Pulse Oximetry Is Insensitive for Detection of Hepatopulmonary Syndrome in Patients Evaluated for Liver Transplantation

for the Pulmonary Vascular Complications of Liver Disease 2 Study Group

Research output: Contribution to journalArticle

3 Citations (Scopus)

Abstract

Screening for hepatopulmonary syndrome (HPS) using pulse oximetry is recommended in liver transplant (LT) candidates because mortality is increased, independently of the severity of the oxygenation defect. LT exception points may be afforded to those with HPS and severe hypoxemia. We assessed the screening characteristics of pulse oximetry for HPS. The Pulmonary Vascular Complications of Liver Disease 2 study is a multicenter, prospective cohort study of adults undergoing their first LT evaluation. Patients underwent protocolized assessment of oxygen saturation by pulse oximetry (SpO 2 ), arterial blood gas, spirometry, and contrast-enhanced echocardiography (CE). HPS was defined as an alveolar-arterial gradient ≥15 mm Hg (≥20 mm Hg if age >64 years), intrapulmonary vascular dilatation on CE, and absence of lung disease. The study sample included 363 patients. Of these, 75 (20.7%; 95% confidence interval [CI], 16.6%-25.2%) met the criteria for HPS. The area under the receiver operating characteristic curve (or c-statistic) for SpO 2 in discriminating HPS was 0.59 (95% CI, 0.51-0.66). An SpO 2 <96%, recommended by practice guidelines as a threshold to require further testing, had low sensitivity (28%; 95% CI, 18%-28%). The c-statistic of SpO 2 in discriminating HPS with a partial pressure of oxygen (PaO 2 ) <60 mm Hg (eligible for LT exception points) was 0.76 (95% CI, 0.46-1.00). An SpO 2 cutoff of <96% had higher sensitivity for detecting HPS with PaO 2 <60 mm Hg (71%; 95% CI, 38%-100%) but was still inadequate. Conclusion: Pulse oximetry is not sufficiently sensitive to screen for HPS in LT candidates. Arterial blood gas and CE are required in LT candidates for diagnosis of HPS.

Original languageEnglish (US)
Pages (from-to)270-281
Number of pages12
JournalHepatology
Volume69
Issue number1
DOIs
StatePublished - Jan 1 2019

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Hepatopulmonary Syndrome
Oximetry
Liver Transplantation
Transplants
Confidence Intervals
Liver
Echocardiography
Blood Vessels
Gases
Oxygen
Partial Pressure
Spirometry
Practice Guidelines
ROC Curve
Lung Diseases
Liver Diseases
Dilatation
Cohort Studies

All Science Journal Classification (ASJC) codes

  • Hepatology

Cite this

for the Pulmonary Vascular Complications of Liver Disease 2 Study Group. / Pulse Oximetry Is Insensitive for Detection of Hepatopulmonary Syndrome in Patients Evaluated for Liver Transplantation. In: Hepatology. 2019 ; Vol. 69, No. 1. pp. 270-281.
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title = "Pulse Oximetry Is Insensitive for Detection of Hepatopulmonary Syndrome in Patients Evaluated for Liver Transplantation",
abstract = "Screening for hepatopulmonary syndrome (HPS) using pulse oximetry is recommended in liver transplant (LT) candidates because mortality is increased, independently of the severity of the oxygenation defect. LT exception points may be afforded to those with HPS and severe hypoxemia. We assessed the screening characteristics of pulse oximetry for HPS. The Pulmonary Vascular Complications of Liver Disease 2 study is a multicenter, prospective cohort study of adults undergoing their first LT evaluation. Patients underwent protocolized assessment of oxygen saturation by pulse oximetry (SpO 2 ), arterial blood gas, spirometry, and contrast-enhanced echocardiography (CE). HPS was defined as an alveolar-arterial gradient ≥15 mm Hg (≥20 mm Hg if age >64 years), intrapulmonary vascular dilatation on CE, and absence of lung disease. The study sample included 363 patients. Of these, 75 (20.7{\%}; 95{\%} confidence interval [CI], 16.6{\%}-25.2{\%}) met the criteria for HPS. The area under the receiver operating characteristic curve (or c-statistic) for SpO 2 in discriminating HPS was 0.59 (95{\%} CI, 0.51-0.66). An SpO 2 <96{\%}, recommended by practice guidelines as a threshold to require further testing, had low sensitivity (28{\%}; 95{\%} CI, 18{\%}-28{\%}). The c-statistic of SpO 2 in discriminating HPS with a partial pressure of oxygen (PaO 2 ) <60 mm Hg (eligible for LT exception points) was 0.76 (95{\%} CI, 0.46-1.00). An SpO 2 cutoff of <96{\%} had higher sensitivity for detecting HPS with PaO 2 <60 mm Hg (71{\%}; 95{\%} CI, 38{\%}-100{\%}) but was still inadequate. Conclusion: Pulse oximetry is not sufficiently sensitive to screen for HPS in LT candidates. Arterial blood gas and CE are required in LT candidates for diagnosis of HPS.",
author = "{for the Pulmonary Vascular Complications of Liver Disease 2 Study Group} and Forde, {Kimberly A.} and Fallon, {Michael B.} and Krowka, {Michael J.} and Michael Sprys and Goldberg, {David S.} and Krok, {Karen L.} and Mamta Patel and Karen Krok and Oh, {Jae K.} and Mottram, {Carl D.} and Scanlon, {Paul D.} and Kawut, {Steven M.}",
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for the Pulmonary Vascular Complications of Liver Disease 2 Study Group 2019, 'Pulse Oximetry Is Insensitive for Detection of Hepatopulmonary Syndrome in Patients Evaluated for Liver Transplantation', Hepatology, vol. 69, no. 1, pp. 270-281. https://doi.org/10.1002/hep.30139

