchymal cells overexpressing KLF2 were studied. Effects of in vivo hepatic KLF2 overexpression on liver fibrosis and systemic and hepatic haemodynamics were assessed in cirrhotic rats. KLF2 upregulation profoundly ameliorated HSC phenotype (reduced α-smooth muscle actin, procollagen I and oxidative stress) partly via the activation of the nuclear factor (NF)-E2-related factor 2 (Nrf2). Coculture experiments showed that improvement in HSC phenotype paracrinally ameliorated liver sinusoidal endothelial cells probably through a vascular endothelial growth factor-mediated mechanism. No paracrine interactions between hepatocytes and HSC were observed. Cirrhotic rats treated with simvastatin or Ad-KLF2 showed hepatic upregulation in the KLF2-Nrf2 pathway, deactivation of HSC and prominent reduction in liver fibrosis. Hepatic KLF2 overexpression was associated with lower portal pressure (-15%) due to both attenuations in the increased portal blood flow and hepatic vascular resistance, together with a significant improvement in hepatic endothelial dysfunction. Exogenous hepatic KLF2 upregulation improves liver fibrosis, endothelial dysfunction and portal hypertension in cirrhosis.
American Journal of Gastroenterology, 1999
Asymptomatic persistent hypertransaminasemia unrelated to hepatitis viral infection is a common c... more Asymptomatic persistent hypertransaminasemia unrelated to hepatitis viral infection is a common cause of referral to the hepatologist. Less frequent liver diseases should then be considered, as well as extrahepatic-origin hypertransaminasemia. Celiac disease, although it has repeatedly been reported as a cause of persistent hypertransaminasemia, is often not included in its differential diagnosis in the absence of the classic malabsorption syndrome. We present the cases of four patients sent to a liver unit for evaluation of persistent hypertransaminasemia in whom celiac disease was finally discovered. Our report highlights the importance of including celiac disease in list of conditions potentially responsible for chronic hypertransaminasemia of unknown cause. (Am J Gastroenterol 1999;94:1095-1097
Portal hypertension is a severe, almost unavoidable complication of chronic liver diseases and is... more Portal hypertension is a severe, almost unavoidable complication of chronic liver diseases and is responsible for the main clinical consequences of cirrhosis. Measurement of the hepatic venous pressure gradient (HVPG) is currently the best available method to evaluate the presence and severity of portal hypertension. Clinically significant portal hypertension is defined as an increase in HVPG to &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;or=10 mmHg; above this threshold, the complications of portal hypertension might begin to appear. Measurement of HVPG is increasingly used in clinical hepatology, and numerous studies have demonstrated that the parameter is a robust surrogate marker for hard clinical end points. The main clinical applications for HVPG include diagnosis, risk stratification, identification of patients with hepatocellular carcinoma who are candidates for liver resection, monitoring of the efficacy of medical treatment, and assessment of progression of portal hypertension. Patients who experience a reduction in HVPG of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;or=20% or to &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;12 mmHg in response to drug therapy are defined as &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;responders&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;. Responders have a markedly decreased risk of bleeding (or rebleeding), ascites, and spontaneous bacterial peritonitis, which results in improved survival.
Liver Transplantation, 2001
We report 2 patients with Budd-Chiari (BC) syndrome secondary to thrombogenic conditions who unde... more We report 2 patients with Budd-Chiari (BC) syndrome secondary to thrombogenic conditions who underwent transjugular intrahepatic portosystemic shunt (TIPS) placement because of refractory ascites and impending liver failure. After TIPS placement, there was marked symptomatic relief and improvement in liver function, but the courses of both patients were complicated by the development of an inferior vena cava (IVC) syndrome caused by segmental stenosis of the suprahepatic IVC just at the outflow jet of the TIPS at 11 and 9 months later. One patient underwent liver transplantation, and the other patient, caval angioplasty and stenting. Stenosis of the IVC represents an unrecognized complication of TIPS in patients with BC syndrome. (Liver Transpl 2001;7: 649-651.)
