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Prevalence and risk factors of portopulmonary hypertension in chronic liver disease: systematic review and meta-analysis
Journal article   Peer reviewed

Prevalence and risk factors of portopulmonary hypertension in chronic liver disease: systematic review and meta-analysis

Tareq Alsaleh, Amir Harb, Parikshit Chapagain, Bassel Dakkak, Prachi Mann, Nouman Shafique, Nihal Khan, Mohamad Khaled Almujarkesh and Ayman Koteish
Clinics and research in hepatology and gastroenterology, Vol.50(1), pp.102748-102748
01/01/2026
DOI: 10.1016/j.clinre.2025.102748
PMID: 41412478

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Abstract

•We synthesized 48 studies (16,351 CLD patients) on portopulmonary hypertension (PoPH) prevalence and risk factors.•RHC-confirmed PoPH prevalence was 2.4% (95% CI 1.4–4.1); TTE-estimated prevalence was 8.7% (5.9–12.7).•Among PoPH cases, viral hepatitis and alcohol-associated liver disease (AALD) accounted for most causes of CLD. AALD was the most common cause in Europe and North America, while viral hepatitis was most common in Asia.•TTE overestimates PoPH versus RHC; standardized echocardiographic thresholds are needed to reduce false positives.•Risk factors: female sex, autoimmune hepatitis, older age, and higher INR; these groups merit earlier screening.•There was a wide variation in screening practices and diagnostic thresholds. Prospective multicenter studies should refine screening algorithms and risk prediction, as early detection and management improves peri-transplant survival. Portopulmonary hypertension (PoPH) increases perioperative mortality in liver transplantation, underscoring the need for early detection. To better quantify its burden and improve detection, we performed a systematic review and meta-analysis of studies reporting PoPH prevalence and risk factors among adults with chronic liver disease (CLD). We searched multiple databases through March 2025 for studies reporting the prevalence and risk factors of PoPH in CLD. The primary outcome of interest was the pooled prevalence, while the secondary outcome was risk factors. Standard meta-analysis methods were followed using the random-effects model, generating pooled effect estimates with 95% confidence intervals (CI). Heterogeneity was assessed using the I2% statistic. A total of 48 studies were included, comprising 16,351 CLD patients (mean age 55.5; 60% males). The pooled prevalence of PoPH on RHC was 2.4 % (95% CI: 1.4, 4.1; I2 = 93.3%), whereas the pooled prevalence on TTE was 8.7% (95% CI: 5.9, 12.7). Significant risk factors for PoPH on TTE were female sex (OR 1.83), autoimmune hepatitis (AIH) (OR 1.92), older age (MD 2.19), and higher INR (MD 0.11). AIH was a significant risk factor for PoPH on RHC (OR 2.28). Meta-regression revealed significant decrease of RHC-based prevalence with time (-0.07% per year; p=0.007). Egger’s tests showed no publication bias. PoPH confirmed by RHC is uncommon but appears overestimated by TTE. Females, patients with AIH, older age, and coagulopathy may benefit from earlier screening. Standardized echocardiographic thresholds and prospective multicenter studies are needed to refine prevalence and risk prediction.
 Chronic liver disease Hepatology Liver transplant Portopulmonary hypertension Prevalence

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