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Twohig PA, Peeraphatdit TB, Samson K, Schissel M, Smith L, Ashford A, Freese L, McCashland T. A Prospective Multimodal Education Intervention for Providers Does Not Increase Hepatic Encephalopathy Treatment Rates. Dig Dis Sci 2024; 69:1996-2007. [PMID: 38652390 DOI: 10.1007/s10620-024-08445-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Over 50% of hospitalizations from hepatic encephalopathy (HE) are preventable, but patients often do not receive medical treatment. AIMS To use a multimodal education intervention (MMEI) to increase HE treatment rates and to evaluate (1) trends in HE treatment, (2) predictors of receiving treatment, and (3) the impact of treatment on hospitalization outcomes. METHODS Prospective single-center cohort study of patients hospitalized with HE from April 1, 2020-September 30, 2022. The first 15 months were a control ("pre-MMEI"), the subsequent 15 months (MMEI) included three phases: (1) prior authorization resources, (2) electronic order set, and (3) in-person provider education. Treatment included receiving any drug (lactulose or rifaximin), or combination therapy. Treatment rates pre- vs. post-MMEI were compared using logistic regression. RESULTS 471 patients were included. There were lower odds of receiving any drug post-MMEI (p = 0.03). There was no difference in receiving combination therapy pre- or post-MMEI (p = 0.32). Predictors of receiving any drug included alcohol-related or cryptogenic cirrhosis (p's < 0.001), and the presence of ascites (p = 0.005) and/or portal hypertension (p = 0.003). The only significant predictor of not receiving any drug treatment was having autoimmune cirrhosis (p < 0.001). Patients seen by internal medicine (p = 0.01) or who were intoxicated (p = 0.02) were less likely to receive rifaximin. Any treatment was associated with higher 30-day liver disease-specific readmission (p < 0.001). CONCLUSION This MMEI did not increase HE treatment rates, suggesting that alternative strategies are needed to identify and address barriers to treatment.
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Affiliation(s)
- Patrick A Twohig
- Division of Gastroenterology & Hepatology, University of Nebraska Medical Center, 982000 Medical Center Drive, Omaha, NE, 68198-2000, USA.
| | - Thoetchai Bee Peeraphatdit
- Division of Gastroenterology & Hepatology, University of Nebraska Medical Center, 982000 Medical Center Drive, Omaha, NE, 68198-2000, USA
| | - Kaeli Samson
- Department of Biostatistics, University of Nebraska Medical Center, 984375 Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Makayla Schissel
- Department of Biostatistics, University of Nebraska Medical Center, 984375 Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Lynette Smith
- Department of Biostatistics, University of Nebraska Medical Center, 984375 Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Allison Ashford
- Departments of Internal Medicine & Hospital Medicine, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Laura Freese
- Departments of Internal Medicine & Hospital Medicine, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Timothy McCashland
- Department of Biostatistics, University of Nebraska Medical Center, 984375 Nebraska Medical Center, Omaha, NE, 68198, USA
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Redfield R, Latt N, Munoz SJ. Minimal Hepatic Encephalopathy. Clin Liver Dis 2024; 28:237-252. [PMID: 38548436 DOI: 10.1016/j.cld.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Minimal hepatic encephalopathy (MHE) is a pervasive frequent complication of cirrhosis of any etiology. The diagnosis of MHE is difficult as the standard neurologic examination is essentially within normal limits. None of the symptoms and signs of overt HE is present in a patient with MHE, such as confusion, disorientation, or asterixis. Progress has been made in diagnostic tools for detection of attention and cognitive deficits at the point of care of MHE. The development of MHE significantly impacts quality of life and activities of daily life in affected patients including driving motor vehicles and machine operation.
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Affiliation(s)
- Rachel Redfield
- Thomas Jefferson Hospital, Division of Gastroenterology, 132 S. 10th Street, Suite 480, Philadelphia, PA 19106, USA
| | - Nyan Latt
- Virtua Health System, Center for Liver Disease and Transplant Program, 63 Kresson Road, Suite 101, Cherry Hill, NJ 08034, USA
| | - Santiago J Munoz
- The Johns Hopkins University School of Medicine and Medical Institutions, Division of Gastroenterology and Hepatology, 600 N. Wolfe Street, Blalock Building, Suite 465, Baltimore, MD 21287, USA.
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Shetty A, Saab EG, Choi G. Social Impact of Hepatic Encephalopathy. Clin Liver Dis 2024; 28:273-285. [PMID: 38548439 DOI: 10.1016/j.cld.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Hepatic encephalopathy is a medical condition that stems from liver dysfunction, leading to the accumulation of toxins in the bloodstream. This can result in cognitive impairments, mood changes, and motor dysfunction. Its social impact includes challenges in employment, relationships, and daily functioning for affected individuals. Stigma and misunderstanding around the condition can further exacerbate the difficulties faced by both patients and their caregivers. Efforts to raise awareness, improve medical management, and provide support systems can help mitigate the social impact of hepatic encephalopathy.
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Affiliation(s)
- Akshay Shetty
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA.
| | - Elena G Saab
- School of Medicine, Wake Forest University, Winston Salem, NC, USA
| | - Gina Choi
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
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He Q, Mao C, Chen Z, Zeng Y, Deng Y, Hu R. Efficacy of L-ornithine L-aspartate for minimal hepatic encephalopathy in patients with cirrhosis: A meta-analysis of randomized controlled trials. Arab J Gastroenterol 2024; 25:84-92. [PMID: 38403493 DOI: 10.1016/j.ajg.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 11/12/2023] [Accepted: 01/06/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND AND STUDY AIMS Minimal hepatic encephalopathy (MHE) is an early stage of hepatic encephalopathy (HE) and is highly prevalent. The efficacy of L-ornithine L-aspartate (LOLA) for the treatment of HE is well known but its role in MHE remains uncertain. The objectives of the current study were to evaluate the efficacy of LOLA for the treatment of MHE in patients with cirrhosis. METHODS The Cochrane Library, PubMed, EMBASE, Web of Science and Ovid databases were searched. Only randomized controlled trials (RCTs) that compared the efficacy of LOLA with placebo or no intervention for the treatment of MHE in patients with cirrhosis were included from inception to January 2023. The primary outcomes were reversal of MHE and development of overt hepatic encephalopathy (OHE). RESULTS Overall, six RCTs comprising 292 patients were included. Compared with placebo or no intervention, LOLA was more effective in reversing MHE (RR = 2.264, 95 % CI = 1.528, 3.352, P = 0.000, I2 = 0.0 %) and preventing progression of OHE (RR = 0.220, 95 % CI = 0.076, 0.637, P = 0.005, I2 = 0.0 %). Based on subgroup analyses, oral LOLA treatment appeared more likely to reverse MHE (RR = 2.648, 95 % CI = 1.593, 4.402, P = 0.000, I2 = 0.0 %), intravenous LOLA treatment yielded a similar probability of reversing MHE (RR = 1.669, 95 % CI = 0.904, 3.084, P = 0.102, I2 = 0.0 %). LOLA did not show a superior possibility in reducing mortality (RR = 0.422, 95 % CI = 0.064, 2.768, P = 0.368, I2 = 0.0 %) and ammonia levels (SMD = 0.044, 95 % CI = -0.290, 0.379, P = 0.795, I2 = 0.0 %) compared with placebo or no intervention. CONCLUSIONS LOLA has significant beneficial effects on reversal of MHE and prevention of OHE in patients with cirrhosis compared with placebo or no intervention.
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Affiliation(s)
- Qiufeng He
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Chuangjie Mao
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Zhili Chen
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Yilan Zeng
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Yang Deng
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Rong Hu
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China.
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Elsabaawy M, Alhaddad O. Forgettable in the care of liver cirrhosis: the unseen culprits of progression from bad to worse. PRZEGLAD GASTROENTEROLOGICZNY 2024; 19:6-17. [PMID: 38571544 PMCID: PMC10985753 DOI: 10.5114/pg.2024.136361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/20/2023] [Indexed: 04/05/2024]
Abstract
Patients with liver cirrhosis constitute a critically ill and unique population, and their stability relies on a well-coordinated multidisciplinary team with a carefully structured plan. Overlooking any aspect of this plan can expedite disease progression, leading to severe complications. The lack of disease-specific nutritional guidance, the prevalent sedentary lifestyle among patients, and insufficient screening for hepatocellular carcinoma, oesophageal varices, sarcopaenia, minimal hepatic encephalopathy, and diabetes mellitus, along with fibrosis progression and cirrhosis decompensation, can add further complexities. Additionally, devaluing the impact of obesity in triggering liver cirrhosis can be disadvantageous. Prolonged and inappropriate use of proton pump inhibitors also poses a significant challenge with a wide range of complications. These often-unheeded aspects in the care of liver cirrhosis patients represents the unseen culprits of progression from bad to worse and warrant serious consideration.