The American Journal of Gastroenterology, 2008
We aimed to develop a model based on noninvasive variables for the prediction of clinically signi... more We aimed to develop a model based on noninvasive variables for the prediction of clinically significant portal hypertension (CSPH) and of esophageal varices (EV) in patients with compensated liver disease. Sixty patients with compensated liver cirrhosis diagnosed by histology were included in the training set. All patients had physical examination, laboratory tests, abdominal color-Doppler ultrasound, upper digestive tract endoscopy, and measurement of hepatic venous pressure gradient. Predictive models for the presence of CSPH and of EV were calculated. The models were validated in an independent series of 74 patients with compensated liver disease. Clinical and laboratory variables were selected in the final models, while ultrasonography did not add statistical power for the prediction of CSPH and EV. The model for prediction of CSPH included albumin, INR, and ALT. The best cutoff had 93% sensitivity and 61% specificity in the training set, and correctly classified 77% of patients in the validation set. Spider angiomas, ALT, and albumin predicted EV. The best cutoff of the model in the training set had a sensitivity of 93% and a specificity of 37% and correctly classified 72% of cases in the validation set. Noninvasive prediction of EV in well-compensated cirrhotic patients is not accurate. However, a model obtained by combining simple laboratory variables has a high sensitivity to predict CSPH in this population and may be useful to select the subset of patients requiring screening endoscopy. By this method, endoscopic screening could be obviated in about 40% of patients.
The American Journal of Gastroenterology, 2005
Color Doppler ultrasonography (CDUS) has been proposed as an alternative to portal pressure gradi... more Color Doppler ultrasonography (CDUS) has been proposed as an alternative to portal pressure gradient (PPG) measurement to detect transjugular intrahepatic portosystemic shunt (TIPS) dysfunction but with inconsistent results. This study aimed at developing and validating CDUS criteria to assess TIPS dysfunction. A total of 117 consecutive follow-up simultaneous CDUS and hemodynamic evaluations in 34 patients with TIPS were analyzed. TIPS dysfunction was defined as a PPG &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;12 mmHg. A predictive model was obtained with logistic regression and was validated in an independent, prospective sample of 119 consecutive paired CDUS/hemodynamic evaluations in 55 patients. TIPS dysfunction was present in 57 of the 117 studies in the retrospective series. At multivariate analysis, mean maximum flow velocity at the portal vein (mVPmax) and direction of flow in the intrahepatic portal vein branches (FD) were the only independent predictors of TIPS dysfunction. The prediction rule for TIPS dysfunction derived from the model (mVPmax &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;28 cm/s when flow is hepatofugal or mVPmax &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;39 cm/s when flow is hepatopetal) had 90% sensitivity, 45% specificity, and negative likelihood ratio of 0.23. This prediction rule was validated both in patients with bare stents and in patients with polytetra fluoroethylene (PTFE)-covered stents, showing an overall 87% sensitivity, 57% specificity, and 0.23 negative likelihood ratio. The combination of two CDUS parameters correlate with TIPS dysfunction with high sensitivity and low specificity but with a good negative likelihood ratio. TIPS catheterization can be safely avoided in half of the patients using this predictive rule.
The American Journal of Gastroenterology, 2006
A reduction in hepatic venous pressure gradient (HVPG) of &amp;amp;amp;amp;amp;amp;amp;am... more A reduction in hepatic venous pressure gradient (HVPG) of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or =20% of baseline or to &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; or =12 mmHg (responders) is associated with a reduced risk of first variceal bleeding. The aim of this study was to evaluate whether this protective effect is maintained in the long term and if it extends to other portal hypertension complications. Seventy-one cirrhotic patients with esophageal varices and without previous variceal bleeding who entered into a program of prophylactic pharmacological therapy and were followed for up to 8 yr were evaluated. All had two separate HVPG measurements, at baseline and after pharmacological therapy with propranolol +/- isosorbide mononitrate. Forty-six patients were nonresponders and 25 were responders. Eight-year cumulative probability of being free of first variceal bleeding was higher in responders than in nonresponders (90% vs 45%, p= 0.026). The lack of hemodynamic response and low platelet count were the only independent predictors of first variceal bleeding. Additionally, reduction of HVPG was independently associated with a decreased risk of spontaneous bacterial peritonitis (SBP) or bacteremia. No significant differences in the development of ascites, hepatic encephalopathy, or survival were observed. The hemodynamic response in cirrhotic patients is associated with a sustained reduction in the risk of first variceal bleeding over a long-term follow-up. Reduction of HVPG also correlate with a reduced risk of SBP or bacteremia.
