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Intrapulmonary shunt in the course of pediatric liver transplantation
1Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
Insights
Intrapulmonary shunt (IPS) affects 16.8% of pediatric liver transplant recipients, causing hypoxemia and increased mortality. However, IPS is often reversible within six months post-transplant, highlighting the need for early CEE assessment.
Area of Science:
- Pediatric Gastroenterology and Hepatology
- Cardiology
- Pulmonology
Background:
- Hepatopulmonary syndrome (HPS) is linked to intrapulmonary shunts (IPS) causing hypoxemia in cirrhosis patients.
- IPS is poorly defined in pediatric populations, necessitating investigation in children undergoing liver transplantation (OLT).
Purpose of the Study:
- To determine the prevalence, clinical characteristics, and outcomes of IPS in pediatric OLT recipients.
- To assess the impact of IPS on postoperative morbidity and mortality.
- To evaluate the reversibility of IPS after OLT.
Main Methods:
- A cohort of 107 pediatric OLT recipients were evaluated for IPS using contrast-enhanced echocardiography (CEE).
- IPS was graded based on microbubble extent in the left ventricle; significant IPS was defined as grade II or higher.
- Clinical data, including oxygenation, ventilation duration, hospital stay, and postoperative outcomes, were compared between patients with and without IPS.
Main Results:
- IPS was identified in 18 (16.8%) pediatric OLT recipients.
- Patients with IPS exhibited lower Pao2 and Sao2, prolonged mechanical ventilation and hospital stays, and increased postoperative morbidity and mortality.
- Significant IPS (grade II or higher) was associated with substantially greater morbidity and mortality compared to grade I IPS.
Conclusions:
- Intrapulmonary shunt is a common complication in pediatric OLT recipients and is associated with adverse outcomes.
- Severe IPS significantly increases patient morbidity and mortality, underscoring the importance of early CEE screening.
- Most IPS findings resolve within six months post-transplant, indicating reversibility.
Abstract:
The hepatopulmonary syndrome occurs when an intrapulmonary shunt (IPS) causes hypoxemia in patients with cirrhosis. Because IPS has not been clearly defined in children, we investigated the prevalence, clinical characteristics, and outcomes of IPS in children undergoing liver transplantation (OLT). Of the 107 pediatric OLT recipients between December 1994 and March 2005, 18 (16.8%) had IPS, as evaluated by contrast-enhanced echocardiography (CEE) at 9 months to 16 years of age. The degree of IPS was classified into five grades according to the extent of microbubbles in the left ventricle, with significant IPS defined as grade II or higher. Baseline characteristics, including serum total bilirubin, albumin, aminotransferase, and prothrombin time, did not differ in patients with or without IPS. The patients with IPS had significantly lower Pao2 and Sao2, longer duration of mechanical ventilation and hospital stay, and higher postoperative morbidity and mortality than patients without IPS (P < .05 each), but there were no other significant differences between the groups. The six patients with significant IPS (one grade II, three grade III, and two grade IV) showed a significantly greater morbidity and mortality than patients with grade I IPS (P < .05). Most of the positive CEE findings of IPS regressed within 6 months after OLT. These findings indicated that IPS is not uncommon among children undergoing OLT, but is reversible. Because severe IPS may increase patient morbidity and mortality, early assessment of IPS status using CEE is essential for pediatric OLT candidates.