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Affiliation(s)
- Maha Elsabaawy
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebin Elkom, Menoufia, Egypt
| | - Omkosoum Alhaddad
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebin Elkom, Menoufia, Egypt
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Zhang P, Gan D, Chi X, Mao D, Gao Y, Li Y, Zhou D, Li Q, Zhang M, Lu B, Li F, Xue J, Wang X, Du H, Li X, Liang Y, Ye Y. Regression-based Chinese norms of number connection test A and digit symbol test for diagnosing minimal hepatic encephalopathy. Sci Rep 2024; 14:4005. [PMID: 38369632 PMCID: PMC10874952 DOI: 10.1038/s41598-024-54696-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 02/15/2024] [Indexed: 02/20/2024] Open
Abstract
Number connection test A (NCT-A) and digit symbol test (DST), the preferential neuropsychological tests to detect minimal hepatic encephalopathy (MHE) in China, haven't been standardized in Chinese population. We aimed to establish the norms based on a multi-center cross-sectional study and to detect MHE in cirrhotic patients. NCT-A and DST were administered to 648 healthy controls and 1665 cirrhotic patients. The regression-based procedure was applied to develop demographically adjusted norms for NCT-A and DST based on healthy controls. Age, gender, education, and age by education interaction were all predictors of DST, while age, gender, and education by gender interaction were predictors of log10 NCT-A. The predictive equations for expected scores of NCT-A and DST were established, and Z-scores were calculated. The norm for NCT-A was set as Z ≤ 1.64, while the norm for DST was set as Z ≥ - 1.64. Cirrhotic patients with concurrent abnormal NCT-A and DST results were diagnosed with MHE. The prevalence of MHE was 8.89% in cirrhotic patients, and only worse Child-Pugh classification (P = 0.002, OR = 2.389) was demonstrated to be the risk factor for MHE. The regression-based normative data of NCT-A and DST have been developed to detect MHE in China. A significant proportion of Chinese cirrhotic patients suffered from MHE, especially those with worse Child-Pugh classification.
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Affiliation(s)
- Peng Zhang
- Institute of Liver Disease, Beijing University of Chinese Medicine, Beijing, China
- Department of Gastroenterology and Hepatology, Beijing University of Chinese Medicine Affiliated Dongfang Hospital, Beijing, China
| | - Danan Gan
- Institute of Liver Disease, Beijing University of Chinese Medicine, Beijing, China
- Department of Gastroenterology and Hepatology, Institute of Liver Disease, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
| | - Xiaoling Chi
- Department of Hepatology, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, China
| | - Dewen Mao
- Department of Hepatology, The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, Guangxi Province, China
| | - Yueqiu Gao
- Department of Hepatology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yong Li
- Department of Hepatology, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, China
| | - Daqiao Zhou
- Department of Hepatology, Shenzhen Hospital of Traditional Chinese Medicine, Shenzhen, Guangdong Province, China
| | - Qin Li
- The Fourth Ward, Fuzhou Infectious Disease Hospital, Fuzhou, Fujian Province, China
| | - Mingxiang Zhang
- Department of Integrated Traditional and Western Medicine on Liver Diseases, Shenyang Infectious Disease Hospital, Shenyang, Liaoning Province, China
| | - Bingjiu Lu
- Department of Hepatology, The Affiliated Hospital of Liaoning University of Traditional Chinese Medicine, Shenyang, Liaoning Province, China
| | - Fengyi Li
- Treatment and Research Center of Infectious Disease, The Fifth Medical Center of the General Hospital of the People's Liberation Army, Beijing, China
| | - Jingdong Xue
- Department of Hepatology, Shanxi Hospital of Traditional Chinese Medicine, Xi'an, Shanxi Province, China
| | - Xianbo Wang
- Department of Hepatology, Beijing Ditan Hospital, Beijing, China
| | - Hongbo Du
- Institute of Liver Disease, Beijing University of Chinese Medicine, Beijing, China
- Department of Gastroenterology and Hepatology, Institute of Liver Disease, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
| | - Xiaoke Li
- Institute of Liver Disease, Beijing University of Chinese Medicine, Beijing, China
- Department of Gastroenterology and Hepatology, Institute of Liver Disease, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
| | - Yijun Liang
- Institute of Liver Disease, Beijing University of Chinese Medicine, Beijing, China
- Department of Gastroenterology and Hepatology, Institute of Liver Disease, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
| | - Yongan Ye
- Institute of Liver Disease, Beijing University of Chinese Medicine, Beijing, China.
- Department of Gastroenterology and Hepatology, Institute of Liver Disease, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China.
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Casanova-Ferrer F, Gallego JJ, Fiorillo A, Urios A, Ríos MP, León JL, Ballester MP, Escudero-García D, Kosenko E, Belloch V, Montoliu C. Improved cognition after rifaximin treatment is associated with changes in intra- and inter-brain network functional connectivity. J Transl Med 2024; 22:49. [PMID: 38217008 PMCID: PMC10787503 DOI: 10.1186/s12967-023-04844-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 12/29/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Rifaximin is a non-reabsorbable antibiotic which acts at gut level, and improves cognition and inflammatory parameters in minimal hepatic encephalopathy (MHE) patients, but not all patients show the same level of response. This study aims to assess brain activity, both within and between brain networks, following rifaximin treatment, considering the differences between response groups as well. METHODS Twenty-two healthy controls and 53 patients with cirrhosis (22 without and 31 with MHE, diagnosed by Psychometric Hepatic Encephalopathy Score, PHES) performed psychometric, attention and coordination tests, and blood inflammatory parameters were measured. Resting-state functional magnetic resonance imaging (fMRI) acquisitions were performed on controls and MHE patients. Eighteen MHE patients underwent a rifaximin treatment for 6 months, after which all measures were repeated. fMRI images were analysed and changes after treatment were assessed. RESULTS After rifaximin treatment, 13 patients improved their PHES score (Responder patients) while 5 did not (Non-responder patients). No significant decrease in blood ammonia was observed after rifaximin treatment, but there was a decrease in plasma inflammatory cytokines in responder patients. A global effect of rifaximin was detected on the sensorimotor and fronto-parietal networks. Responder patients showed a relative increase of thalamic network connectivity in comparison to non-responder patients. Before treatment, responder and non-responder patients showed connectivity differences in basal ganglia network. The connection of the sensorimotor and thalamic networks between them and with other networks suffered changes after treatment. These connections between networks mostly decreased after treatment. All changes and differences showed a significant level of correlation with the performance of psychometric tests and the blood levels of inflammatory biomarkers. CONCLUSIONS There was an improvement of the communication between executive, motor and attention-related brain areas, and their functional independence following rifaximin treatment. Patients who respond also show a less deteriorated connection involved in these functions before treatment. Results suggest that the improved inflammatory state of MHE patients, following rifaximin treatment would favour the observed changes in brain function and enhanced cognitive performance.
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Affiliation(s)
- Franc Casanova-Ferrer
- Fundacion de Investigación Hospital Clinico Universitario de Valencia-INCLIVA, Valencia, Spain
| | - Juan-José Gallego
- Fundacion de Investigación Hospital Clinico Universitario de Valencia-INCLIVA, Valencia, Spain
| | - Alessandra Fiorillo
- Fundacion de Investigación Hospital Clinico Universitario de Valencia-INCLIVA, Valencia, Spain
| | - Amparo Urios
- Fundacion de Investigación Hospital Clinico Universitario de Valencia-INCLIVA, Valencia, Spain
| | - María-Pilar Ríos
- Servicio de Medicina Digestiva, Hospital Arnau de Vilanova de Valencia, Valencia, Spain
| | - José Luis León
- Universitats Neurorradiology Unit, Ascires Biomedical Group, Valencia, Spain
| | - María-Pilar Ballester
- Servicio de Medicina Digestiva, Hospital Clinico Universitario de Valencia, Valencia, Spain
| | - Desamparados Escudero-García
- Servicio de Medicina Digestiva, Hospital Clinico Universitario de Valencia, Valencia, Spain
- Departamento de Medicina, University of Valencia, Valencia, Spain
| | - Elena Kosenko
- Institute of Theoretical and Experimental Biophysics of Russian Academy of Sciences, Pushchino, Russia
| | - Vicente Belloch
- Universitats Neurorradiology Unit, Ascires Biomedical Group, Valencia, Spain
| | - Carmina Montoliu
- Fundacion de Investigación Hospital Clinico Universitario de Valencia-INCLIVA, Valencia, Spain.