Journal of Hepatology, 2014
Real-time shear wave elastography (RT-SWE) might be useful to assess the severity of portal hyper... more Real-time shear wave elastography (RT-SWE) might be useful to assess the severity of portal hypertension; reliability criteria for measurement are needed. We prospectively included 88 consecutive patients undergoing hepatic venous pressure gradient measurement (HVPG, reference standard) for portal hypertension. Liver stiffness (LS) was measured by RT-SWE and by transient elastography (TE). Spleen stiffness (SS) was measured by RT-SWE. Reliability criteria for RT-SWE were searched, and the accuracy of these techniques to identify HVPG ⩾10mmHg (clinically significant portal hypertension, CSPH) was tested and internally validated by bootstrapping analysis. LS and SS by RT-SWE were feasible respectively in 87 (99%) and 58 (66%) patients. Both correlated with HVPG (LS: R=0.611, p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001 and SS: R=0.514, p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001). LS performed well for diagnosing CSPH (optimism corrected AUROC=0.858). Reliability of measurements was influenced by standard deviation (SD)/median ratio and depth. SD/median ⩽0.10 and depth of measurement &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;5.6cm were associated to 96.3% well classified for CSPH, while when one or none of the criteria were fulfilled the rates were 76.4% and 44.4%, respectively. Measurements fulfilling at least one criterion were considered acceptable; in these patients, RT-SWE performance to detect CSPH was excellent (AUROC=0.939; 95% CI: 0.865-1.000; p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001; best cut-off: 15.4kPa). LS by RT-SWE and by TE were strongly correlated (R=0.795, p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001) and performed similarly both in &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;per protocol&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; and in &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;intention-to-diagnose&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; analysis after applying reliability criteria. LS by RT-SWE is an accurate method to diagnose CSPH if reliability criteria (SD/median ⩽0.10 and/or depth &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;5.6cm) are fulfilled.
The American Journal of Gastroenterology, 2005
BACKGROUND: In patients with idiopathic myelofibrosis (IM), portal hypertension (PHT) without thr... more BACKGROUND: In patients with idiopathic myelofibrosis (IM), portal hypertension (PHT) without thrombosis of the hepatic or splenoportal veins is infrequent.
The American Journal of Gastroenterology, 2011
Mexicans have an increased rate of alcohol abuse and alcoholic liver disease. Factors infl uencin... more Mexicans have an increased rate of alcohol abuse and alcoholic liver disease. Factors infl uencing the severity of alcoholic hepatitis (AH) in Mexicans are unknown. The aims of the present study were to identify the prognostic factors of short-term mortality in Mexican patients with AH and to validate the existing prognostic models.
Gastroenterología y Hepatología, 2012
Disponible en Internet el 26 de mayo de 2012 * Autor para correspondencia.
Liver International - LIVER INT, 2008
Transplant International, 2010
Seminars in Liver Disease, 2006
Portal hypertension is a major cause of morbidity and mortality in liver cirrhosis. This article ... more Portal hypertension is a major cause of morbidity and mortality in liver cirrhosis. This article provides a background on the most important aspects of the evaluation of portal hypertension in patients with chronic liver diseases, with special attention to the measurement of portal pressure by hepatic vein catheterization. The rationale, technique, applications, costs, and limitations of measurements of the hepatic venous pressure gradient are thoroughly reviewed. Emerging, noninvasive methodologies for the evaluation of the patient with portal hypertension are also discussed.
Liver Transplantation, 2010
Portopulmonary hypertension (PoPH) is a serious condition without an established treatment. Drugs... more Portopulmonary hypertension (PoPH) is a serious condition without an established treatment. Drugs used to treat pulmonary hypertension may have detrimental effects on portal hypertension. This study was designed to assess in patients with PoPH the acute effects of inhaled iloprost (iILO) on pulmonary and hepatic hemodynamics and to evaluate the clinical outcome after 12 months of treatment. We conducted 2 separate studies. In the first one, 21 patients with PoPH were acutely tested with 2.8 lg of iILO. Pulmonary and hepatic hemodynamics were assessed at the baseline and through 60 minutes after iILO. In the second one, we retrospectively evaluated 12 patients treated with iILO (30 lg/day) for more than 1 year. The 6-minute walk distance (6MWD), functional class (FC), and echocardiogram were analyzed at the baseline and after 12 months of treatment. In the acute study, iILO rapidly reduced pulmonary artery pressure (PAP; À16% 6 8%, P < 0.001) and pulmonary vascular resistance (À18% 6 14%, P < 0.001). The cardiac output did not change initially but decreased after 30 minutes. The hepatic venous pressure gradient (HVPG) and hepatic blood flow did not vary through the study. Pulmonary