Portopulmonary hypertension and hepatopulmonary syndrome: a clinician-oriented overview.

Liver disease and portal hypertension can be associated with pulmonary vascular complications, including portopulmonary hypertension (POPH), characterised by an elevated mean pulmonary artery pressure secondary to an increased pulmonary vascular resistance, and hepatopulmonary syndrome (HPS), characterised by hypoxaemia due to pulmonary vasodilatation and shunting. Although clear diagnostic guidelines exist for both conditions on the basis of echocardiography, right heart catheterisation and arterial blood gases, there is considerable variation between centres regarding diagnosis and management of these conditions. Awareness of evaluation and management algorithms for POPH and HPS are critical for optimisation of outcomes in patients with these conditions. Key aspects of management of POPH and HPS include identification of patients likely to benefit from liver transplantation (LTx) and management before and after LTx. Although both disorders may improve after LTx, severe forms of POPH represent a contraindication to LTx. Novel approaches to the treatment of POPH and HPS offer new management options that may expand the pool of transplantable patients and improve overall outcomes.

Predicting early mortality after acute variceal hemorrhage based on classification and regression tree analysis.

BACKGROUND & AIMS: Available prognostic models for mortality after an acute variceal hemorrhage have limitations that restrict their clinical value. We assessed the performance of a novel prognostic approach based on classification and regression tree (CART) analysis. METHODS: Logistic regression (LR) and CART analyses were performed to identify prognostic models for mortality at 6 weeks in a single-center cohort of 267 consecutive patients with acute variceal bleeding. Receiver operating characteristic (ROC) curves were constructed to assess the performance of the models. Prognostic models were fitted and validated by split-sample technique (training set, 164 patients, 2001-2005; test set, 103 patients, 2006-2008). RESULTS: After 6 weeks, 21% of patients experienced rebleeding and 24% died. The best LR model was based on Child-Pugh score, creatinine level, bacterial infection, and hepatocellular carcinoma. CART analysis provided a simple algorithm based on the combined use of just 3 variables (Child-Pugh score, creatinine level, and bacterial infection), allowing accurate early discrimination of 3 distinct prognostic subgroups with 8% (low risk), 17% (intermediate), and 50% to 73% (high) mortality. Its accuracy was similar to the LR model (area under the ROC curves, 0.81 vs 0.84; P = .17) and better than that of Child-Pugh (0.75; P = .05) and model for end-stage liver disease (0.74; P = .05). The prognostic accuracy of both LR and CART models was validated in the test set (area under the ROC curve values, 0.81 and 0.83, respectively). CONCLUSIONS: A simple CART algorithm based on Child-Pugh score, creatinine level, and infection allowed an accurate predictive assessment of 6-week mortality after acute variceal bleeding.