- Department of Pathology, Faculty of Medicine, University of Valencia, Av Blasco Ibáñez, 15, 46010, Valencia, Spain.
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Ufere NN, Lago-Hernandez C, Alejandro-Soto A, Walker T, Li L, Schoener K, Keegan E, Gonzalez C, Bethea E, Singh S, El-Jawahri A, Nephew L, Jones P, Serper M. Health care-related transportation insecurity is associated with adverse health outcomes among adults with chronic liver disease. Hepatol Commun 2024; 8:e0358. [PMID: 38206200 PMCID: PMC10786597 DOI: 10.1097/hc9.0000000000000358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 11/07/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Health care-related transportation insecurity (delayed or forgone medical care due to transportation barriers) is being increasingly recognized as a social risk factor affecting health outcomes. We estimated the national burden and adverse outcomes of health care-related transportation insecurity among US adults with chronic liver disease (CLD). METHODS Using the U.S. National Health Interview Survey from 2014 to 2018, we identified adults with self-reported CLD. We used complex weighted survey analysis to obtain national estimates of health care-related transportation insecurity. We examined the associations between health care-related transportation insecurity and health care-related financial insecurity, food insecurity, self-reported health status, work productivity, health care use, and mortality. RESULTS Of the 3643 (representing 5.2 million) US adults with CLD, 267 [representing 307,628 (6%; 95% CI: 5%-7%)] reported health care-related transportation insecurity. Adults with CLD experiencing health care-related transportation insecurity had 3.5 times higher odds of cost-related medication nonadherence [aOR, 3.5; (2.4-5.0)], 3.5 times higher odds of food insecurity [aOR, 3.5; (2.4-5.3)], 2.5 times higher odds of worsening self-reported health status over the past year [aOR, 2.5; (1.7-3.7)], 3.1 times higher odds of being unable to work due to poor health over the past year [aOR, 3.1; (2.0-4.9)], and 1.7 times higher odds of being in a higher-risk category group for number of hospitalizations annually [aOR, 1.7; (1.2-2.5)]. Health care-related transportation insecurity was independently associated with mortality after controlling for age, income, insurance status, comorbidity burden, financial insecurity, and food insecurity [aHR, 1.7; (1.4-2.0)]. CONCLUSIONS Health care-related transportation insecurity is a critical social risk factor that is associated with health care-related financial insecurity, food insecurity, poorer self-reported health status and work productivity, and increased health care use and mortality among US adults with CLD. Efforts to screen for and reduce health care-related transportation insecurity are warranted.
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Affiliation(s)
- Nneka N. Ufere
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos Lago-Hernandez
- Department of Medicine, Division of Hospital Medicine, University of California San Diego, La Jolla, California, USA
| | - Alysa Alejandro-Soto
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tiana Walker
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lucinda Li
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kimberly Schoener
- Department of Social Services, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Eileen Keegan
- Department of Social Services, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Carolina Gonzalez
- Department of Social Services, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Emily Bethea
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Siddharth Singh
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Diego, La Jolla, California, USA
- Department of Medicine, Division of Biomedical Informatics, University of California San Diego, La Jolla, California, USA
| | - Areej El-Jawahri
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren Nephew
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Patricia Jones
- Department of Medicine, Division of Digestive Health and Liver Services, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Hammd M, Elghezewi A, Abdulhadi A, Alabid A, Alabid A, Badi Y, Kamal I, Hesham Gamal M, Mohamed Fisal K, Mujtaba M, Sherif A, Frandah W. Efficacy and Safety of Variable Treatment Options in the Prevention of Hepatic Encephalopathy: A Systematic Review and Network Meta-Analysis. Cureus 2024; 16:e53341. [PMID: 38435950 PMCID: PMC10907550 DOI: 10.7759/cureus.53341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2024] [Indexed: 03/05/2024] Open
Abstract
There are no guidelines for the most effective medication to reduce hepatic encephalopathy (HE) or the associated mortality. The purpose of this study is to determine the most effective possible treatment among the single treatment options or the combined treatment options for decreasing the morbidity and mortality of HE. We evaluated the outcomes by various parameters such as the quality of life, reduction in ammonia, all causes of mortality, adverse events, reversal of minimal HE, and development of overt HE. We systematically searched PubMed, Cochrane, Web of Science, and Scopus till the 19th of January 2023 for studies that assess various treatment options for HE. Data were extracted from eligible studies and pooled in a frequentist network meta-analysis as standardized mean difference (SMD) and their 95% confidence interval (CI) using the MetaInsight web-based tool. The Cochrane Tool was used to assess the randomized controlled trials' quality (RCT), while the NIH tool was used to assess the quality of the included cohort studies. Utilizing the R software, the network meta-analysis was conducted. In addition to a significant variation in cases of (Lactulose and Rifaximin) compared with Rifaximin (RR= 0.39, 95% CI [0.17; 0.89]), the results demonstrated a significantly lower incidence of overt HE in (Lactulose and Rifaximin) compared with placebo (RR=0.19, 95% CI [0.09; 0.40]). Most arms demonstrated a statistically significant reduction in the incidence of overt HE compared to albumin and placebo. The results also demonstrated a significant reduction in ammonia between L-ornithine-L-aspartate (LOLA) and probiotics (MD= -19.17, 95% CI [-38.01; -0.32]), as well as a significant difference in the incidence of LOLA compared to placebo (MD= -22.62, 95% CI [-39.16; -6.07]). This network meta-analysis has significant data for managing subclinical HE in people without a history of overt HE. Our analysis showed that (Lactulose and Rifaximin), followed by (Rifaximin and L-carnitine), followed by (Lactulose and Rifaximin with zinc) were the best combinations regarding overt HE. LOLA reduced ammonia best, followed by Nitazoxanide and finally Lactulose. (Lactulose and Nitazoxanide) have the least adverse effects, followed by (Rifaximin and L-carnitine), then Probiotics. Yet, all mortality outcomes and quality of life changes yielded no useful findings. Future studies like RCTs must be done to compare our therapies directly.
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Affiliation(s)
- Mohamed Hammd
- Internal Medicine/Gastroenterology, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Abdelwahap Elghezewi
- Internal Medicine/Gastroenterology, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Ahmed Abdulhadi
- Internal Medicine, Faculty of Medicine, Tripoli University, Tripoli, LBY
| | - Abdelwahhab Alabid
- Internal Medicine, Faculty of Medicine, Tripoli University, Tripoli, LBY
| | - Abdulfatah Alabid
- Internal Medicine, Faculty of Medicine, Tripoli University, Tripoli, LBY
| | - Yasra Badi
- Internal Medicine, All Saints University School of Medicine, Dominica, USA
| | - Ibrahem Kamal
- General Medicine, Al-Azhar University, Alexandria, EGY
| | - Mohamed Hesham Gamal
- Pharmacology and Therapeutics, Faculty of Pharmacy, Tanta University, Banha, EGY
| | - Khalid Mohamed Fisal
- Pharmacology and Therapeutics, Faculty of Pharmacy, Deraya University, Minia, EGY
| | - Mohamed Mujtaba
- Internal Medicine/Gastroenterology, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Ahmed Sherif
- Internal Medicine/Gastroenterology, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Wesam Frandah
- Internal Medicine/Gastroenterology, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
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Gairing SJ, Mangini C, Zarantonello L, Gioia S, Nielsen EJ, Danneberg S, Gabriel M, Ehrenbauer AF, Bloom PP, Ripoll C, Sultanik P, Galle PR, Labenz J, Thabut D, Zipprich A, Lok AS, Weissenborn K, Marquardt JU, Lauridsen MM, Nardelli S, Montagnese S, Labenz C. Prevalence of Minimal Hepatic Encephalopathy in Patients With Liver Cirrhosis: A Multicenter Study. Am J Gastroenterol 2023; 118:2191-2200. [PMID: 36940426 DOI: 10.14309/ajg.0000000000002251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/01/2023] [Indexed: 03/22/2023]
Abstract
INTRODUCTION The prevalence of minimal hepatic encephalopathy (MHE), in particular in different subgroups, remains unknown. This study aimed to analyze the prevalence of MHE in different subgroups to identify patients at high risk and to pave the way for personalized screening approaches. METHODS In this study, data of patients recruited at 10 centers across Europe and the United States were analyzed. Only patients without clinical signs of hepatic encephalopathy were included. MHE was detected using the Psychometric Hepatic Encephalopathy Score (PHES, cut-off < or ≤-4 depending on local norms). Clinical and demographic characteristics of the patients were assessed and analyzed. RESULTS In total, 1,868 patients with cirrhosis with a median model for end-stage liver disease (MELD) of 11 were analyzed (Child-Pugh [CP] stages: A 46%, B 42%, and C 12%). In the total cohort, MHE was detected by PHES in 650 patients (35%). After excluding patients with a history of overt hepatic encephalopathy, the prevalence of MHE was 29%. In subgroup analyses, the prevalence of MHE in patients with CP A was low (25%), whereas it was high in CP B or C (42% and 52%). In patients with a MELD score <10, the prevalence of MHE was only 25%, but it was 48% in patients with a MELD score ≥20. Standardized ammonia levels (ammonia level/upper limit of normal of each center) correlated significantly, albeit weakly with PHES (Spearman ρ = -0.16, P < 0.001). DISCUSSION The prevalence of MHE in patients with cirrhosis was high but varied substantially between diseases stages. These data may pave the way for more individualized MHE screening approaches.
