Scientific and Technological Research
Predictors of mortality and early detection strategies for hepatopulmonary syndrome in liver transplant patients
Factores predictores de mortalidad y estrategias de detección precoz de sindrome hepatopulmonar en pacientes trasplantados hepáticos
Margarita Orozco-Delgadoa,
, Martha López-Canterob, Vanessa Zampellaa, Rosario Vicentec,d, Juan Galáne
Corresponding author
margaorozco@hotmail.com
Corresponding author at: Calle vicente raga 3, esc 2, 3-B 46023 Valencia, Spain.
Corresponding author at: Calle vicente raga 3, esc 2, 3-B 46023 Valencia, Spain.
a MD, Resident of Anesthesiology and Resuscitation, Hospital Universitari i politecnic La Fe, Valencia, Spain
b MD, Assistant Physician of Anesthesiology and Resuscitation, Hospital la Fe, Valencia, Spain
c Head of the Anesthesiology and Resuscitation Department, Hospital Universitari i politecnic La Fe, Valencia, Spain
d Coordinator of Resuscitation, Critical Care and Organ Transplants, Associate Professor, Universidad de Valencia, Valencia, Spain
e Sectorial Transplant Coordinator, Head of the Transplant Coordination Service, Hospital Universitari i politecnic La Fe, Valencia, Spain
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"Galán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "MD, Resident of Anesthesiology and Resuscitation, Hospital Universitari i politecnic La Fe, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "MD, Assistant Physician of Anesthesiology and Resuscitation, Hospital la Fe, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Head of the Anesthesiology and Resuscitation Department, Hospital Universitari i politecnic La Fe, Valencia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Coordinator of Resuscitation, Critical Care and Organ Transplants, Associate Professor, Universidad de Valencia, Valencia, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Sectorial Transplant Coordinator, Head of the Transplant Coordination Service, Hospital Universitari i politecnic La Fe, Valencia, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author at</span>: Calle vicente raga 3, esc 2, 3-B 46023 Valencia, Spain." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Factores predictores de mortalidad y estrategias de detección precoz de sindrome hepatopulmonar en pacientes trasplantados hepáticos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 888 "Ancho" => 1631 "Tamanyo" => 32371 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Survival curve. None of the qualitative variables studied was associated with death (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.05).</p> <p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Source: authors.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The first publication evidencing the association between liver and pulmonary disorders was in 1884 by Fluckieger; however, it was not until 1977 that Kennedy and Knudson coined the term hepatopulmonary syndrome (HPS).<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> It was initially thought that this was a reversible condition and hence LT was contraindicated. The observation that HPS could be resolved after LT and that this was the only effective treatment to revert the condition was only made early in the 90s.</p><p id="par0010" class="elsevierStylePara elsevierViewall">HPS is a low prevalence condition but with high morbidity and morality that may severely compromise the functional status of patients with advanced liver disease and/or portal hypertension.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> HPS results from impaired liver clearance of various vascular mediators leading to an imbalance between vasodilators and vasoconstrictors that causes abnormal intrapulmonary vasodilation and intrapulmonary shunt. The resulting disruption in arterial oxygenation not always improves with supplemental O<span class="elsevierStyleInf">2</span>, with a clinical presentation of platypnea (dyspnea induced by upright posture) and orthodeoxia (>5% desaturation or >4<span class="elsevierStyleHsp" style=""></span>mmHg PaO<span class="elsevierStyleInf">2</span> drop when moving from decubitus to an upright posture). These PaO<span class="elsevierStyleInf">2</span> alterations are mainly the result of a ventilation/perfusion imbalance, with pulmonary shunt in addition to an impaired oxygen diffusion capacity due to the increased capillary diameter and reduced transit time of the erythrocytes through the capillaries as a consequence of the elevated cardiac output characteristic of HPS.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The echocardiographic finding of an extracardiac and intrapulmonary shunt confirms the diagnosis.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> To differentiate whether the shunt is intra or extra cardiac the observation of whether the passage of microbubbles following an intravenous injection o cold stirred serum from both right and left cavities is early (<3 cardiac cycles), which will indicate intracardiac shunting, or late (>3 cardiac cycles) which will be diagnostic for intrapulmonary shunting. The diagnostic criteria for HPS are: “Partial oxygen pressure<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>80<span class="elsevierStyleHsp" style=""></span>mmHg or oxygen alveolar–arterial gradient<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>mmHg while breathing room air, positive findings in the contrast, portal hypertension (more common) with or without cirrhosis. With an alveolar–arterial oxygen gradient<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>mmHg the severity grade depends on the partial oxygen pressure, where mild severity is PO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>80<span class="elsevierStyleHsp" style=""></span>mmHg, moderate severity is PO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>60 to <<span class="elsevierStyleHsp" style=""></span>80<span class="elsevierStyleHsp" style=""></span>mmHg, severe is PO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>50 to <<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>mmHg and extremly severe is PO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>mmHg”.