Low doses of isosorbide mononitrate attenuate the postprandial increase in portal pressure in patients with cirrhosis

Authors

  • Lia Bellis,

    1. Hepatic Hemodynamic Laboratory, Liver Unit, IMD, Hospital Clinic, Institut de Investigacions Biomediques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Spain
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    • L.B. and A.B. equally contributed to this work and share first authorship.

  • Annalisa Berzigotti,

    1. Hepatic Hemodynamic Laboratory, Liver Unit, IMD, Hospital Clinic, Institut de Investigacions Biomediques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Spain
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    • L.B. and A.B. equally contributed to this work and share first authorship.

  • Juan G. Abraldes,

    1. Hepatic Hemodynamic Laboratory, Liver Unit, IMD, Hospital Clinic, Institut de Investigacions Biomediques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Spain
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  • Eduardo Moitinho,

    1. Hepatic Hemodynamic Laboratory, Liver Unit, IMD, Hospital Clinic, Institut de Investigacions Biomediques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Spain
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  • Juan C. García-Pagán,

    1. Hepatic Hemodynamic Laboratory, Liver Unit, IMD, Hospital Clinic, Institut de Investigacions Biomediques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Spain
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  • Jaime Bosch,

    Corresponding author
    1. Hepatic Hemodynamic Laboratory, Liver Unit, IMD, Hospital Clinic, Institut de Investigacions Biomediques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Spain
    • Hepatic Hemodinamic Laboratory, Liver Unit, Hospital Clinic, Villarroel 170, 08036 Barcelona, Spain; fax: (34) 932 279 856
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  • Juan Rodés

    1. Hepatic Hemodynamic Laboratory, Liver Unit, IMD, Hospital Clinic, Institut de Investigacions Biomediques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Spain
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Abstract

Postprandial hyperemia is associated with a significant increase in portal pressure in cirrhosis, which may contribute to progressive dilation and rupture of gastroesophageal varices. In cirrhosis, an insufficient hepatic production of nitric oxide (NO) may impair the expected hepatic vasodilatory response to increased blood flow, further exaggerating the postprandial increase in portal pressure. This study was aimed at investigating whether low doses of an oral NO donor might counteract the postprandial peak in portal pressure. Twenty-three portal hypertensive cirrhotics, 8 of them under propranolol therapy, were randomized to receive orally 5-isosorbide mononitrate (ISMN; 10 mg; n = 11) or placebo (n = 12) and a standard liquid meal 15 minutes later. Hepatic venous pressure gradient (HVPG), mean arterial pressure (MAP), and hepatic blood flow (HBF) were measured at baseline and 15, 30, and 45 minutes after a meal. ISMN significantly attenuated the postprandial increase in portal pressure as compared with placebo (peak HVPG increase: 2.4 ± 1.4 mm Hg vs. 5.2 ± 2.1 mm Hg, P = .002). Percentual increases in HBF were similar in both groups. MAP decreased slightly in ISMN group (−7.5% ± .5%; P < .01 vs. baseline). These effects were also observed in patients on chronic propranolol therapy. In conclusion, hepatic NO supplementation by low doses of ISMN effectively reduces the postprandial increase of portal pressure in cirrhosis, with only a mild effect on arterial pressure. The same was observed in patients receiving propranolol. Our results suggest that therapeutic strategies based on selective hepatic NO delivery may improve the treatment of portal hypertension.

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