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Affiliation(s)
- Simon Johannes Gairing
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Chiara Mangini
- Department of Medicine, University of Padova, Padova, Italy
| | | | - Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Elise Jonasson Nielsen
- Department of Gastroenterology and Hepatology, Hospital of South West Jutland, Esbjerg, Denmark
| | - Sven Danneberg
- Department of Medicine I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Maria Gabriel
- Clinic for Neurology, Hannover Medical School, Hannover, Germany
| | | | - Patricia P Bloom
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Cristina Ripoll
- Department of Internal Medicine IV, Jena University Hospital, Jena, Germany
- First Department of Internal Medicine, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Philippe Sultanik
- Service d'hépato-gastroentérologie, Sorbonne Université, Hôpital Pitié-Salpêtrière Assistance Publique Hôpitaux de Paris, Paris, France
| | - Peter Robert Galle
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Joachim Labenz
- Department of Medicine, Diakonie Hospital Jung-Stilling, Siegen, Germany
| | - Dominique Thabut
- Service d'hépato-gastroentérologie, Sorbonne Université, Hôpital Pitié-Salpêtrière Assistance Publique Hôpitaux de Paris, Paris, France
| | - Alexander Zipprich
- Department of Internal Medicine IV, Jena University Hospital, Jena, Germany
- First Department of Internal Medicine, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Anna S Lok
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Jens Uwe Marquardt
- Department of Medicine I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Mette Munk Lauridsen
- Department of Gastroenterology and Hepatology, Hospital of South West Jutland, Esbjerg, Denmark
| | - Silvia Nardelli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Sara Montagnese
- Department of Medicine, University of Padova, Padova, Italy
- Chronobiology Section, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Christian Labenz
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
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11
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Gairing SJ, Schleicher EM, Kaps L, Schulte-Beerbuehl S, Steiner K, Labenz J, Schattenberg JM, Galle PR, Wörns MA, Labenz C. Development and evaluation of a virtual reality driving test for patients with cirrhosis. Hepatol Commun 2023; 7:e0303. [PMID: 37902506 PMCID: PMC10617881 DOI: 10.1097/hc9.0000000000000303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 09/10/2023] [Indexed: 10/31/2023] Open
Abstract
BACKGROUND Patients with cirrhosis and especially those with HE may have impaired driving skills and may be prone to car accidents. This proof-of-concept study aimed to develop and evaluate the applicability of a virtual reality (VR)-based driving test in patients with cirrhosis. Additionally, the association between the results in the VR test and car accidents was investigated. METHODS A short driving test using a VR head-mounted display (HTC Vive Pro Eye) was developed to simulate five hazardous situations. The patient has to pull the brake when the hazardous situations occur. The time from triggering the event to pressing the brake is recorded as reaction time. Total reaction time (TRT) is defined as the combined reaction time to all 5 events. Car accidents were assessed retrospectively (previous 12 months) and patients were followed prospectively for 6 months. Minimal HE (MHE) was diagnosed using Psychometric Hepatic Encephalopathy Score. RESULTS In total, 112 outpatients with cirrhosis and 52 controls without cirrhosis were recruited. MHE was detected in 14% (n = 15). Patients with cirrhosis and MHE (5.67 s) had higher TRTs compared to patients without MHE (5.02 s) and controls without cirrhosis above the age of 50 (4.98 s) (MHE vs. no MHE or controls p<0.01, no MHE vs. controls: not significant). Seven patients reported car accidents during the twelve months prior to study inclusion. TRTs were numerically higher in patients with reported car accidents (p = 0.099). When patients who stopped driving for HE-related/cirrhosis-related reasons (n = 14) were added to the group of patients with accidents, then a longer TRT was significantly associated with the modeled outcome in univariable (p<0.01) and multivariable analyses (OR 2.83, p<0.01). Two car accidents occurred during follow-up. Both patients had TRTs above the 90th percentile. CONCLUSIONS The VR driving test is easy and rapid to perform in patients with cirrhosis and could be helpful as a point-of-care tool for predicting car accidents.
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Affiliation(s)
- Simon J. Gairing
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Eva M. Schleicher
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Leonard Kaps
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Sophia Schulte-Beerbuehl
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Kristina Steiner
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Joachim Labenz
- Department of Medicine, Diakonie Hospital Jung-Stilling, Siegen
| | - Jörn M. Schattenberg
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Metabolic Liver Research Program, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Peter R. Galle
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Marcus-Alexander Wörns
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Department of Gastroenterology, Hematology, Oncology and Endocrinology, Klinikum Dortmund, Germany
| | - Christian Labenz
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
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12
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Hamzaoui L, Mahmoudi M, Mohamed G, Elloumi H, Laabidi A, Boubaker J, Boudabbous M, Tahri N, Jemni I, Safer L, Jomni T, Douggui H, Trad D, Gargouri D, Ayadi S, Debbeche R, Belhouchet S, Marouani R, Cheikh I, Abdelli MN. EncephalApp Stroop Test for covert hepatic encephalopathy screening in Tunisian cirrhotic patients. F1000Res 2023; 11:686. [PMID: 37767072 PMCID: PMC10521086 DOI: 10.12688/f1000research.121781.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Background: Covert hepatic encephalopathy (CHE) is underdiagnosed and is difficult to detect. The EncephalApp Stroop test is validated for its screening. The aim of the study was to define Tunisian norms for the test based on healthy controls norms and to estimate the prevalence of CHE in cirrhotic Tunisian patients. Methods: A prospective, multicenter, cross-sectional study was conducted. Ambulatory or hospitalized cirrhotic patients aged 40 years and over were recruited at 11 centers. Healthy subjects aged 40 years and over were recruited at 8 centers. We used a translated Arabic version of the streamlined EncephalApp Stroop test. The task has two components: "Off" and "On" state depending on the discordance or concordance of the stimuli. Results: 142 patients were included. The mean age was 57.26 years [40-86]. 40 (28.17%) of cirrhotic patients who were included were diagnosed as having a minimal hepatic encephalopathy or CHE. Among the ineligible patients, 22 had overt hepatic encephalopathy. If we consider these patients, the overall prevalence rate of CHE was around 24.39% in cirrhotic patients. It was more frequent in women (34.21% vs 25.96%), and in patients whose level of school education is between 6 and 13 years. Its prevalence does not appear to be affected by gender, MELD score, etiology of cirrhosis and age group of patients, as these variables were independent with respective p according to the chi-square test 0.413; 0.736; 0.663 and 0.1. The stroop times (On / Off and On + Off) correlated significantly with each other, are associated significantly and positively with age (respective Pearson coefficients: 0.578; 0.567 and 0.6). The more the age increases, the more the stroop response times increases (p > 10 -3). Conclusions: EncephalApp Stroop test was an efficient screening tool for CHE in Tunisian cirrhotic patients.
