S5577 Breathing Easier: High Dose Garlic for Refractory HPS After Liver Transplant

Introduction: Hepatopulmonary syndrome (HPS) is a pulmonary vascular complication of cirrhosis characterized by intrapulmonary vasodilation and impaired oxygenation. Liver transplantation (LT) is the only curative treatment, but persistent hypoxemia occurs in up to 25% of HPS patients post-LT.1 We present a patient with refractory post-LT HPS who improved with high-dose garlic therapy. Case Description/Methods: A 67-year-old man with decompensated alcohol-related cirrhosis with portal hypertension and pre-transplant oxygen requirements of 3–6 L/min for >1 year prior to presentation developed worsening hypoxemia following orthotopic LT. Despite appropriate post-LT graft function, he experienced positional desaturation (70%–80% upright, 80%–90% supine) on 6 L/min of oxygen. A comprehensive workup, including contrast-enhanced echocardiography, computed tomography chest with intravenous contrast, and pulmonary angiography, excluded thromboembolic and structural pulmonary pathology. Findings were consistent with persistent HPS. Initial trials of high-flow nasal cannula and intravenous methylene blue (100 mg) had no effect. After multidisciplinary discussion, the patient was started on high-dose garlic (4 g daily), based on limited data supporting its nitric oxide–modulating effects. Within one week, oxygenation improved and discharged on 10–15 L/min. By 3 months, oxygen was discontinued. Discussion: Persistent post-LT HPS is challenging, with limited options. Extracorporeal membrane oxygenation (ECMO) was not pursued due to uncertain timing, and pulmonary vasodilators were withheld to avoid exacerbating shunting and worsening hypoxemia. Garlic was used based on limited data and expert input as a low-risk option.2,3 Although the exact mechanism is not understood, garlic may cause uniform vasodilation and redistribute blood flow from dilated basal to better-ventilated upper lung zones, improving ventilation/perfusion and reducing nitric oxide.3 As HPS recovery is often gradual, garlic may safely bridge this period. Given its safety, garlic may be a supportive option in select patients. Further studies are needed to define its role in post-LT hypoxemia. References 1. Pascasio JM, Grilo I, López-Pardo FJ, et al. Prevalence and severity of hepatopulmonary syndrome and its influence on survival in cirrhotic patients evaluated for liver transplantation. Am J Transplant. 2014;14(6):1391-9. 2. Abrams GA, Fallon MB. Treatment of hepatopulmonary syndrome with Allium sativum L. (garlic): A pilot trial. J Clin Gastroenterol. 1998;27(3):232-5. 3. De BK, Dutta D, Pal SK, Gangopadhyay S, Das Baksi S, Pani A. The role of garlic in hepatopulmonary syndrome: A randomized controlled trial. Can J Gastroenterol. 2010;24(3):183-8.