Early Portopulmonary Hypertension in Cirrhosis: Journal of Hepatology | February 2026

Introduction

Portopulmonary hypertension represents a complex cardiopulmonary complication of cirrhosis that significantly impacts prognosis and transplant eligibility. Recent data from the PORTO-DETECT cohort have suggested that even early-stage portopulmonary hypertension, defined using updated hemodynamic criteria, is associated with increased mortality. This has generated considerable interest, particularly regarding whether early disease represents a true biological risk state or simply reflects differences in treatment exposure and detection.

Problem Statement

The key clinical uncertainty is whether early portopulmonary hypertension independently predicts mortality or whether observed outcomes are confounded by treatment bias, patient selection, and methodological limitations inherent to observational studies. Additionally, it remains unclear whether early detection should alter management, given the lack of evidence supporting early therapeutic intervention and the challenges in implementing invasive screening strategies such as right-heart catheterisation.

Summary

The association between early portopulmonary hypertension and increased mortality compared to patients with normal hemodynamics, independent of liver disease severity and portal hypertension. Importantly, no patients were on pulmonary vasodilator therapy at baseline, minimising treatment-related confounding in the early disease group. The authors acknowledge that treatment imbalance and observational design limit causal inference but argue that these factors do not fully explain the observed mortality signal. They emphasise that early portopulmonary hypertension should currently be viewed as a prognostic marker rather than an indication for immediate treatment. The findings support closer surveillance and risk stratification rather than therapeutic escalation. Future prospective studies and dedicated trials are needed to determine whether early intervention can improve outcomes and to define optimal screening strategies in patients with cirrhosis.