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Affiliation(s)
- Lamine Hamzaoui
- Gastroenterology, Mohamed Taher Maamouri Hospital, Tunis El Manar University, Faculty of Medicine of Tunis, Nabeul, Tunisia
| | - Moufida Mahmoudi
- Gastroenterology, Mohamed Taher Maamouri Hospital, Tunis El Manar University, Faculty of Medicine of Tunis, Nabeul, Tunisia
| | - Ghanem Mohamed
- Gastroenterology, Military Hospital of Tunis, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
| | - Hanene Elloumi
- Gastroenterology, Habib Bougatfa Hospital, Tunis El Manar University, Faculty of Medicine of Tunis, Bizerte, Tunisia
| | - Asma Laabidi
- Gastroenterology, La Rabta Hospital A, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
| | - Jalel Boubaker
- Gastroenterology, La Rabta Hospital A, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
| | - Mona Boudabbous
- Gastroenterology, Hedi Chaker Hospital, Faculty of Medicine of Sfax, Sfax, Tunisia
| | - Nabil Tahri
- Gastroenterology, Hedi Chaker Hospital, Faculty of Medicine of Sfax, Sfax, Tunisia
| | - Imen Jemni
- Gastroenterology, Fattouma Bourguiba University Hospital, Monastir, Monastir, Tunisia
| | - Leila Safer
- Gastroenterology, Fattouma Bourguiba University Hospital, Monastir, Monastir, Tunisia
| | - Taieb Jomni
- Gastroenterology, La Marsa Internal Security Forces Hospital, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
| | - Hedi Douggui
- Gastroenterology, La Marsa Internal Security Forces Hospital, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
| | - Dorra Trad
- Gastroenterology, Habib Thameur Hospital, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
| | - Dalila Gargouri
- Gastroenterology, Habib Thameur Hospital, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
| | - Shema Ayadi
- Gastroenterology, Hospital Charles Nicolle, Tunis, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
| | - Radhouane Debbeche
- Gastroenterology, Hospital Charles Nicolle, Tunis, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
| | | | - Ridha Marouani
- Gastroenterology, Kasserine Hospital, Kasserine, Tunisia
| | - Imed Cheikh
- Gastroenterology, Habib Bougatfa Hospital, Tunis El Manar University, Faculty of Medicine of Tunis, Bizerte, Tunisia
| | - Mohamed Nabil Abdelli
- Gastroenterology, Military Hospital of Tunis, Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
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13
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Mansour D, Masson S, Corless L, Douds AC, Shawcross DL, Johnson J, Leithead JA, Heneghan MA, Rahim MN, Tripathi D, Ross V, Hammond J, Grapes A, Hollywood C, Botterill G, Bonner E, Donnelly M, McPherson S, West R. British Society of Gastroenterology Best Practice Guidance: outpatient management of cirrhosis - part 2: decompensated cirrhosis. Frontline Gastroenterol 2023; 14:462-473. [PMID: 37862447 PMCID: PMC10579554 DOI: 10.1136/flgastro-2023-102431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2023] Open
Abstract
There are two distinct phases in the natural history of cirrhosis: compensated disease (corresponding to Child Pugh A and early Child Pugh B disease), where the patient may be largely asymptomatic, progressing with increasing portal hypertension and liver dysfunction to decompensated disease (corresponding to Child Pugh late B-C), characterised by the development of overt clinical signs, including jaundice, hepatic encephalopathy (HE), ascites, renal dysfunction and variceal bleeding. The transition from compensated cirrhosis to decompensated cirrhosis (DC) heralds a watershed in the nature and prognosis of the disease. DC is a systemic disease, characterised by multiorgan/system dysfunction, including haemodynamic and immune dysfunction. In this second part of our three-part series on the outpatient management of cirrhosis, we address outpatient management of DC, including management of varices, ascites, HE, nutrition, liver transplantation and palliative care. We also introduce an outpatient DC care bundle. For recommendations on screening for osteoporosis, hepatocellular carcinoma surveillance and vaccination see part one of the guidance. Part 3 of the guidance focusses on special circumstances encountered in patients with cirrhosis, including surgery, pregnancy, travel, management of bleeding risk for invasive procedures and portal vein thrombosis.
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Affiliation(s)
- Dina Mansour
- Gateshead Health NHS Foundation Trust, Gateshead, UK
- Newcastle University, Newcastle upon Tyne, UK
| | - Steven Masson
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Lynsey Corless
- Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Andrew C Douds
- Gastroenterology, Queen Elizabeth Hospital, Kings Lynn, UK
| | | | - Jill Johnson
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Joanna A Leithead
- Addenbrooke's Hospital, Cambridge, UK
- Forth Valley Royal Hospital, Larbert, UK
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Dhiraj Tripathi
- University Hospitals Birmingham NHS Foundation Trust, Liver Unit, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | | | - John Hammond
- Hepatopancreatobiliary Multidisciplinary Team, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Coral Hollywood
- Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | | | | | | | - Stuart McPherson
- Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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14
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Zacharias HD, Kamel F, Tan J, Kimer N, Gluud LL, Morgan MY. Rifaximin for prevention and treatment of hepatic encephalopathy in people with cirrhosis. Cochrane Database Syst Rev 2023; 7:CD011585. [PMID: 37467180 PMCID: PMC10360160 DOI: 10.1002/14651858.cd011585.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
BACKGROUND Hepatic encephalopathy describes the spectrum of neuropsychiatric changes that may complicate the course of cirrhosis and detrimentally affect outcomes. Ammonia plays a key role in its development. Rifaximin is a non-absorbable antibiotic that inhibits urease-producing bacteria and reduces absorption of dietary and bacterial ammonia. OBJECTIVES To evaluate the beneficial and harmful effects of rifaximin versus placebo, no intervention, or non-absorbable disaccharides for: (i) the prevention of hepatic encephalopathy, and (ii) the treatment of minimal and overt hepatic encephalopathy, in people with cirrhosis, both when used alone and when combined with a non-absorbable disaccharide. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Clinical Trials Register, CENTRAL, MEDLINE, Embase, three other databases, the reference lists of identified papers, and relevant conference proceedings. We wrote to authors and pharmaceutical companies for information on other published, unpublished, or ongoing trials. Searches were performed to January 2023. SELECTION CRITERIA We included randomised clinical trials assessing prevention or treatment of hepatic encephalopathy with rifaximin alone, or with a non-absorbable disaccharide, versus placebo/no intervention, or a non-absorbable disaccharide alone. DATA COLLECTION AND ANALYSIS Six authors independently searched for studies, extracted data, and validated findings. We assessed the design, bias risk, and participant/intervention characteristics of the included studies. We assessed mortality, serious adverse events, health-related quality of life, hepatic encephalopathy, non-serious adverse events, blood ammonia, Number Connection Test-A, and length of hospital stay. MAIN RESULTS We included 41 trials involving 4545 people with, or at risk for, developing hepatic encephalopathy. We excluded 89 trials and identified 13 ongoing studies. Some trials involved participants with more than one type of hepatic encephalopathy or more than one treatment comparison. Hepatic encephalopathy was classed as acute (13 trials), chronic (7 trials), or minimal (8 trials), or else participants were considered at risk for its development (13 trials). The control groups received placebo (12 trials), no/standard treatment (1 trial), or a non-absorbable disaccharide (14 trials). Eighteen trials assessed rifaximin plus a non-absorbable disaccharide versus a non-absorbable disaccharide alone. We classified 11 trials as at high risk of overall bias for mortality and 28 for non-mortality outcomes, mainly due to lack of blinding, incomplete outcome data, and selective reporting. Compared to placebo/no intervention, rifaximin likely has no overall effect on mortality (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.50 to 1.38; P = 48, I2 = 0%; 13 trials, 1007 participants; moderate-certainty evidence), and there may be no overall effect when compared to non-absorbable disaccharides (RR 0.99, 95% CI 0.49 to 1.97; P = 0.97, I2 = 0%; 10 trials, 786 participants; low-certainty evidence). However, there is likely a reduction in the overall risk of mortality when comparing rifaximin plus a non-absorbable disaccharide to a non-absorbable disaccharide alone (RR 0.69, 95% CI 0.55 to 0.86; number needed to treat for an additional beneficial outcome (NNTB) = 22; P = 0.001, I2 = 0%; 14 trials, 1946 participants; moderate-certainty evidence). There is likely no effect on the overall risk of serious adverse events when comparing rifaximin to placebo/no intervention (RR 1.05, 95% CI 0.83 to 1.32; P = 68, I2 = 0%; 9 trials, 801 participants; moderate-certainty evidence) and there may be no overall effect when compared to non-absorbable disaccharides (RR 0.97, 95% CI 0.66 to 1.40; P = 85, I2 = 0%; 8 trials, 681 participants; low-certainty evidence). However, there was very low-certainty evidence that use of rifaximin plus a non-absorbable disaccharide may be associated with a lower risk of serious adverse events than use of a non-absorbable disaccharide alone (RR 0.66, 95% CI 0.45 to 0.98; P = 0.04, I2 = 60%; 7 trials, 1076 participants). Rifaximin likely results in an overall effect on health-related quality of life when compared to placebo/no intervention (mean difference (MD) -1.43, 95% CI -2.87 to 0.02; P = 0.05, I2 = 81%; 4 trials, 214 participants; moderate-certainty evidence), and may benefit health-related quality of life in people with minimal hepatic encephalopathy (MD -2.07, 95% CI -2.79 to -1.35; P < 0.001, I2 = 0%; 3 trials, 176 participants). The overall effect on health-related quality of life when comparing rifaximin to non-absorbable disaccharides is very uncertain (MD -0.33, 95% CI -1.65 to 0.98; P = 0.62, I2 = 0%; 2 trials, 249 participants; very low-certainty evidence). None of the combined rifaximin/non-absorbable disaccharide trials reported on this outcome. There is likely an overall beneficial effect on hepatic encephalopathy when comparing rifaximin to placebo/no intervention (RR 0.56, 95% CI 0.42 to 0.77; NNTB = 5; P < 0.001, I2 = 68%; 13 trials, 1009 participants; moderate-certainty evidence). This effect may be more marked in people with minimal hepatic encephalopathy (RR 0.40, 95% CI 0.31 to 0.52; NNTB = 3; P < 0.001, I2 = 10%; 6 trials, 364 participants) and in prevention trials (RR 0.71, 95% CI 0.56 to 0.91; NNTB = 10; P = 0.007, I2 = 36%; 4 trials, 474 participants). There may be little overall effect on hepatic encephalopathy when comparing rifaximin to non-absorbable disaccharides (RR 0.85, 95% CI 0.69 to 1.05; P = 0.13, I2 = 0%; 13 trials, 921 participants; low-certainty evidence). However, there may be an overall beneficial effect on hepatic encephalopathy when comparing rifaximin plus a non-absorbable disaccharide to a non-absorbable disaccharide alone (RR 0.58, 95% CI 0.48 to 0.71; NNTB = 5; P < 0.001, I2 = 62%; 17 trials, 2332 participants; low-certainty evidence). AUTHORS' CONCLUSIONS Compared to placebo/no intervention, rifaximin likely improves health-related quality of life in people with minimal hepatic encephalopathy, and may improve hepatic encephalopathy, particularly in populations with minimal hepatic encephalopathy and when it is used for prevention. Rifaximin likely has no overall effect on mortality, serious adverse events, health-related quality of life, or hepatic encephalopathy compared to non-absorbable disaccharides. However, when used in combination with a non-absorbable disaccharide, it likely reduces overall mortality risk, the risk of serious adverse events, improves hepatic encephalopathy, reduces the length of hospital stay, and prevents the occurrence/recurrence of hepatic encephalopathy. The certainty of evidence for these outcomes is very low to moderate; further high-quality trials are needed.