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Up until now, the only effective treatment is liver transplantation in properly selected cases and when the procedure is indicated at a particular time moment of the pulmonary disease.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patients and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">We have completed an observational descriptive trial with retrospective data collection from patients who received a LT between April 2006 and August 2014. From a total of 815 transplants performed during that period, there were 8 patients (1%) diagnosed with HPS, 7 of which were males (87.5%) and 1 (12.5%) was a female. The age range was 32–60 years at the time of the LT. All patients had been diagnosed with HPS through pulmonary scan or echocardiography. Additionally, the patients presented with altered oxygenation in the arterial gases. The trial was approved by the institutional ethics committee under code 2016/0125.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The clinical data collected included age, gender, MELD and Child–Pugh, etiology of the liver pathology, last gasometry immediately before transplantation, preoperative home oxygen requirements, postoperative mechanical ventilation (MV) time, length of stay in resuscitation and causes of death.</p><p id="par0035" class="elsevierStylePara elsevierViewall">For the qualitative variable distribution, the absolute frequencies of each category were used and Fisher's test was administered. The dependent variable was survival and the independent variables were: pre-LT home O<span class="elsevierStyleInf">2</span> requirements, signs of reperfusion syndrome during LT, post-extubation non-invasive mechanical ventilation (NIMV) requirements, and whether the patient has a long postoperative resuscitation unit stay with 48<span class="elsevierStyleHsp" style=""></span>h being the estimated normal length of stay.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The statistical analysis of quantitative variables used the mean and standard deviation of living and death patients (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>). Likewise, a multivariable study<span class="elsevierStyleHsp" style=""></span>–<span class="elsevierStyleHsp" style=""></span>stepwise forward logistic regression analysis<span class="elsevierStyleHsp" style=""></span>–<span class="elsevierStyleHsp" style=""></span>was performed to determine which variable could significantly predict the risk of death. The statistical significance value was set at 0.05.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">The baseline characteristics of the 8 patients transplanted with HPS during the trial period are presented in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a> and refer to the typology and the severity of the liver disease, as well as the data used to evaluate the pre and post-operative pulmonary status. The etiology of liver failure was defined as: enolic cirrhosis, hepatitis C virus (HCV), cryptogenic cirrhosis, and 1 case of HPS due to non-cirrhotic portal hypertension of presinusoidal prehepatic origin. The Child–Pugh status distribution of the sample was 1 patient in Stage A, 3 in stage B, and the other 4 in stage C.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">All of them had variable levels of altered oxygenation according to the arterial gases.</p><p id="par0055" class="elsevierStylePara elsevierViewall">According to our statistical analysis, the fatality outcome could only have been significantly predicted based on PaO<span class="elsevierStyleInf">2</span> (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.002). The other variables were not significant predictors of the risk of death: age (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.798), PCO<span class="elsevierStyleInf">2</span> (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.672), Child–Pugh (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.496), MELD (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.560), and MV time (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.284).</p><p id="par0060" class="elsevierStylePara elsevierViewall">The average pre-LT PaO<span class="elsevierStyleInf">2</span> of the patients that died was 51.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.49 SD, and the average of patients that survived was 70.54<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.86 SD, with a statistically significant difference (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.002).</p><p id="par0065" class="elsevierStylePara elsevierViewall">Of the total number of patients studied, 3 (37.5%) died during the postop, between days 3 and 33. The causes of death were: 2 patients died from sepsis and the third one due to multiple organ failure in the context of global respiratory failure. It should be highlighted that the most frequent cause of mortality is the same as in non HPS transplanted patients.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The patients that survived had a follow-up period ranging from 5 to 979 days until the trial was closed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Similarly, there was a attempt to establish possibility for the studied variables to predict reversibility of the HPS, considering total reversibility as improvement in hypoxemia (PaO<span class="elsevierStyleInf">2</span>) and partial reversibility as a reduction in the home O<span class="elsevierStyleInf">2</span> requirements. Keeping in mind the same test and the same variables, none of them was statistically significant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>0.05); of the 5 patients that were alive, 3 had total HPS reversal, 2 at hospital discharge and 1 6 months after the LT. 2 patients presented a partial HPS reversal with reduced home O<span class="elsevierStyleInf">2</span> requirements versus the pre-transplantation requirements.