vasodilation induced by iILO was inversely related to HVPG. In the long-term evaluation, iILO improved FC by 1 or more in 7 patients (P ¼ 0.04) and increased 6MWD by 67 6 59 m at 12 months (P < 0.001). No change in systolic PAP was observed. Two patients died because of hepatic complications, and 4 additional patients presented clinically significant events that were related to hepatic disease in 2 and worsening of pulmonary hypertension in 2. We conclude that in patients with PoPH, iILO produces rapid and selective pulmonary vasodilation without altering the hepatic hemodynamics. Its long-term use may provide sustained improvements in symptoms and exercise tolerance in some patients with PoPH. A randomized, controlled trial is warranted to establish its clinical role in this serious condition. Liver Transpl 16:348-356, Portopulmonary hypertension (PoPH), the association of pulmonary arterial hypertension (PAH) and portal hypertension, accounts for 10% of cases with PAH 1 and is present in 3.5% to 5% of patients with endstage liver cirrhosis. 2,3 Patients with PoPH have a high mortality rate, 4,5 especially if they are left Abbreviations: 6MWD, 6-minute walk distance; CI, cardiac index; CVP, central venous pressure; DLCO, diffusion capacity of the lung for carbon monoxide; FC, functional class; FEV 1 , forced expiratory volume in the first second; HBF, hepatic blood flow; HBV, hepatitis B virus; HCV, hepatitis C virus; HVPG, hepatic venous pressure gradient; iILO, inhaled iloprost; MELD, Model for End-Stage Liver Disease; OLT, orthotopic liver transplantation; PAH, pulmonary arterial hypertension; PAOP, pulmonary artery occlusion pressure; PAP, pulmonary artery pressure; PoPH, portopulmonary hypertension; PVR, pulmonary vascular resistance; SVR, systemic vascular resistance; TIPS, transjugular intrahepatic portosystemic shunt.
The present article aims to provide answers to questions frequently asked by physicians attending... more The present article aims to provide answers to questions frequently asked by physicians attending patients with Wilson&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease (WD) or those with a suspected diagnosis of WD. The article is divided into 2 parts: a first part with answers to questions relating to the diagnosis of this entity and a second with answers to questions concerning treatment. A brief appendix is included with responses to questions not falling into either of these 2 categories.
Hepatology (Baltimore, Md.), Jan 4, 2015
Non-selective beta-blockers (NSBB) are widely used since they have been proved effective in the p... more Non-selective beta-blockers (NSBB) are widely used since they have been proved effective in the prophylaxis of acute variceal bleeding (AVB). However, still a significant proportion of patients experience AVB whilst on treatment with NSBB and their impact on prognosis of AVB is unknown. The present study aimed at assessing the effect of being on prophylactic therapy with NSBB on 5-day failure and 6-week mortality of cirrhotic patients admitted with AVB. 142 patients were included: 49 patients were receiving prophylactic therapy with NSBB (NSBB group) and 93 patients were not (control group). There were some differences in the baseline characteristics between the groups: higher proportion of alcoholic etiology and active alcoholism (37% vs. 10%), higher platelets count and lower hematocrit at admission in the control group. However, the severity of AVB and initial treatment were similar. 5-day failure occurred in 20% of patients (14% in NSBB vs. 24% in controls; p = 0.27). The adjust...
Clinical Gastroenterology and Hepatology, 2015
Hepatic venous pressure gradient (HVPG) is associated with risk of liver events in patients with ... more Hepatic venous pressure gradient (HVPG) is associated with risk of liver events in patients with chronic hepatitis C. Antiviral therapies that lead to a sustained virologic response (SVR) reduce portal pressure and prevent liver disease progression. However, it is not clear to what extent the progression of hepatitis C is modified once patients develop cirrhosis with severe portal hypertension (CSPH, HVPG≥10 mmHg). We assessed the effects of HVPG and SVR on the risk of liver decompensation, hepatocellular carcinoma, and/or death in patients with hepatitis C-related cirrhosis. We collected data from 100 patients with hepatitis C and compensated cirrhosis who underwent HVPG measurement ≤3 months before (baseline) and 24 weeks after therapy with pegylated interferon alfa-2a and ribavirin at 4 hospitals in Spain, from 2001 through 2009. SVR was defined as undetectable serum HCV RNA 24 weeks after treatment ended. Clinical data were collected until death, liver transplantation, or December 2012 (median 5 y; interquartile range, 1.4-7 y). Seventy-four patients had CSPH at baseline and 35% of patients achieved an SVR. During the follow-up period, 19 patients developed liver decompensation (ascites, variceal bleeding, or encephalopathy). The actuarial probability values for liver decompensation at 1, 5, and 7 years were 3%, 19% and 22%, respectively. Baseline level of HVPG, but not SVR, was independently associated to the risk of liver decompensation. Patients with CSPH, regardless of an SVR to therapy for hepatitis C, remain at risk for liver decompensation within the 5 y after treatment; they should be closely monitored.
