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• W2890806462 abstract "To the Editor: With great interest we read the article by Forde et al., regarding pulse oximetry as a screening tool for hepatopulmonary syndrome (HPS).1 Their results indicate that pulse oximetry is insensitive for HPS detection in patients with liver cirrhosis. We aimed to further clarify the underlying physiologic mechanisms that result in poor correlation between pulse oximetry and arterial oxygenation in this patient population. The oxyhemoglobin dissociation curve (ODC) is a sigmoid curve that plots the relation between oxygen saturation (SO2) and partial pressure of oxygen in the blood. The strength with which oxygen binds hemoglobin is influenced by several factors, which might reshape the ODC. In patients with cirrhosis, the ODC is significantly dispersed relative to normal conditions,2 which might result in normal SO2 readings despite a state of hypoxemia. This dispersion can at least in part be attributed to increased 2,3‐diphosphoglycerate (2,3‐DPG) levels (Fig. 1).3 2,3‐DPG is formed in erythrocytes during glycolysis and represents an adaptive mechanism that enables compensation for several disease states characterized by reduced tissue oxygenation, e.g., a hyperdynamic circulation.3 At least four mechanisms have been identified that enhance 2,3‐DPG production in cirrhosis. First, sodium and water excretion are affected, which most frequently result in hyponatremia and hypokalemia, hyperchloremia, and hyperphosphatemia. These plasma ion disturbances are known to stimulate 2,3‐DBP synthesis,2 which can moreover be influenced by diuretic treatment.2 Second, the rate of glycolysis is increased and 2,3‐DPG phosphatase is decreased, with a resultant increase in 2,3‐DPG, during alkalosis, which is frequent in patients with cirrhosis due to hyperventilation.2 Third, low glucokinase and glucose‐6‐phosphatase activity and high hexokinase have been observed in cirrhosis and stimulate the glycolysis cycle.5 Fourth, erythrocytes increase their 2,3‐DPG content in response to chronic anemia, to ensure proper tissue oxygenation.3Figure 1: Dispersion of the ODC in liver cirrhosis. Abbreviation: PO2, partial pressure of oxygen.Furthermore, mechanisms other than 2,3‐DPG may influence the position of the ODC, including propranolol intake, elevated carbon monoxide levels, and peripheral vasodilation.1 Also, as correctly stated by the authors, SO2 measurements can be normal in HPS patients who have an increased alveolar‐arterial oxygen gradient with preserved partial pressure of oxygen levels, due to hypocapnia from hyperventilation. To conclude, the work by the Pulmonary Vascular Complications of Liver Disease study group not only carries great clinical implications with regard to our current HPS screening program but also highlights the pitfalls of using pulse oximetry in the general population with cirrhosis. Potential conflict of interest Dr. Isabelle Colle consults for Promethera." @default.
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• W2890806462 date "2019-01-01" @default.
• W2890806462 modified "2023-09-23" @default.
• W2890806462 title "Why Pulse Oximetry Is Inaccurate in Liver Cirrhosis: Ancient Knowledge" @default.
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• W2890806462 doi "https://doi.org/10.1002/hep.30260" @default.
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