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">The LT due to HPS represent 1% of the liver transplants performed in our center during the period described, with an approximate post-LT survival of 62.5%, as compared to the series in other transplant centers that report a variable prevalence of 4–30%.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a> This reflects on the one hand a potential over-diagnosis of the institution in certain series, and on the other an underestimation in our own series. The reason is the difficulty to identify the condition until advanced stages of the disease when dyspnea is already present and the overall condition of the patients, particularly the respiratory status, could have excluded them from being candidates for transplantation. It seems that during the study period some cases where LT could have been the first line treatment would have been excluded in our center because they were missed. This leads us to reflect on the need to do routine pulmonary screening beyond the functional respiratory tests (FRT) that are normal in many patients with HPS.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Liver transplantation controls HPS by correcting the intrapulmonary shunt and improving arterial circulation. Consequently, LT should be a priority in this patients in the light of the significant survival in properly selected cases that are identified at a stage in which the LT is still feasible, with a postoperative morbidity similar to non-HPS LTs, with the sale level of pre-LT liver disease.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> According to the current information, the worsening of hypoxemia is progressive and refractory to medical treatment.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> Several trials have shown a mortality increase in patients with HPS-associated cirrhosis and consequently, LT is suggested as the only effective treatment for this rare but lethal condition.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Neither the etiology nor the severity of the liver disease affects the development of the syndrome. This contributes to the hypothesis of a genetic predisposition as the cause of HPS in patients with liver disease. However, a significant association with portal hypertension has been identified, as is the case in Budd–Chiari syndrome or in liver fibrosis.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">13,14</span></a> Consequently, maybe the way to approach a HPS screening program could be in patients diagnosed with portal hypertension with cirrhosis and/or syndromes associated with the occurrence of cirrhosis, despite a normal liver function, but that additionally present with non-specific respiratory problems such as dyspnea, that could represent a warning sign for some level of clinical suspicion. In this setting, the accuracy and usefulness of pulse oximetry becomes relevant. Numerous studies have shown that an O<span class="elsevierStyleInf">2</span> peripheral saturation (SpO<span class="elsevierStyleInf">2</span>) equal to or less than 94% identifies any subject with a PaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>mmHg.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a> This cost-effectiveness analyses conclude that it is a simple and low-cost technique, in addition to being non-invasive, precise, reliable and applicable at the time of the hepatology visit for regular follow-up.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a> It should be noted however, that after the initial screening, the dyspnea and/or hypoxia of the patients identified could be the result of cardiac causes of usual pulmonary diseases that coexist in up to one third of liver disease patients,<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> more specific tests such as contrast echocardiography, pulmonary angiography, and comprehensive pulmonary function tests shall be indicated.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The fact that pre-LT PaO<span class="elsevierStyleInf">2</span> is suggested as a significant post-LT predictor of mortality, and is considered to be the primary tool for decision-making regarding the timeliness for LT, it becomes necessary to establish a range of PO<span class="elsevierStyleInf">2</span> for which LT should be prioritized to optimize the success of therapy. Other groups with large series of LTs with HPS set PO<span class="elsevierStyleInf">2</span> levels between 50–60<span class="elsevierStyleHsp" style=""></span>mmHg as the appropriate range for LT indication. In general, patients with PaO<span class="elsevierStyleInf">2</span> values under 50<span class="elsevierStyleHsp" style=""></span>mmHg are excluded from the procedure and a PO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>mmHg is considered by some groups as contraindicated for the procedure.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a> However, here are some cases with successful post LT outcomes with a higher survival than non-transplanted cases within the same gasometry range with pre-LT PaO<span class="elsevierStyleInf">2</span> below 50<span class="elsevierStyleHsp" style=""></span>mmHg. This means that some cases of HPS with severe hypoxemia shall be comprehensively evaluated and the liver transplant shall be indicated regardless of the severity of hypoxemia.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The finding that PO<span class="elsevierStyleInf">2</span> is the only predictor of mortality may be explained on the basis the pulmonary shunt present if HPS individuals, due to the disrupted oxygen diffusion capacity as a consequence of capillary vasodilation, in addition to a shortened erythrocyte transit time through the capillaries and an elevated cardiac output. This alteration tends to be relatively permanent if not corrected promptly. Therefore, patients with a not excessively low PO<span class="elsevierStyleInf">2</span> are excellent candidates for priority liver transplant; on the contrary, patients with low PO<span class="elsevierStyleInf">2</span> have a poor prognosis and poor ventilator response, even before transplantation.