World journal of gastroenterology : WJG, Jan 7, 2006
Animal models have allowed detailed study of hemodynamic alterations typical of portal hypertensi... more Animal models have allowed detailed study of hemodynamic alterations typical of portal hypertension and the molecular mechanisms involved in abnormalities in splanchnic and systemic circulation associated with this syndrome. Models of prehepatic portal hypertension can be used to study alterations in the splanchnic circulation and the pathophysiology of the hyperdynamic circulation. Models of cirrhosis allow study of the alterations in intrahepatic microcirculation that lead to increased resistance to portal flow. This review summarizes the currently available literature on animal models of portal hypertension and analyzes their relative utility. The criteria for choosing a particular model, depending on the specific objectives of the study, are also discussed.
Hepatology (Baltimore, Md.), Jan 11, 2015
Alcoholic hepatitis (AH) frequently progresses to multiple organ failure (MOF) and death. However... more Alcoholic hepatitis (AH) frequently progresses to multiple organ failure (MOF) and death. However, the driving factors are largely unknown. At admission, patients with AH often show criteria of systemic inflammatory response syndrome (SIRS) even in the absence of an infection. We hypothesize that the presence of SIRS may predispose to MOF and death. To test this hypothesis, we studied a cohort including 162 patients with biopsy-proven AH. The presence of SIRS and infections was assessed in all patients and multivariate analyses identified variables independently associated with MOF and 90-day mortality. At admission, 32 (19.8%) patients were diagnosed with a bacterial infection, while 75 (46.3%) fulfilled SIRS criteria. 58 patients (35.8%) developed MOF during hospitalization. Short-term mortality was significantly higher among patients who developed MOF (62.1% vs. 3.8%, p<.001). The presence of SIRS was a major predictor of MOF (odds ratio 2.69, p=.025) and strongly correlated w...
Gut, 2014
In the liver, the transcription factor, Kruppel-like factor 2 (KLF2), is induced early during pro... more In the liver, the transcription factor, Kruppel-like factor 2 (KLF2), is induced early during progression of cirrhosis to lessen the development of vascular dysfunction; nevertheless, its endogenous expression results insufficient to attenuate establishment of portal hypertension and aggravation of cirrhosis. Herein, we aimed to explore the effects and the underlying mechanisms of hepatic KLF2 overexpression in in vitro and in vivo models of liver cirrhosis. Activation phenotype was evaluated in human and rat cirrhotic hepatic stellate cells (HSC) treated with the pharmacological inductor of KLF2 simvastatin, with adenovirus codifying for this transcription factor (Ad-KLF2), or vehicle, in presence/absence of inhibitors of KLF2. Possible paracrine interactions between parenchymal and non-parenchymal cells overexpressing KLF2 were studied. Effects of in vivo hepatic KLF2 overexpression on liver fibrosis and systemic and hepatic haemodynamics were assessed in cirrhotic rats. KLF2 upregulation profoundly ameliorated HSC phenotype (reduced α-smooth muscle actin, procollagen I and oxidative stress) partly via the activation of the nuclear factor (NF)-E2-related factor 2 (Nrf2). Coculture experiments showed that improvement in HSC phenotype paracrinally ameliorated liver sinusoidal endothelial cells probably through a vascular endothelial growth factor-mediated mechanism. No paracrine interactions between hepatocytes and HSC were observed. Cirrhotic rats treated with simvastatin or Ad-KLF2 showed hepatic upregulation in the KLF2-Nrf2 pathway, deactivation of HSC and prominent reduction in liver fibrosis. Hepatic KLF2 overexpression was associated with lower portal pressure (-15%) due to both attenuations in the increased portal blood flow and hepatic vascular resistance, together with a significant improvement in hepatic endothelial dysfunction. Exogenous hepatic KLF2 upregulation improves liver fibrosis, endothelial dysfunction and portal hypertension in cirrhosis.
