Unmasking hypoxia in Cirrhosis patients: Six-minute walk test as a screening tool for hepatopulmonary syndrome

Singhai, Abhishek; Mallik, Manaswinee; Jain, Pragya

Unmasking hypoxia in Cirrhosis patients: Six-minute walk test as a screening tool for hepatopulmonary syndrome

Document Type : Original Article

Authors

¹ Department of Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India

² Department of Ophthalmology, Peoples College of Medical Sciences, Bhopal, Madhya Pradesh, India

Abstract

Background: Hepatopulmonary syndrome (HPS) is one of the complications of advanced cirrhosis which has a serious impact on prognosis of patient. Finding arterial deoxygenation early and initiating higher-level treatment is one of the most critical strategies in the therapy of HPS. In this study, we aimed to assess the utility of six-minute walk test (6MWT) in the diagnosis of HPS. Materials and Methods: We have enrolled 100 consecutive cirrhosis patients referred to the Liver Clinic of a tertiary care centre of India for >1 year. The Child-Pugh score and the MELD score were used to determine the severity of cirrhosis. All the patients underwent transthoracic contrast echocardiography, arterial blood gas measurements on room air, 6MWT, and chest imaging. Results: A total of 100 patients were included in the study after fulfilling the inclusion criteria. HPS was present in 21 out of 100 patients (21%). Median (twenty fifth to seventy fifth percentile) MELD score in patients with HPS was 29 (26–33), which was significantly higher as compared to patients without HPS 22 (14.5–26); P <.0001. The 6MWT was positive in 20 (95.23%) HPS patients, while only 1 patient (4.77%) of HPS had negative 6MWT. If 6MWT is positive, then there was 76.92% probability of HPS and if 6MWT is negative, then 98.65% chances of no HPS. Conclusion: The 6MWT is a simple and effective screening test for HPS, it helps in identifying the patients early who have a potential to deteriorate. This simple intervention would help in prioritizing patients for liver transplantation as liver transplant is the only effective treatment for HPS.

Keywords

References

1.	Weinfurtner K, Forde K. Hepatopulmonary syndrome and portopulmonary hypertension: Current status and implications for liver transplantation. Curr Hepatol Rep 2020;19:174-85.
2.	Soulaidopoulos S, Goulis I, Cholongitas E. Pulmonary manifestations of chronic liver disease: A comprehensive review. Ann Gastroenterol 2020;33:237-49.
3.	Riou M, Jutant EM, Mignard X, Canuet M, Humbert M, Sitbon O. Hépatopathies et maladies vasculaires pulmonaires [Liver diseases and pulmonary vascular disorders]. Rev Med Interne 2018;39:925-34.
4.	Raevens S, Geerts A, Devisscher L, Van Vlierberghe H, Van Steenkiste C, Colle I. Recent advances in the approach to hepatopulmonary syndrome and portopulmonary hypertension. Acta Gastroenterol Belg 2021;84:95-9.
5.	Del Valle K, DuBrock HM. Hepatopulmonary syndrome and portopulmonary hypertension: Pulmonary vascular complications of liver disease. Compr Physiol 2021;11:1-22.
6.	Mallik M, Singhai A, Khadanga S, Ingle V. The significant morbidity and mortality indicators in patients of cirrhosis. Cureus 2022;14:e21226.
7.	Soulaidopoulos S, Cholongitas E, Giannakoulas G, Vlachou M, Goulis I. Review article: Update on current and emergent data on hepatopulmonary syndrome. World J Gastroenterol 2018;24:1285-98.
8.	Forde KA, Fallon MB, Krowka MJ, Sprys M, Goldberg DS, Krok KL, et al. Pulmonary vascular complications of liver disease 2 study group. pulse oximetry is insensitive for detection of hepatopulmonary syndrome in patients evaluated for liver transplantation. Hepatology 2019;69:270-81.
9.	Kennedy TC, Knudson RJ. Exercise-aggravated hypoxemia and orthodeoxia in cirrhosis. Chest 1977;72:305-9.
10.	Kumar P, Rao PN. Hepatopulmonary Syndrome. N Engl J Med 2020;382:e14.
11.	Fuhrmann V, Krowka M. Hepatopulmonary syndrome. J Hepatol 2018;69:744-5.
12.	Cywinski JB, Makarova N, Arney A, Liu Q, Fujiki M, Menon KVN, et al. Resources utilization after liver transplantation in patients with and without hepatopulmonary syndrome: Cleveland clinic experience. Transplant Direct 2020;6:e545.
13.	Sendra C, Carballo-Rubio V, Sousa JM. Hepatopulmonary syndrome and portopulmonary hypertension: Management in liver transplantation in the horizon 2020. Transplant Proc 2020;52:1503-6.
14.	Haj M, Rockey DC. Predictors of clinical outcomes in cirrhosis patients. Curr Opin Gastroenterol 2018;34:266-71.
15.	Benz F, Mohr R, Tacke F, Roderburg C. Pulmonary complications in patients with liver cirrhosis. J Transl Int Med 2020;8:150-8.
16.	Jose A, Shah SA, Anwar N, Jones CR, McCormack FX, Sherman KE, et al. Predictors of outcomes following liver transplant in hepatopulmonary syndrome: An OPTN database analysis. Respir Med 2021;190:106683.
17.	Parikh H, Lui E, Faughnan ME, Al-Hesayen A, Segovia S, Gupta S. Supine vs upright exercise in patients with hepatopulmonary syndrome and orthodeoxia: Study protocol for a randomized controlled crossover trial. Trials 2021;22:683.
18.	Marroni CA, Fleck AM Jr, Fernandes SA, Galant LH, Mucenic M, de Mattos Meine MH, et al. Liver transplantation and alcoholic liver disease: History, controversies, and considerations. World J Gastroenterol 2018;24:2785-805.
19.	Marsico A, Dal Corso S, Carvalho EF, Arakelian V, Phillips S, Stirbulov R, et al. A more effective alternative to the 6-minute walk test for the assessment of functional capacity in patients with pulmonary hypertension. Eur J Phys Rehabil Med 2021;57:645-52.
20.	Roncato G, da Fontoura FF, Spilimbergo FB, Meyer GMB, Watte G, de Vargas WO, et al. Parasympathetic modulation withdrawal improves functional capacity in pulmonary arterial hypertension. Respir Physiol Neurobiol 2021;287:103620.
21.	Liu F, Tsang RCC, Jones AYM, Zhou M, Xue K, Chen M, et al. Cardiodynamic variables measured by impedance cardiography during a 6-minute walk test are reliable predictors of peak oxygen consumption in young healthy adults. PLoS One 2021;16:e0252219.

Advanced Biomedical Research