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Affiliation(s)
- Harry D Zacharias
- UCL Institute for Liver & Digestive Health, Division of Medicine, Royal Free Campus, University College London, London, UK
| | - Fady Kamel
- UCL Institute for Liver & Digestive Health, Division of Medicine, Royal Free Campus, University College London, London, UK
| | - Jaclyn Tan
- UCL Institute for Liver & Digestive Health, Division of Medicine, Royal Free Campus, University College London, London, UK
| | - Nina Kimer
- Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Lise Lotte Gluud
- Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Marsha Y Morgan
- UCL Institute for Liver & Digestive Health, Division of Medicine, Royal Free Campus, University College London, London, UK
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15
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Bajaj JS, Lai JC, Tandon P, O'Leary JG, Wong F, Garcia-Tsao G, Vargas HE, Kamath PS, Biggins SW, Limon-Miro A, Shaw J, Mbachi C, Chew M, Golob Deeb J, Thacker LR, Reddy KR. Role of Oral Health, Frailty, and Minimal Hepatic Encephalopathy in the Risk of Hospitalization: A Prospective Multi-Center Cohort of Outpatients With Cirrhosis. Clin Gastroenterol Hepatol 2023; 21:1864-1872.e2. [PMID: 36328307 PMCID: PMC11057906 DOI: 10.1016/j.cgh.2022.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/23/2022] [Accepted: 10/17/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND & AIMS Hospitalizations are a sentinel event in cirrhosis; however, the changing demographics in patients with cirrhosis require updated hospitalization prediction models. Periodontitis is a risk factor for liver disease and potentially progression. The aim of this study was to determine factors, including poor oral health, associated with 3-month hospitalizations in a multi-center cohort of outpatients with cirrhosis. METHODS North American Consortium for Study of End-stage Liver Disease (NACSELD-3), a new study cohort, recruits outpatients with cirrhosis. Cirrhosis details, demographics, minimal hepatic encephalopathy (MHE), frailty, and comorbid conditions including oral health were collected. All patients were followed for 3 months for nonelective hospitalizations. Multi-variable models were created for this outcome using demographics, cirrhosis details, oral health, MHE, frailty, and comorbid conditions with K-fold internal validation using 25%/75% split. RESULTS A total of 442 outpatients (70% men; 37% compensated; Model for End-stage Liver Disease-Sodium, 12; 42% ascites; and 33% prior HE) were included. MHE was found in 70%, frailty in 10%; and both in 8%. In terms of oral health, 15% were edentulous and 10% had prior periodontitis. Regarding 3-month hospitalizations, 14% were admitted for mostly liver-related reasons. These patients were more likely to be decompensated with higher cirrhosis complications, MHE, frailty and periodontitis history. Multi-variable analysis showed prior periodontitis (P = .026), composite MHE + frailty score (P = .0016), ascites (P = .004), prior HE (P = .008), and hydrothorax (P = .004) were associated with admissions using the training and validation subsets. CONCLUSIONS In a contemporaneous, prospective, multi-center cohort study in outpatients with cirrhosis, poor oral health is significantly associated with 3-month hospitalizations independent of portal hypertensive complications, MHE, and frailty. Potential strategies to reduce hospitalizations should consider oral evaluation in addition to MHE and frailty assessment in practice pathways.
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Affiliation(s)
- Jasmohan S Bajaj
- Department of Medicine, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia.
| | - Jennifer C Lai
- Department of Medicine, University of California, San Francisco, California
| | - Puneeta Tandon
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Florence Wong
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Hugo E Vargas
- Department of Medicine, Mayo Clinic, Phoenix, Arizona
| | | | - Scott W Biggins
- Department of Medicine, University of Washington, Seattle, Washington
| | - Ana Limon-Miro
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jawaid Shaw
- Department of Medicine, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia
| | - Chimezie Mbachi
- Department of Medicine, West Haven VA Medical Center, West Haven, Connecticut
| | - Michael Chew
- Department of Medicine, West Haven VA Medical Center, West Haven, Connecticut
| | - Janina Golob Deeb
- Department of Periodontics, Virginia Commonwealth University, Richmond, Virginia
| | - Leroy R Thacker
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - K Rajender Reddy
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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16
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Sun T, Feng M, Manyande A, Xiang H, Xiong J, He Z. Regulation of mild cognitive impairment associated with liver disease by humoral factors derived from the gastrointestinal tract and MRI research progress: a literature review. Front Neurosci 2023; 17:1206417. [PMID: 37397455 PMCID: PMC10312011 DOI: 10.3389/fnins.2023.1206417] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Patients with liver disease are prone to various cognitive impairments. It is undeniable that cognitive impairment is often regulated by both the nervous system and the immune system. In this review our research focused on the regulation of mild cognitive impairment associated with liver disease by humoral factors derived from the gastrointestinal tract, and revealed that its mechanisms may be involved with hyperammonemia, neuroinflammation, brain energy and neurotransmitter metabolic disorders, and liver-derived factors. In addition, we share the emerging research progress in magnetic resonance imaging techniques of the brain during mild cognitive impairment associated with liver disease, in order to provide ideas for the prevention and treatment of mild cognitive impairment in liver disease.