Pulse Oximetry Is Insensitive for Detection of Hepatopulmonary Syndrome in Patients Evaluated for Liver Transplantation. / for the Pulmonary Vascular Complications of Liver Disease 2 Study Group.

In: Hepatology, Vol. 69, No. 1, 01.01.2019, p. 270-281.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Pulse Oximetry Is Insensitive for Detection of Hepatopulmonary Syndrome in Patients Evaluated for Liver Transplantation

AU - for the Pulmonary Vascular Complications of Liver Disease 2 Study Group

AU - Forde, Kimberly A.

AU - Fallon, Michael B.

AU - Krowka, Michael J.

AU - Sprys, Michael

AU - Goldberg, David S.

AU - Krok, Karen L.

AU - Patel, Mamta

AU - Krok, Karen

AU - Oh, Jae K.

AU - Mottram, Carl D.

AU - Scanlon, Paul D.

AU - Kawut, Steven M.

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Screening for hepatopulmonary syndrome (HPS) using pulse oximetry is recommended in liver transplant (LT) candidates because mortality is increased, independently of the severity of the oxygenation defect. LT exception points may be afforded to those with HPS and severe hypoxemia. We assessed the screening characteristics of pulse oximetry for HPS. The Pulmonary Vascular Complications of Liver Disease 2 study is a multicenter, prospective cohort study of adults undergoing their first LT evaluation. Patients underwent protocolized assessment of oxygen saturation by pulse oximetry (SpO 2 ), arterial blood gas, spirometry, and contrast-enhanced echocardiography (CE). HPS was defined as an alveolar-arterial gradient ≥15 mm Hg (≥20 mm Hg if age >64 years), intrapulmonary vascular dilatation on CE, and absence of lung disease. The study sample included 363 patients. Of these, 75 (20.7%; 95% confidence interval [CI], 16.6%-25.2%) met the criteria for HPS. The area under the receiver operating characteristic curve (or c-statistic) for SpO 2 in discriminating HPS was 0.59 (95% CI, 0.51-0.66). An SpO 2 <96%, recommended by practice guidelines as a threshold to require further testing, had low sensitivity (28%; 95% CI, 18%-28%). The c-statistic of SpO 2 in discriminating HPS with a partial pressure of oxygen (PaO 2 ) <60 mm Hg (eligible for LT exception points) was 0.76 (95% CI, 0.46-1.00). An SpO 2 cutoff of <96% had higher sensitivity for detecting HPS with PaO 2 <60 mm Hg (71%; 95% CI, 38%-100%) but was still inadequate. Conclusion: Pulse oximetry is not sufficiently sensitive to screen for HPS in LT candidates. Arterial blood gas and CE are required in LT candidates for diagnosis of HPS.

AB - Screening for hepatopulmonary syndrome (HPS) using pulse oximetry is recommended in liver transplant (LT) candidates because mortality is increased, independently of the severity of the oxygenation defect. LT exception points may be afforded to those with HPS and severe hypoxemia. We assessed the screening characteristics of pulse oximetry for HPS. The Pulmonary Vascular Complications of Liver Disease 2 study is a multicenter, prospective cohort study of adults undergoing their first LT evaluation. Patients underwent protocolized assessment of oxygen saturation by pulse oximetry (SpO 2 ), arterial blood gas, spirometry, and contrast-enhanced echocardiography (CE). HPS was defined as an alveolar-arterial gradient ≥15 mm Hg (≥20 mm Hg if age >64 years), intrapulmonary vascular dilatation on CE, and absence of lung disease. The study sample included 363 patients. Of these, 75 (20.7%; 95% confidence interval [CI], 16.6%-25.2%) met the criteria for HPS. The area under the receiver operating characteristic curve (or c-statistic) for SpO 2 in discriminating HPS was 0.59 (95% CI, 0.51-0.66). An SpO 2 <96%, recommended by practice guidelines as a threshold to require further testing, had low sensitivity (28%; 95% CI, 18%-28%). The c-statistic of SpO 2 in discriminating HPS with a partial pressure of oxygen (PaO 2 ) <60 mm Hg (eligible for LT exception points) was 0.76 (95% CI, 0.46-1.00). An SpO 2 cutoff of <96% had higher sensitivity for detecting HPS with PaO 2 <60 mm Hg (71%; 95% CI, 38%-100%) but was still inadequate. Conclusion: Pulse oximetry is not sufficiently sensitive to screen for HPS in LT candidates. Arterial blood gas and CE are required in LT candidates for diagnosis of HPS.

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DO - 10.1002/hep.30139

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