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Cirrhotic portal hypertension: From pathophysiology to novel therapeutics
journal contributionposted on 17.12.2020, 01:13 by LS Gunarathne, Kolin RajapakshaKolin Rajapaksha, N Shackel, PW Angus, CB Herath
©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved. Portal hypertension and bleeding from gastroesophageal varices is the major cause of morbidity and mortality in patients with cirrhosis. Portal hypertension is initiated by increased intrahepatic vascular resistance and a hyperdynamic circulatory state. The latter is characterized by a high cardiac output, increased total blood volume and splanchnic vasodilatation, resulting in increased mesenteric blood flow. Pharmacological manipulation of cirrhotic portal hypertension targets both the splanchnic and hepatic vascular beds. Drugs such as angiotensin converting enzyme inhibitors and angiotensin II type receptor 1 blockers, which target the components of the classical renin angiotensin system (RAS), are expected to reduce intrahepatic vascular tone by reducing extracellular matrix deposition and vasoactivity of contractile cells and thereby improve portal hypertension. However, these drugs have been shown to produce significant off-target effects such as systemic hypotension and renal failure. Therefore, the current pharmacological mainstay in clinical practice to prevent variceal bleeding and improving patient survival by reducing portal pressure is non-selective -blockers (NSBBs). These NSBBs work by reducing cardiac output and splanchnic vasodilatation but most patients do not achieve an optimal therapeutic response and a significant proportion of patients are unable to tolerate these drugs. Although statins, used alone or in combination with NSBBs, have been shown to improve portal pressure and overall mortality in cirrhotic patients, further randomized clinical trials are warranted involving larger patient populations with clear clinical end points. On the other hand, recent findings from studies that have investigated the potential use of the blockers of the components of the alternate RAS provided compelling evidence that could lead to the development of drugs targeting the splanchnic vascular bed to inhibit splanchnic vasodilatation in portal hypertension. This review outlines the mechanisms related to the pathogenesis of portal hypertension and attempts to provide an update on currently available therapeutic approaches in the management of portal hypertension with special emphasis on how the alternate RAS could be manipulated in our search for development of safe, specific and effective novel therapies to treat portal hypertension in cirrhosis.
Supported by National Health and Medical Research Council (NHMRC) of Australia Project Grants, No. APP1124125.
JournalWorld Journal of Gastroenterology
Pagination29p. (p. 6111-6140)
PublisherBaishideng Publishing Group
Rights StatementThe Author reserves all moral rights over the deposited text and must be credited if any re-use occurs. Documents deposited in OPAL are the Open Access versions of outputs published elsewhere. Changes resulting from the publishing process may therefore not be reflected in this document. The final published version may be obtained via the publisher’s DOI. Please note that additional copyright and access restrictions may apply to the published version.
Science & TechnologyLife Sciences & BiomedicineGastroenterology & HepatologyPortal hypertensionCirrhosisIntrahepatic vascular resistanceHyperdynamic circulatory stateSplanchnic vasodilatationPortal blood flowNon-selective beta-blockersAlternate renin angiotensin systemRENIN-ANGIOTENSIN SYSTEMNITRIC-OXIDE SYNTHASEHEPATIC VENOUS-PRESSUREPROPRANOLOL PLUS ISOSORBIDE-5-MONONITRATEPROSPECTIVE RANDOMIZED-TRIALNONSELECTIVE BETA-BLOCKERCHRONIC LIVER-DISEASESENDOTHELIAL DYSFUNCTIONRECEPTOR MASDOUBLE-BLIND