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The rest of our study variables do not significantly predict the risk of death or reversibility, meaning that they cannot be related since probably these results are limited by the size of the sample. It will be necessary to work on larger samples to assess those variables.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Moreover, keep in mind that in terms of the level of liver disease, MELD is not prognostic in liver cancer-associated HPS patients, neither in metabolic diseases, portal hypertension syndromes, and any other clinical condition not directly associated to the extent of cirrhosis. In this cases, the prioritization for LT indication shall be done based on progression of the disease and patients should be closely monitored for a level of hypoxemia that may question the indication of liver transplantation on account of the high postoperative morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">It should be highlighted however that in terms of the patients that died during the immediate postoperative period, the primary cause of death was unrelated to respiratory failure but rather is mostly associated with primary graft dysfunction, biliary complications, perioperative bleeding, sepsis, and other usual morbimortality causes in non-HPS LT, as demonstrated by the Toronto group paper in 2010, involving a large series of cases in two transplantation centers for 6 years.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">21</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">All patients that survived the LT had improved arterial oxygenation, although the systematic literature reviews of large series of cases show more variable results in terms of the reversibility of post LT hypoxemia.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a> Notwithstanding the fact there was some level of persistent hypoxemia in 2 patients, the condition improved gradually in the course of further control visits, with reduced home O<span class="elsevierStyleInf">2</span> requirements (partial HPS reversibility). This ratifies the significance of liver dysfunction in the HPS pathogenesis.</p><p id="par0125" class="elsevierStylePara elsevierViewall">In conclusion, according to our series, despite the low prevalence of HPS among the patients who are candidates for LT, a considerable morbimortality exists with the current medical treatment modalities.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a> PO<span class="elsevierStyleInf">2</span> has been identified as a statistically significant predictor of postoperative mortality and must be taken into consideration when prioritizing patients in the waiting list for LT. PO<span class="elsevierStyleInf">2</span> should be the key tool for screening programs to identify concomitant and potentially reversible lung disease. Although the other variables studied fail to significantly predict the risk of death or reversibility, additional studies with larger samples are needed.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors did not receive sponsorship to carry out this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres737134" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Patients and methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec741231" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres737133" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Pacientes y métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec741232" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-07-12" "fechaAceptado" => "2016-06-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec741231" "palabras" => array:5 [ 0 => "Hepatopulmonary syndrome" 1 => "Liver transplantation" 2 => "Hepatic insufficiency" 3 => "Anesthesia" 4 => "Mortality" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec741232" "palabras" => array:5 [ 0 => "Síndrome, hepatopulmonar" 1 => "Transplante de hígado" 2 => "Insuficiencia hepática" 3 => "Anestesia" 4 => "Mortalidad" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hepatopulmonary syndrome (HPS) is a serious, progressive disease. Its pathophysiology resides in a hypoxic intrapulmonary shunt and severe clinical deterioration. Liver transplantation (LT) is the only effective treatment in appropriately selected patients.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To acknowledge the importance of early diagnosis of HPS.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Patients and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Observational, descriptive, retrospective trial including 8 patients with HPS that received LT between April 2006 and August 2014. The clinical data prior to transplantation and follow-up after the procedure were reviewed.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A multivariate analysis (stepwise forward logistic regression analysis) was used to identify the variable that could potentially increase the risk of death.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Of the 8 patients, death could only be significantly predicted based on the pre-LT arterial blood partial oxygen pressure (PaO<span class="elsevierStyleInf">2</span>) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.002).</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The average pre-LT PaO<span class="elsevierStyleInf">2</span> of the patients that died was 51.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.49 SD, with a statistically significant difference (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.002).</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">None of the variables was statistically significant for HPS reversibility.