Liver transplantation for pulmonary vascular complications of pediatric end-stage liver disease

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• 作者：Corey W. Iqbal ; Michael J. Krowka ; Tuan H. Pham ; Deborah K. Freese ; Mounif El Youssef ; Michael B. Ishitani
• 关键词：Hepatopulmonary syndrome ; Portopulmonary hypertension ; End-stage liver disease ; Liver transplant ; Portal hypertension
• 刊名：Journal of Pediatric Surgery
• 出版年：2008
• 出版时间：October 2008
• 年：2008
• 卷：43
• 期：10
• 页码：1813-1820
• 全文大小：116 K

文摘

Purpose

Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PPH) are poorly understood pulmonary complications of end-stage liver disease (ESLD). We present a case series of children with HPS and PPH.

Methods

After institutional review board approval, query of our medical database identified children 0 to 18 years of age with ESLD diagnosed with HPS or PPH. Data were collected via chart review.

Results

We identified 7 children with either HPS (n = 5) or PPH (n = 2). Patients with HPS presented with progressive dyspnea over a mean of 7 months (range, 4-12 months) at a mean of 13 years (range, 5-17 years) of age. Pulmonary shunting by albumin perfusion scan averaged 41 % (range, 20 % -66 % ) with an initial mean resting Spo₂ of 88 % (range, 84 % -94 % ) and mean Spo₂ during exertion of 79 % (range, 60 % -89 % ). Four patients required supplemental O₂ and, upon United Network for Organ Sharing (UNOS) appeal, received pediatric model for ESLD (or Child-Pugh) score exceptions, enabling them to undergo orthotopic liver transplant (OLT) within 1-2 months. The fifth patient was initially rejected by the UNOS regional review board, but 6 months of worsening hypoxemia led to OLT 2 months after successful UNOS appeal. All patients with HPS undergoing OLT experienced complete resolution of hypoxemia within 8 months. Both children with PPH were treated with intravenous epoprostenol, which lowered or stabilized mean pulmonary artery pressure and bridged them to OLT within 7 months of listing. Overall, there were no pulmonary complications; however, 1 patient with PPH expired shortly after OLT. The remaining patients are alive at a median follow-up of 27 months (range, 6-96 months).

Conclusion

Hepatopulmonary syndrome and PPH are uncommon complications of ESLD in children. Epoprostenol can bridge PPH patients to OLT. OLT leads to rapid resolution of HPS and PPH and currently represents the only successful treatment for these children.