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REPLY
Nitric Oxide and Impaired Oxygenation before and after Liver Transplantation
Giovanni Rolla, MD;
Luisa Brussino, MD; and
Paola Colagrande, MD
6 July 1999 | Volume 131 Issue 1 | Page 69
IN RESPONSE:
Teramoto and colleagues question our conclusion that most cases of abnormal oxygenation in patients with cirrhosis are reversible after liver transplantation. We defined oxygenation abnormality as an increase in alveolar-arterial oxygen gradient greater than 15 mm Hg, which was present in 11 patients before and in 4 patients after liver transplantation (P < 0.05). We think our data justify this conclusion. Moreover, Battaglia and colleagues (1) have obtained similar results. That some patients with hepatopulmonary syndrome develop profound, early postoperative hypoxemia (which has been reported to improve after NO inhalation) does not contradict the postulated effect of endogenous NO in determining hypoxemia in cirrhosis. Exhaled NO represents endogenous production throughout the respiratory system, whereas NO administered by inhalation may shift blood flow from nonventilated to ventilated lung units accessible to NO (2).
In a previous study (3), we found a correlation between alveolar-arterial oxygen gradient and respiratory NO output before liver transplantation. Teramoto and colleagues state that this correlation is stronger than the correlation we had previously found between the decrease in alveolar-arterial oxygen gradient and exhaled NO concentration after liver transplantation. To properly make such a comparison, one must consider the different measurement units of exhaled NO used in our two studies. In particular, NO output takes into account minute ventilation, which is increased in liver cirrhosis (particularly in patients with the hepatopulmonary syndrome, who have the worst oxygenation).
We agree with Teramoto and colleagues that the improvement in oxygenation after liver transplantation depends on the decrease in intrapulmonary vasodilatation and portal hypertension, both of which are related to NO production (4).
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Author and Article Information
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Dr. Rolla: Università di Torino; Torino, Italy
Dr. Brussino: Università di Torino; Torino, Italy
Dr. Colagrande: Università di Torino; Torino, Italy
1. Battaglia SE, Pretto JJ, Irving LB, Jones RM, Angus PW. Resolution of gas exchange abnormalities and intrapulmonary shunting following liver transplantation Hepatology. 1997;25:1228-32.[Medline]
2. Rossaint R, Falke KJ, Lopez F, Slama K, Pison U, Zapol WM. Inhaled nitric oxide for the adult respiratory distress syndrome N Engl J Med. 1993;328:399-405.[Abstract/Free Full Text]
3. Rolla G, Brussino L, Colagrande P, Dutto L, Polizzi S, Scappaticci E, et al. Exhaled nitric oxide and oxygenation abnormalities in hepatic cirrhosis Hepatology. 1997;26:842-7.[Medline]
4. Sogni P, Moreau R, Gadano A, Lebrec D. The role of nitric oxide in the hyperdynamic circulatory syndrome associated with portal hypertension J Hepatol. 1995;23:218-24.[Medline]
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Brief Communications
Exhaled Nitric Oxide and Impaired Oxygenation in Cirrhotic Patients before and after Liver Transplantation
Giovanni Rolla, Luisa Brussino, Paola Colagrande, Ermanno Scappaticci, Mara Morello, Serena Bergerone, Antonio Ottobrelli, Elisabetta Cerutti, Salvatore Polizzi, AND Caterina Bucca
- Annals 1998 129: 375-378.
[ABSTRACT][Full Text]
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