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The survival rate of patients diagnosed with HPS following the LT was 62.5%.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The level of pre-LT hypoxemia is an important predictor for immediate postoperative mortality. Early detection of the condition is critical to reduce the post LT morbidity and mortality so that the indication for transplant is made at the right time, regardless of the stage of liver disease. The most efficient clinical strategy could be the use of appropriate early detection protocols for HPS through screening of hypoxemia in patients with portal hypertension.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Patients and methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducción</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El síndrome hepatopulmonar (SHP) es una enfermedad grave y progresiva cuya fisiopatología reside en un shunt intrapulmonar con hipoxia y deterioro clínico severo. Como único tratamiento efectivo se ha postulado el trasplante hepático (TH), en pacientes adecuadamente seleccionados.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Reconocer la importancia del diagnostico temprano del SHP.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Pacientes y métodos</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Mediante un estudio observacional, descriptivo, con carácter retrospectivo de 8 pacientes con SHP, a los que se les realizó TH en el período entre Abril 2006-Agosto 2014. Se han revisado los datos clínicos previos al trasplante y el seguimiento tras este.</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Se empleó un estudio multivariante (stepwise forward logistic regression analisis), para determinar cual variable podría incrementar el riesgo de muerte.</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">De los 8 pacientes, el resultado de muerte sólo pudo ser predicho significativamente por el factor presión parcial de oxígeno en sangre arterial (PaO2) pre-TH (p=0,002).</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">La PaO2 pre-TH promedio de los pacientes que fallecieron era de 51,5 +/- 2,49 DS, siendo la diferencia estadísticamente significativa (p=0,002).</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Ninguna variable resultó estadísticamente significativa para reversibilidad del SHP.</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">La supervivencia de los pacientes con criterio de SHP posterior al TH fue de 62,5%.</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">El grado de hipoxemia pre-TH es un factor predictor importante de mortalidad en el postoperatorio inmediato. La precocidad en la detección de la entidad es fundamental tanto para disminuir la morbimortalidad post TH como para indicar éste en el momento óptimo independientemente del estadío de la enfermedad hepática. Protocolos adecuados de detección precoz del SHP mediante screening de hipoxemias en pacientes con hipertensión portal, puede ser la estrategia clínica más eficiente.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Pacientes y métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Orozco-Delgado M, López-Cantero M, Zampella V, Vicente R, Galán J. Factores predictores de mortalidad y estrategias de detección precoz de sindrome hepatopulmonar en pacientes trasplantados hepáticos. Rev Colomb Anestesiol. 2016;44:311–316.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 888 "Ancho" => 1631 "Tamanyo" => 32371 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Survival curve. None of the qualitative variables studied was associated with death (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.05).</p> <p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Source: authors.</p>" ] ] 1 => array:9 [ "identificador" => "tbl0010" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: the authors" "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Living \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Death \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PO<span class="elsevierStyleInf">2</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.86 SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.49 SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.002 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PCO<span class="elsevierStyleInf">2</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36.1<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.91 SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.69 SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.672 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AGE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.55 SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.18 SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.798 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Child–Pugh \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.65 SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.67<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.58 SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.496 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MELD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.18 SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.33<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.53 SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.560 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TIME VM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.25<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.06 SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">165<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>272.22 SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.284 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1217107.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Demographic and clinical characteristics and hepatic functional status.