American Journal of Gastroenterology, 1999
Asymptomatic persistent hypertransaminasemia unrelated to hepatitis viral infection is a common c... more Asymptomatic persistent hypertransaminasemia unrelated to hepatitis viral infection is a common cause of referral to the hepatologist. Less frequent liver diseases should then be considered, as well as extrahepatic-origin hypertransaminasemia. Celiac disease, although it has repeatedly been reported as a cause of persistent hypertransaminasemia, is often not included in its differential diagnosis in the absence of the classic malabsorption syndrome. We present the cases of four patients sent to a liver unit for evaluation of persistent hypertransaminasemia in whom celiac disease was finally discovered. Our report highlights the importance of including celiac disease in list of conditions potentially responsible for chronic hypertransaminasemia of unknown cause. (Am J Gastroenterol 1999;94:1095-1097
Portal hypertension is a severe, almost unavoidable complication of chronic liver diseases and is... more Portal hypertension is a severe, almost unavoidable complication of chronic liver diseases and is responsible for the main clinical consequences of cirrhosis. Measurement of the hepatic venous pressure gradient (HVPG) is currently the best available method to evaluate the presence and severity of portal hypertension. Clinically significant portal hypertension is defined as an increase in HVPG to &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;or=10 mmHg; above this threshold, the complications of portal hypertension might begin to appear. Measurement of HVPG is increasingly used in clinical hepatology, and numerous studies have demonstrated that the parameter is a robust surrogate marker for hard clinical end points. The main clinical applications for HVPG include diagnosis, risk stratification, identification of patients with hepatocellular carcinoma who are candidates for liver resection, monitoring of the efficacy of medical treatment, and assessment of progression of portal hypertension. Patients who experience a reduction in HVPG of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;or=20% or to &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;12 mmHg in response to drug therapy are defined as &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;responders&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;. Responders have a markedly decreased risk of bleeding (or rebleeding), ascites, and spontaneous bacterial peritonitis, which results in improved survival.
Liver Transplantation, 2001
We report 2 patients with Budd-Chiari (BC) syndrome secondary to thrombogenic conditions who unde... more We report 2 patients with Budd-Chiari (BC) syndrome secondary to thrombogenic conditions who underwent transjugular intrahepatic portosystemic shunt (TIPS) placement because of refractory ascites and impending liver failure. After TIPS placement, there was marked symptomatic relief and improvement in liver function, but the courses of both patients were complicated by the development of an inferior vena cava (IVC) syndrome caused by segmental stenosis of the suprahepatic IVC just at the outflow jet of the TIPS at 11 and 9 months later. One patient underwent liver transplantation, and the other patient, caval angioplasty and stenting. Stenosis of the IVC represents an unrecognized complication of TIPS in patients with BC syndrome. (Liver Transpl 2001;7: 649-651.)
The American Journal of Gastroenterology, 2008
We aimed to develop a model based on noninvasive variables for the prediction of clinically signi... more We aimed to develop a model based on noninvasive variables for the prediction of clinically significant portal hypertension (CSPH) and of esophageal varices (EV) in patients with compensated liver disease. Sixty patients with compensated liver cirrhosis diagnosed by histology were included in the training set. All patients had physical examination, laboratory tests, abdominal color-Doppler ultrasound, upper digestive tract endoscopy, and measurement of hepatic venous pressure gradient. Predictive models for the presence of CSPH and of EV were calculated. The models were validated in an independent series of 74 patients with compensated liver disease. Clinical and laboratory variables were selected in the final models, while ultrasonography did not add statistical power for the prediction of CSPH and EV. The model for prediction of CSPH included albumin, INR, and ALT. The best cutoff had 93% sensitivity and 61% specificity in the training set, and correctly classified 77% of patients in the validation set. Spider angiomas, ALT, and albumin predicted EV. The best cutoff of the model in the training set had a sensitivity of 93% and a specificity of 37% and correctly classified 72% of cases in the validation set. Noninvasive prediction of EV in well-compensated cirrhotic patients is not accurate. However, a model obtained by combining simple laboratory variables has a high sensitivity to predict CSPH in this population and may be useful to select the subset of patients requiring screening endoscopy. By this method, endoscopic screening could be obviated in about 40% of patients.