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Affiliation(s)
- Tianning Sun
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Maohui Feng
- Department of Gastrointestinal Surgery, Wuhan Peritoneal Cancer Clinical Medical Research Center, Zhongnan Hospital of Wuhan University, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Wuhan, Hubei, China
| | - Anne Manyande
- School of Human and Social Sciences, University of West London, London, United Kingdom
| | - Hongbing Xiang
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jun Xiong
- Center for Liver Transplantation, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhigang He
- Department of Anesthesiology, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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17
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Abstract
Importance Cirrhosis affects approximately 2.2 million adults in the US. From 2010 to 2021, the annual age-adjusted mortality of cirrhosis increased from 14.9 per 100 000 to 21.9 per 100 000 people. Observations The most common causes of cirrhosis in the US, which can overlap, include alcohol use disorder (approximately 45% of all cases of cirrhosis), nonalcoholic fatty liver disease (26%), and hepatitis C (41%). Patients with cirrhosis experience symptoms including muscle cramps (approximately 64% prevalence), pruritus (39%), poor-quality sleep (63%), and sexual dysfunction (53%). Cirrhosis can be diagnosed by liver biopsy but may also be diagnosed noninvasively. Elastography, a noninvasive assessment of liver stiffness measured in kilopascals, can typically confirm cirrhosis at levels of 15 kPa or greater. Approximately 40% of people with cirrhosis are diagnosed when they present with complications such as hepatic encephalopathy or ascites. The median survival time following onset of hepatic encephalopathy and ascites is 0.92 and 1.1 years, respectively. Among people with ascites, the annual incidence of spontaneous bacterial peritonitis is 11% and of hepatorenal syndrome is 8%; the latter is associated with a median survival of less than 2 weeks. Approximately 1% to 4% of patients with cirrhosis develop hepatocellular carcinoma each year, which is associated with a 5-year survival of approximately 20%. In a 3-year randomized clinical trial of 201 patients with portal hypertension, nonselective β-blockers (carvedilol or propranolol) reduced the risk of decompensation or death compared with placebo (16% vs 27%). Compared with sequential initiation, combination aldosterone antagonist and loop diuretics were more likely to resolve ascites (76% vs 56%) with lower rates of hyperkalemia (4% vs 18%). In meta-analyses of randomized trials, lactulose was associated with reduced mortality relative to placebo (8.5% vs 14%) in randomized trials involving 705 patients and reduced risk of recurrent overt hepatic encephalopathy (25.5% vs 46.8%) in randomized trials involving 1415 patients. In a randomized clinical trial of 300 patients, terlipressin improved the rate of reversal of hepatorenal syndrome from 39% to 18%. Trials addressing symptoms of cirrhosis have demonstrated efficacy for hydroxyzine in improving sleep dysfunction, pickle brine and taurine for reducing muscle cramps, and tadalafil for improving sexual dysfunction in men. Conclusions and Relevance Approximately 2.2 million US adults have cirrhosis. Many symptoms, such as muscle cramps, poor-quality sleep, pruritus, and sexual dysfunction, are common and treatable. First-line therapies include carvedilol or propranolol to prevent variceal bleeding, lactulose for hepatic encephalopathy, combination aldosterone antagonists and loop diuretics for ascites, and terlipressin for hepatorenal syndrome.
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Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
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18
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Gairing SJ, Schleicher EM, Galle PR, Labenz C. Prediction and prevention of the first episode of overt hepatic encephalopathy in patients with cirrhosis. Hepatol Commun 2023; 7:02009842-202304010-00007. [PMID: 36930868 PMCID: PMC10027066 DOI: 10.1097/hc9.0000000000000096] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/13/2022] [Indexed: 03/19/2023] Open
Abstract
Hepatic encephalopathy (HE) is one of the most important complications of patients with liver cirrhosis. In addition, HE is associated with a dismal prognosis and has detrimental effects on patients' quality of life. Thus, it is of pivotal importance to identify patients at high risk for overt HE (OHE) in whom primary prophylaxis may be justified. In this narrative review, we aim to provide insight into predictors and prediction tools for a first-time episode of OHE and to scrutinize the current level of evidence of primary prophylaxis. In recent decades, several cognitive tests, composite scores, and blood-based biomarkers have been demonstrated to be predictive of a first-time episode of OHE. Among the best validated are the established tests for minimal HE, such as the Psychometric Hepatic Encephalopathy Score, determination of the critical flicker frequency, Stroop EncephalApp, or the Animal Naming Test. Individualized risk stratification using blood-based biomarkers and cross-sectional imaging (sarcopenia and spontaneous portosystemic shunts) is coming to the fore, but validation in larger multicenter cohorts is often lacking. On the basis of current evidence, a recommendation for primary prophylaxis of a first episode of OHE cannot be made in general. Only 2 studies have investigated the prevention of a first-time OHE episode as the primary endpoint. In this narrative review, we provide a concise overview of the current evidence levels on prediction tools and pharmacological prevention of a first episode of OHE. In addition, we give an outlook on future research targets to improve knowledge on this important topic.
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Affiliation(s)
- Simon J Gairing
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Eva M Schleicher
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Peter R Galle
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Christian Labenz
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
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19
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Stoll AM, Guido M, Pence A, Gentene AJ. Lack of Access to Rifaximin Upon Hospital Discharge Is Frequent and Results in Increased Hospitalizations for Hepatic Encephalopathy. Ann Pharmacother 2023; 57:133-140. [PMID: 35658580 DOI: 10.1177/10600280221100537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Hepatic encephalopathy (HE) is a complication of cirrhosis. Rifaximin, added to lactulose, effectively maintains remission and reduces hospitalizations from HE compared with lactulose alone. Although the clinical evidence supports the use of rifaximin, concerns remain regarding the financial implications and subsequent impact on medication access and outcomes. OBJECTIVE The goal of this study was to determine whether medication access to rifaximin at hospital discharge reduces readmission and office visits related to HE. METHODS A retrospective study was conducted in compliance with local institutional review board including cirrhotic patients discharged with a rifaximin prescription for HE. Patients were stratified into 2 groups: those able to obtain rifaximin and those unable to obtain rifaximin upon discharge. The primary outcome was to evaluate the rate of HE recurrence in each group as defined as a composite of readmission or office visit for acute HE within 12 months of discharge. RESULTS Access to rifaximin significantly reduced the risk of hospital admission and office visit for acute HE over 12 months. A hospitalization or office visit occurred in 24.5% of patients in the medication access group compared with 50% in the group without medication access. Only 58% of patients had access to rifaximin at discharge. CONCLUSION AND RELEVANCE Rifaximin use was associated with significantly reduced risk of hospitalization and office visits for HE. At discharge, 42% of patients did not have access to rifaximin regardless of being prescribed the medication, identifying that copay is a significant barrier in allowing patients to have access to rifaximin.
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Affiliation(s)
- Ann Marie Stoll
- Internal Medicine, Department of Pharmacy Services, University of Cincinnati Medical Center, UC Health, Cincinnati, OH, USA
| | - Maria Guido
- Internal Medicine, Department of Pharmacy Services, University of Cincinnati Medical Center, UC Health, Cincinnati, OH, USA.,Division of Pharmacy Practice and Administration, University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
| | - Alicia Pence
- Specialty Pharmacy, Department of Pharmacy Services, University of Cincinnati Specialty Pharmacy, UC Health, Cincinnati, OH, USA
| | - Anthony J Gentene
- Internal Medicine, Department of Pharmacy Services, University of Cincinnati Medical Center, UC Health, Cincinnati, OH, USA.,Division of Pharmacy Practice and Administration, University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
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20
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Wang MW, Ma WJ, Wang Y, Ma XH, Xue YF, Guan J, Chen X. Comparison of the effects of probiotics, rifaximin, and lactulose in the treatment of minimal hepatic encephalopathy and gut microbiota. Front Microbiol 2023; 14:1091167. [PMID: 37032856 PMCID: PMC10080009 DOI: 10.3389/fmicb.2023.1091167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 03/13/2023] [Indexed: 04/11/2023] Open
Abstract
Background Minimal hepatic encephalopathy (MHE) is an early stage in the pathogenesis of hepatic encephalopathy. Intestinal microbiota is involved in the pathogenesis of hepatic encephalopathy and has become an important therapeutic target. Since there is no unified treatment principle for MHE, this study was conducted to determine the safety and efficacy of different intestinal microecological modulators in the treatment of MHE, and to explore the potential mechanism through intestinal microbiota analysis. Methods Patients with liver cirrhosis were screened for MHE using psychometric hepatic encephalopathy score test. Patients diagnosed with MHE were enrolled and received probiotics, rifaximin, or lactulose for 4 weeks. Adverse events were recorded. The psychometric hepatic encephalopathy score test was performed after treatment. Samples of blood and stool were collected at entry and 4 weeks. Blood samples were analyzed to assess blood ammonia, liver, kidney, and hemostatic functions. Stool microbiota were sequenced to confirm changes in microbial composition. Results Of 323 patients with liver cirrhosis, 74 patients were diagnosed with MHE. In all, 54 patients were enrolled and 52 who agree to follow-up were included in analysis. The recovery rates of MHE patients received probiotics, rifaximin, and lactulose were 58.8% (20/34), 45.5% (5/11), and 57.1% (4/7), respectively. Probiotics and rifaximin improved liver function in MHE patients to a certain extent. Taxonomic compositions of gut microbiota in MHE patients were distinct from healthy people before treatment; the differences were significantly reduced after treatment, and the gut microbiota gradually resembled the structure of healthy individuals. We found that the relative abundance of specific taxa associated with anti-inflammatory and good cognitive functions was increased in MHE patients after treatment. Accordingly, metabolic pathways in MHE patients were altered before and after treatment. Downregulated pathways after probiotics treatment included glycometabolism and degradation of aromatic compounds. After lactulose treatment, degradation pathways of arginine and ornithine showed a downward trend. Conclusion Probiotics, rifaximin, and lactulose are safe and effective in the treatment of MHE, and improve the composition of gut microbiota to some extent.