</p>" ] ] 2 => array:9 [ "identificador" => "tbl0015" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: authors." "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">NIMV, non-invasive mechanical ventilation; MV, mechanical ventilation; LT, liver transplant; Res, resuscitation.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Male \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Male \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Female \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Male \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Male \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Male \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Male \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Male \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Etiology of liver disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HCV<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Enolic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HCV<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Enolic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Non-cirrhotic portal HP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Enolic cirrhosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Enolic cirrhosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cryptogenic cirrhosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Enolic cirrhosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HCV \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pre LT pH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.31 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pre LT PO<span class="elsevierStyleInf">2</span> (mmHg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">71.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">74.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">76.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pre LT PCO<span class="elsevierStyleInf">2</span> (mmHg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MELD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Child–Pugh \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C (10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B (7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B (9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C (12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C (10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B (9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C (10) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pre LT home O<span class="elsevierStyleInf">2</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Perfusion syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Postoperative MV time (h) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">480 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NOMV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Res unit length of stay >48<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cause of death \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Primary graft dysfunction \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1217106.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Clinical aspects.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hepatopulmonary syndorme: current concepts in diagnostic and therapeutic considerations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 0 | 3 |
| 2024 October | 4 | 1 | 5 |
| 2024 September | 11 | 6 | 17 |
| 2024 August | 7 | 2 | 9 |
| 2024 July | 5 | 4 | 9 |
| 2024 June | 19 | 0 | 19 |
| 2024 May | 10 | 5 | 15 |
| 2024 April | 22 | 4 | 26 |
| 2024 March | 16 | 2 | 18 |
| 2024 February | 24 | 5 | 29 |
| 2024 January | 9 | 20 | 29 |
| 2023 December | 16 | 6 | 22 |
| 2023 November | 14 | 4 | 18 |
| 2023 October | 17 | 7 | 24 |
| 2023 September | 18 | 2 | 20 |
| 2023 August | 6 | 3 | 9 |
| 2023 July | 6 | 5 | 11 |
| 2023 June | 17 | 7 | 24 |
| 2023 May | 38 | 2 | 40 |
| 2023 April | 27 | 1 | 28 |
| 2023 March | 8 | 1 | 9 |
| 2023 February | 5 | 6 | 11 |
| 2023 January | 8 | 10 | 18 |
| 2022 December | 11 | 11 | 22 |
| 2022 November | 11 | 7 | 18 |
| 2022 October | 11 | 10 | 21 |
| 2022 September | 9 | 28 | 37 |
| 2022 August | 8 | 12 | 20 |
| 2022 July | 5 | 8 | 13 |
| 2022 June | 11 | 4 | 15 |
| 2022 May | 30 | 5 | 35 |
| 2022 April | 19 | 7 | 26 |
| 2022 March | 20 | 11 | 31 |
| 2022 February | 24 | 4 | 28 |
| 2022 January | 21 | 5 | 26 |
| 2021 December | 8 | 6 | 14 |
| 2021 November | 16 | 6 | 22 |
| 2021 October | 11 | 8 | 19 |
| 2021 September | 6 | 9 | 15 |
| 2021 August | 7 | 5 | 12 |
| 2021 July | 9 | 6 | 15 |
| 2021 June | 4 | 5 | 9 |
| 2021 May | 9 | 4 | 13 |
| 2021 April | 23 | 14 | 37 |
| 2021 March | 27 | 10 | 37 |
| 2021 February | 21 | 7 | 28 |
| 2021 January | 14 | 3 | 17 |
| 2020 December | 12 | 6 | 18 |
| 2020 November | 3 | 4 | 7 |
| 2020 October | 4 | 2 | 6 |
| 2020 September | 3 | 6 | 9 |
| 2020 August | 8 | 7 | 15 |
| 2020 July | 4 | 9 | 13 |
| 2020 June | 3 | 1 | 4 |
| 2020 May | 7 | 5 | 12 |
| 2020 April | 1 | 4 | 5 |
| 2020 March | 3 | 6 | 9 |
| 2020 February | 3 | 1 | 4 |
| 2020 January | 4 | 1 | 5 |
| 2019 December | 8 | 8 | 16 |
| 2019 November | 3 | 1 | 4 |
| 2019 October | 2 | 3 | 5 |
| 2019 September | 1 | 3 | 4 |
| 2019 July | 2 | 7 | 9 |
| 2019 June | 0 | 1 | 1 |
| 2019 May | 1 | 10 | 11 |
| 2019 February | 1 | 0 | 1 |
| 2019 January | 1 | 0 | 1 |
| 2018 September | 1 | 0 | 1 |
| 2018 June | 3 | 0 | 3 |
| 2018 May | 23 | 15 | 38 |
| 2018 April | 32 | 10 | 42 |
| 2018 March | 17 | 9 | 26 |
| 2018 February | 14 | 4 | 18 |
| 2018 January | 21 | 4 | 25 |
| 2017 December | 16 | 8 | 24 |
| 2017 November | 12 | 4 | 16 |
| 2017 October | 21 | 10 | 31 |
| 2017 September | 18 | 7 | 25 |
| 2017 August | 9 | 4 | 13 |
| 2017 July | 25 | 3 | 28 |
| 2017 June | 23 | 9 | 32 |
| 2017 May | 29 | 7 | 36 |
| 2017 April | 36 | 12 | 48 |
| 2017 March | 18 | 8 | 26 |
| 2017 February | 14 | 4 | 18 |
| 2017 January | 21 | 11 | 32 |
| 2016 December | 53 | 22 | 75 |
| 2016 November | 46 | 13 | 59 |
| 2016 October | 66 | 20 | 86 |
| 2016 September | 4 | 7 | 11 |
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