Analysis of intrapulmonary right to left shunt in the hepatopulmonary syndrome

Background/Aims: Severe hypoxaemia in patients with chronic liver disease in the absence of intrinsic lung disease, the hepatopulmonary syndrome, is associated with pulmonary vascular dilatation and may be an indication for liver transplantation. Divergence between two methods of measuring right to left shunt (radiolabelled albumin macroaggregates and 100% oxygen breathing) has been described, but the mechanism and reason for the inter-patient variability for this shunt difference are not well understood. Methods: Eight hepatopulmonary syndrome patients were studied, with characteristic pulmonary diffusion abnormalities (carbon monoxide transfer factor 41+/-5 (mean+/-SE)% predicted) and significant decreases in arterial oxygen saturation (%) on standing vs. supine (-10%+/-3) and on exercise vs. rest (-15%+/-2). All had hypoxaemia at rest (arterial oxygen tension 8.2+/-0.6 kPa), partially corrected by breathing 100% oxygen (48.2+/-8.8 kPa). Pulmonary angiography was performed and right to left shunt measured by two independent methods: (a) 100% oxygen breathing and (b) i.v. injection of radiolabelled microspheres. Results: Measurement of right to left shunt with Tc-99m-labelled albumin macroaggregates confirmed significant intrapulmonary microvascular dilatation, i.e. an "anatomical" shunt equalling 32+/-4% of cardiac output. Shunt measurements made simultaneously by the classical 100% oxygen technique were significantly smaller (19+/-3%, p=0.01). For individuals, the difference between the Tc-99m-albumin macroaggregate shunt and the 100% oxygen shunt ranged from 2% to 30% absolute, convergence suggesting larger shunt channels (pure anatomical shunt) and divergence representing a combination of anatomical shunt and alveolar-capillary diffusion limitation (smaller microvascular channels). Conclusions: Hypoxaemia in the hepatopulmonary syndrome may be due functionally either to right to left shunting or to diffusion limitation, depending upon the degree of dilatation of the pulmonary microvessels.