The American Journal of Gastroenterology, 2005
Color Doppler ultrasonography (CDUS) has been proposed as an alternative to portal pressure gradi... more Color Doppler ultrasonography (CDUS) has been proposed as an alternative to portal pressure gradient (PPG) measurement to detect transjugular intrahepatic portosystemic shunt (TIPS) dysfunction but with inconsistent results. This study aimed at developing and validating CDUS criteria to assess TIPS dysfunction. A total of 117 consecutive follow-up simultaneous CDUS and hemodynamic evaluations in 34 patients with TIPS were analyzed. TIPS dysfunction was defined as a PPG &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;12 mmHg. A predictive model was obtained with logistic regression and was validated in an independent, prospective sample of 119 consecutive paired CDUS/hemodynamic evaluations in 55 patients. TIPS dysfunction was present in 57 of the 117 studies in the retrospective series. At multivariate analysis, mean maximum flow velocity at the portal vein (mVPmax) and direction of flow in the intrahepatic portal vein branches (FD) were the only independent predictors of TIPS dysfunction. The prediction rule for TIPS dysfunction derived from the model (mVPmax &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;28 cm/s when flow is hepatofugal or mVPmax &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;39 cm/s when flow is hepatopetal) had 90% sensitivity, 45% specificity, and negative likelihood ratio of 0.23. This prediction rule was validated both in patients with bare stents and in patients with polytetra fluoroethylene (PTFE)-covered stents, showing an overall 87% sensitivity, 57% specificity, and 0.23 negative likelihood ratio. The combination of two CDUS parameters correlate with TIPS dysfunction with high sensitivity and low specificity but with a good negative likelihood ratio. TIPS catheterization can be safely avoided in half of the patients using this predictive rule.
The American Journal of Gastroenterology, 2006
A reduction in hepatic venous pressure gradient (HVPG) of &amp;amp;amp;amp;amp;amp;amp;am... more A reduction in hepatic venous pressure gradient (HVPG) of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or =20% of baseline or to &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; or =12 mmHg (responders) is associated with a reduced risk of first variceal bleeding. The aim of this study was to evaluate whether this protective effect is maintained in the long term and if it extends to other portal hypertension complications. Seventy-one cirrhotic patients with esophageal varices and without previous variceal bleeding who entered into a program of prophylactic pharmacological therapy and were followed for up to 8 yr were evaluated. All had two separate HVPG measurements, at baseline and after pharmacological therapy with propranolol +/- isosorbide mononitrate. Forty-six patients were nonresponders and 25 were responders. Eight-year cumulative probability of being free of first variceal bleeding was higher in responders than in nonresponders (90% vs 45%, p= 0.026). The lack of hemodynamic response and low platelet count were the only independent predictors of first variceal bleeding. Additionally, reduction of HVPG was independently associated with a decreased risk of spontaneous bacterial peritonitis (SBP) or bacteremia. No significant differences in the development of ascites, hepatic encephalopathy, or survival were observed. The hemodynamic response in cirrhotic patients is associated with a sustained reduction in the risk of first variceal bleeding over a long-term follow-up. Reduction of HVPG also correlate with a reduced risk of SBP or bacteremia.
Journal of Hepatology, 2014
Real-time shear wave elastography (RT-SWE) might be useful to assess the severity of portal hyper... more Real-time shear wave elastography (RT-SWE) might be useful to assess the severity of portal hypertension; reliability criteria for measurement are needed. We prospectively included 88 consecutive patients undergoing hepatic venous pressure gradient measurement (HVPG, reference standard) for portal hypertension. Liver stiffness (LS) was measured by RT-SWE and by transient elastography (TE). Spleen stiffness (SS) was measured by RT-SWE. Reliability criteria for RT-SWE were searched, and the accuracy of these techniques to identify HVPG ⩾10mmHg (clinically significant portal hypertension, CSPH) was tested and internally validated by bootstrapping analysis. LS and SS by RT-SWE were feasible respectively in 87 (99%) and 58 (66%) patients. Both correlated with HVPG (LS: R=0.611, p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001 and SS: R=0.514, p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001). LS performed well for diagnosing CSPH (optimism corrected AUROC=0.858). Reliability of measurements was influenced by standard deviation (SD)/median ratio and depth. SD/median ⩽0.10 and depth of measurement &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;5.6cm were associated to 96.3% well classified for CSPH, while when one or none of the criteria were fulfilled the rates were 76.4% and 44.4%, respectively. Measurements fulfilling at least one criterion were considered acceptable; in these patients, RT-SWE performance to detect CSPH was excellent (AUROC=0.939; 95% CI: 0.865-1.000; p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001; best cut-off: 15.4kPa). LS by RT-SWE and by TE were strongly correlated (R=0.795, p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001) and performed similarly both in &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;per protocol&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; and in &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;intention-to-diagnose&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; analysis after applying reliability criteria. LS by RT-SWE is an accurate method to diagnose CSPH if reliability criteria (SD/median ⩽0.10 and/or depth &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;5.6cm) are fulfilled.
The American Journal of Gastroenterology, 2005
BACKGROUND: In patients with idiopathic myelofibrosis (IM), portal hypertension (PHT) without thr... more BACKGROUND: In patients with idiopathic myelofibrosis (IM), portal hypertension (PHT) without thrombosis of the hepatic or splenoportal veins is infrequent.
