Effects of tilting on central hemodynamics and homeostatic mechanisms in cirrhosis

Hepatology. 2004 Oct;40(4):811-9. doi: 10.1002/hep.20416.


Patients with cirrhosis have a hyperdynamic circulation and an abnormal blood volume distribution with central hypovolemia, an activated sympathetic nervous system (SNS) as well as the renin-angiotensin-aldosterone system (RAAS). As the hyperdynamic circulation in cirrhosis may be present only in the supine patient, we studied the humoral and central hemodynamic responses to changes with posture. Twenty-three patients with alcoholic cirrhosis (Child-Turcotte-Pugh classes A/B/C: 2/13/8) and 14 healthy controls were entered. Measurements of central hemodynamics and activation of SNS and RAAS were taken in the supine position, after 30 degrees head-down tilting, and after 60 degrees passive head-up tilting for a maximum of 20 minutes. After the head-up tilting, the central blood volume (CBV) decreased in both groups, but the decrease was significantly smaller in patients than in controls (-19% vs. -36%, P <.01). Central circulation time increased only in the patients (+30% vs. -1%, P <.01). The absolute increases in circulating norepinephrine and renin after head-up tilting were significantly higher in the patients than in the controls (P <.05 and P <.01, respectively). In patients with cirrhosis, changes in SNS and RAAS were related to changes in arterial blood pressure, systemic vascular resistance, heart rate, non-CBV, plasma volume, and arterial compliance. In conclusion, cardiovascular and humoral responses to changes in posture are clearly abnormal in patients with cirrhosis. Head-up tilting decreases the CBV less in patients with cirrhosis, and the results suggest a differential regulation of central hemodynamics in patients with cirrhosis.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Atrial Natriuretic Factor / blood
  • Blood Pressure
  • Calcitonin Gene-Related Peptide / blood
  • Compliance
  • Female
  • Head-Down Tilt
  • Heart Rate
  • Hemodynamics*
  • Humans
  • Liver Cirrhosis, Alcoholic / physiopathology*
  • Male
  • Middle Aged
  • Norepinephrine / blood
  • Plasma Volume
  • Posture*
  • Renin / blood
  • Vascular Resistance


  • Atrial Natriuretic Factor
  • Renin
  • Calcitonin Gene-Related Peptide
  • Norepinephrine