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Methylene Blue Improves the Hepatopulmonary Syndrome
- Peter Schenk, MD;
- Stephan Lehr; and
- Christian Müller, MD
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IN RESPONSE:
We thank Drs. Groneberg and Fischer for their interest and Dr. Fallon (1) for his excellent editorial. In our study, no significant change was seen in hepatic or renal function before and after methylene blue infusion, respectively (total bilirubin level, 183 ± 202 µmol/L [10.7 ± 11.8 mg/dL] vs. 180 ± 188 µmol/L [10.5 ± 11 mg/dL] [P > 0.2]; serum albumin level, 289 ± 43 g/L vs. 299 ± 38 g/L [P = 0.17]; prothrombin time, 37.7 ± 10 seconds vs. 38 ± 9 seconds [P > 0.2]; serum creatinine concentration, 115 ± 71 µmol/L [1.3 ± 0.8 mg/dL] vs. 115 ± 62 µ mol/L [1.3 ± 0.7 mg/dL] [P > 0.2]). Six patients died. Median survival time was 69 days (range, 6 to 322 days); patient 6 is still alive 34 months after the study. The prognosis of patients with the hepatopulmonary syndrome seems poor (2), but prospective studies are needed.
To answer the questions posed by Dr. Fallon (1), there is some correlation between the improvement in oxygenation (alveolar-arterial difference for PaO2 [PAO2-PaO2]) and the increase in mean pulmonary artery pressure and pulmonary vascular resistance after methylene blue infusion. The correlation coefficient for the difference at 0.5 hour minus baseline was −0.59 for PAO2-PaO2 compared with mean pulmonary artery pressure (P = 0.16) and 0.67 for PAO2-PaO2 compared with pulmonary vascular resistance (P = 0.1). The correlation between changes of systemic vascular resistance and pulmonary vascular resistance was 0.79 (P = 0.03). However, these correlations must be interpreted with caution because of the small sample size. Regarding septic shock, one study reported a decrease in arterial oxygenation after methylene blue administration (3); however, other studies did not report this result (4, 5). Septic shock and the hepatopulmonary syndrome are different diseases with different causes, and direct comparisons are of limited value.
Although methylene blue is relatively safe, its long-term use is limited because it is a strong dye. If used regularly, it would discolor not only urine but also lacrimal fluid, saliva, and probably mucous membranes and the skin. Treatment, especially long-term treatment, is still problematic (1), and further clinical studies using substances that inhibit the production or action of nitric oxide are needed.
Peter Schenk, MD
Stephan Lehr
Christian Müller, MD
University of Vienna
1090 Vienna, Austria
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