The American Journal of Gastroenterology, 2011
Mexicans have an increased rate of alcohol abuse and alcoholic liver disease. Factors infl uencin... more Mexicans have an increased rate of alcohol abuse and alcoholic liver disease. Factors infl uencing the severity of alcoholic hepatitis (AH) in Mexicans are unknown. The aims of the present study were to identify the prognostic factors of short-term mortality in Mexican patients with AH and to validate the existing prognostic models.
Gastroenterología y Hepatología, 2012
Disponible en Internet el 26 de mayo de 2012 * Autor para correspondencia.
Liver International - LIVER INT, 2008
Transplant International, 2010
Seminars in Liver Disease, 2006
Portal hypertension is a major cause of morbidity and mortality in liver cirrhosis. This article ... more Portal hypertension is a major cause of morbidity and mortality in liver cirrhosis. This article provides a background on the most important aspects of the evaluation of portal hypertension in patients with chronic liver diseases, with special attention to the measurement of portal pressure by hepatic vein catheterization. The rationale, technique, applications, costs, and limitations of measurements of the hepatic venous pressure gradient are thoroughly reviewed. Emerging, noninvasive methodologies for the evaluation of the patient with portal hypertension are also discussed.
Liver Transplantation, 2010
Portopulmonary hypertension (PoPH) is a serious condition without an established treatment. Drugs... more Portopulmonary hypertension (PoPH) is a serious condition without an established treatment. Drugs used to treat pulmonary hypertension may have detrimental effects on portal hypertension. This study was designed to assess in patients with PoPH the acute effects of inhaled iloprost (iILO) on pulmonary and hepatic hemodynamics and to evaluate the clinical outcome after 12 months of treatment. We conducted 2 separate studies. In the first one, 21 patients with PoPH were acutely tested with 2.8 lg of iILO. Pulmonary and hepatic hemodynamics were assessed at the baseline and through 60 minutes after iILO. In the second one, we retrospectively evaluated 12 patients treated with iILO (30 lg/day) for more than 1 year. The 6-minute walk distance (6MWD), functional class (FC), and echocardiogram were analyzed at the baseline and after 12 months of treatment. In the acute study, iILO rapidly reduced pulmonary artery pressure (PAP; À16% 6 8%, P < 0.001) and pulmonary vascular resistance (À18% 6 14%, P < 0.001). The cardiac output did not change initially but decreased after 30 minutes. The hepatic venous pressure gradient (HVPG) and hepatic blood flow did not vary through the study. Pulmonary vasodilation induced by iILO was inversely related to HVPG. In the long-term evaluation, iILO improved FC by 1 or more in 7 patients (P ¼ 0.04) and increased 6MWD by 67 6 59 m at 12 months (P < 0.001). No change in systolic PAP was observed. Two patients died because of hepatic complications, and 4 additional patients presented clinically significant events that were related to hepatic disease in 2 and worsening of pulmonary hypertension in 2. We conclude that in patients with PoPH, iILO produces rapid and selective pulmonary vasodilation without altering the hepatic hemodynamics. Its long-term use may provide sustained improvements in symptoms and exercise tolerance in some patients with PoPH. A randomized, controlled trial is warranted to establish its clinical role in this serious condition. Liver Transpl 16:348-356, Portopulmonary hypertension (PoPH), the association of pulmonary arterial hypertension (PAH) and portal hypertension, accounts for 10% of cases with PAH 1 and is present in 3.5% to 5% of patients with endstage liver cirrhosis. 2,3 Patients with PoPH have a high mortality rate, 4,5 especially if they are left Abbreviations: 6MWD, 6-minute walk distance; CI, cardiac index; CVP, central venous pressure; DLCO, diffusion capacity of the lung for carbon monoxide; FC, functional class; FEV 1 , forced expiratory volume in the first second; HBF, hepatic blood flow; HBV, hepatitis B virus; HCV, hepatitis C virus; HVPG, hepatic venous pressure gradient; iILO, inhaled iloprost; MELD, Model for End-Stage Liver Disease; OLT, orthotopic liver transplantation; PAH, pulmonary arterial hypertension; PAOP, pulmonary artery occlusion pressure; PAP, pulmonary artery pressure; PoPH, portopulmonary hypertension; PVR, pulmonary vascular resistance; SVR, systemic vascular resistance; TIPS, transjugular intrahepatic portosystemic shunt.