When pulmonary vasodilator therapy lowers PVR to transplant targets but causes systemic hypotension or worsening renal perfusion in decompensated cirrhosis, how do you adjust therapy (dose reduction, agent change, accepting higher PVR) while preserving both hemodynamic eligibility and overall transplant candidacy?

Fortunately, an uncommon problem, but when it does occur, careful dose reduction of the offending agent may help. Also, I would consider going from any offending oral medication to an inhaled prostacyclin to avoid/minimize systemic effects.

Although anecdotally less common to be clinically relevant in most patients, PAH meds may have a hypotensive effect. Patients with decompensated cirrhosis not infrequently do have systemic blood pressures and SVR on the lower side. Since a life-saving transplant is a goal, and that porto-pulmonary h...