New therapeutic strategy with extracorporeal membrane oxygenation for refractory hepatopulmonary syndrome after liver transplant: A case report

Abstract

Due to the lack of published literature about treatment of refractory hepatopulmonary syndrome(HPS) after liver transplant(LT), this case adds information and experience on this issue along with a treatment with positive outcomes.HPS is a complication of end-stage liver disease with a 10%-30% incidence in cirrhotic patients.LT can reverse the physiopathology of this process and restore normal oxygenation. In some cases, refractory hypoxemia persists, and extracorporeal membrane oxygenation(ECMO) can be used as a rescue therapy with good results Summary:59-year-old patient with alcohol-related liver cirrhosis and portal hypertension was included in the LT waiting list for HPS.He had good liver function(MELD12).He had pulmonary fibrosis and a mild restrictive respiratory pattern with a basal oxygen saturation of 82%.The macroaggregated albumin test result was>30. Spirometry demon strated a forced expiratory volume in one second of 78%, forced vital capacity of 74%, FEV1/FVC ratio of 81%, diffusion capacity for carbon monoxide of 42%, and carbon monoxide transfer coefficient of 57%. He required domiciliary oxygen at 2L/min(16h/d). The patient was admitted to the intensive care unit and extubated in the first 24h, needing high-flow therapy and non-invasive ventilation and inhaled nitric oxide afterwards.Reintubation was needed after 72h.Due to the non-response to supportive therapies, installation of ECMO was decided with progressive recovery after 9 d. Extubation was possible on the 10 day, maintaining a high-flow nasal cannula and de-escalating to conventional oxygen therapy after 48 h.He was discharged from ICU on postoperative day 20 with a 90%-92% oxygen saturation. Steroid recycling was needed twice for acute rejection. The patient was discharged from hospital on POD 27 with no symptoms, with an 89%-90% oxygen saturation Conclusion:Due to the favorable results observed, ECMO could become the central axis of treatment of HPS and refractory hypoxemia after LT