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Affiliation(s)
- Ming-Wei Wang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Wei-Juan Ma
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yan Wang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Xiao-Han Ma
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yu-Feng Xue
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jing Guan
- Anhui Provincial Key Laboratory of Digestive Disease, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- *Correspondence: Jing Guan,
| | - Xi Chen
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Xi Chen,
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21
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Minimal Hepatic Encephalopathy Affects Daily Life of Cirrhotic Patients: A Viewpoint on Clinical Consequences and Therapeutic Opportunities. J Clin Med 2022; 11:jcm11237246. [PMID: 36498820 PMCID: PMC9736966 DOI: 10.3390/jcm11237246] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/21/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022] Open
Abstract
Minimal hepatic encephalopathy (MHE) is a frequent complication of hepatic encephalopathy (HE) and can affect up to 80% of patients with liver cirrhosis. It is characterized by the lack of obvious clinical signs and the presence of alterations detectable using psychometric or electrophysiological testing focused on attention, working memory, psychomotor speed and visuospatial ability. Ideally, each patient should be tested for this condition because, despite the absence of symptoms, it has severe repercussions on daily life activities. It may be responsible for an inability to drive, sleep disturbances, risk of falls and inability to work. Some studies have highlighted its prognostically unfavorable role on mortality and risk of "overt" HE (OHE). Finally, MHE severely affects the lives of patients and caregivers, altering their quality of life and their socioeconomic status. Several treatments have been proposed for MHE treatment, including non-absorbable disaccharides, poorly absorbable antibiotics, such as rifaximin, probiotics and branched-chain amino acids, with promising results. For this reason, early diagnosis and intervention with appropriate measures is essential, with the aim of improving both performance on psychometric tests, as well as clinical aspects related to this condition.
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22
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The role of functional magnetic resonance imaging of the brain in the evaluation of hepatic encephalopathy in cirrhotic patients. Clin Exp Hepatol 2022; 8:321-329. [PMID: 36683873 PMCID: PMC9850304 DOI: 10.5114/ceh.2022.122296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/24/2022] [Indexed: 12/31/2022] Open
Abstract
Introduction Hepatic encephalopathy (HE) is a complication of liver failure, with neurological manifestations ranging from minimal HE (MHE) to deep coma (overt HE). Aim of the study To demonstrate the role of functional magnetic resonance imaging (magnetic resonance spectroscopy [MRS] and apparent diffusion coefficient [ADC] value) in the assessment and grading of HE in cirrhotic patients. Material and methods A prospective cohort study was conducted on three groups: group I - 20 healthy controls, group II - 25 cirrhotic patients with MHE, and group III - 25 cirrhotic patients with overt HE. Each group was subjected to MRS, diffusion-weighted imaging, and neuropsychological examinations. At 1H-MRS, the glutamate/glutamine complex (Glx), myo-inositol (mI), choline (Cho), N-acetyl aspartate (NAA), and creatine (Cr) were determined in the basal ganglia or thalamus. The metabolic ratios and ADC values of Glx/Cr, MI/Cr, Cho/Cr, and NAA/Cr were determined. Results The brain metabolite Glx increased with a significant correlation to HE grade (p = 0.001). Other brain metabolites, such as Cho and mI, decreased significantly (p = 0.001). Two brain metabolites (NAA and Cr) remained unchanged across all HE grades and the control group (p = 0.47 and 0.38, respectively). There was an increase in the Glx/Cr ratio and a decrease in the mI/Cr and Cho/Cr ratios. In addition, ADC values were significantly higher in cirrhotic patients with HE than in the control group. Conclusions ADC values and 1H-MRS are imaging modalities that have the potential to detect MHE and grade HE in cirrhotic patients.
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23
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The Assessment of Driving Fitness Using an On-Road Evaluation in Patients With Cirrhosis. Am J Gastroenterol 2022; 117:2017-2024. [PMID: 36087105 DOI: 10.14309/ajg.0000000000001927] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 07/19/2022] [Indexed: 01/30/2023]
Abstract
INTRODUCTION The association between cirrhosis and driving performance is of particular clinical relevance because of the life-threatening safety issues both for the driver with cirrhosis and the general public. Study aims were to assess (i) driving competency through the use of an in-office computerized battery and on-road driving assessment (DriveABLE) and (ii) the association between minimal hepatic encephalopathy (MHE), in-office paper-pencil tools, and additional measures (e.g., frailty, depression, cognitive testing) with unsafe driving. METHODS Patients were prospectively recruited from 2 tertiary care liver clinics. In-office tests and in-office and on-road assessments of driving competence were completed. The χ 2 test and 1-way analysis of variance were used to analyze differences among those with and without MHE. Logistic regression was used to evaluate predictors of an indeterminate/fail result on the in-office computerized driving assessment battery (DriveABLE Cognitive Assessment Tool [DCAT]). RESULTS Eighty patients participated with a mean age of 57 years, 70% male, 75% Child-Pugh B/C, and 36% with a history of overt hepatic encephalopathy. Thirty percent met MHE criteria on both the psychometric hepatic encephalopathy score and the Stroop app tests. Only 2 patients (3%) were categorized as "unfit to drive" in the on-road driving test, one with MHE and the other without. Fifty-eight percent of the patients were scored as indeterminate/fail on the DCAT. This corresponded to a higher mean number of on-road driving errors (5.3 [SD 2.1] vs 4.2 [SD 1.6] in those who passed the DCAT, P = 0.01). Older age (odds ratio 1.3; confidence interval 1.1, 1.5; P = 0.001) and MHE by Stroop/psychometric hepatic encephalopathy score (odds ratio 11.0; confidence interval 2.3, 51.8; P = 0.002) were independently predictive of worse performance on the DCAT. DISCUSSION Worse performance in in-office testing was associated with worse scores on a computerized driving assessment battery and more on-road driving errors, but in-office tools were insufficient to predict on-road driving failures. A diagnosis of MHE should not be used alone to restrict driving in patients with cirrhosis. At-risk patients require on-road driving tests under the supervision of driving regulatory agencies. Future studies should continue to refine and evaluate in-office or at-home testing to predict driving performance.
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A simple covert hepatic encephalopathy screening model based on blood biochemical parameters in patients with cirrhosis. PLoS One 2022; 17:e0277829. [PMID: 36449492 PMCID: PMC9710772 DOI: 10.1371/journal.pone.0277829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 11/03/2022] [Indexed: 12/05/2022] Open
Abstract
AIM Covert hepatic encephalopathy (CHE) adversely affects clinical outcomes in patients with liver cirrhosis, although its diagnosis is difficult. This study aimed to establish a simple CHE screening model based on blood-related biochemical parameters. METHODS This retrospective study enrolled 439 patients who were assessed for CHE using a neuropsychiatric test between January 2011 and June 2019. A simple CHE (sCHE) score was calculated with hypoalbuminemia (≤ 3.5 g/dL) and hyperammonemia (≥ 80 μg/dL) as 1 point each. The association between sCHE score and CHE or overt hepatic encephalopathy (OHE) was assessed using logistic regression and Fine-Gray competing risk regression models. RESULTS Of 381 eligible patients, 79 (21%) were diagnosed with CHE. The distribution of sCHE scores was 48% with 0 point, 33% with 1 point, and 19% with 2 points. Patients with sCHE score ≥ 1 point had a higher prevalence of CHE than those with sCHE score of 0 (27% vs. 14%, P = 0.002). A cut-off value of 1 point showed high discriminative ability for identifying CHE, with a sensitivity of 0.67, specificity of 0.56, positive predictive value of 0.27, and negative predictive value of 0.86. During the median follow-up period of 2.2 years, 58 (15%) patients developed OHE. Multivariate analysis showed that sCHE score ≥ 1 (sub-distribution hazard ratio [SHR], 2.69; 95% confidence interval [CI], 1.41-5.15) and CHE (SHR, 2.17; 95% CI, 1.26-3.73) independently predicted OHE. CONCLUSIONS The sCHE score is a useful screening model for identifying patients with CHE and for predicting OHE occurrence.
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Casanova-Ferrer F, García-Cena CE, Gallego JJ, Fiorillo A, Urios A, Calvo-Córdoba A, Ballester MP, Ríos MP, Durbán L, Hidalgo MR, García F, Felipo V, Montoliu C. Minimal hepatic encephalopathy is associated to alterations in eye movements. Sci Rep 2022; 12:16837. [PMID: 36207472 PMCID: PMC9547018 DOI: 10.1038/s41598-022-21230-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 09/23/2022] [Indexed: 11/09/2022] Open
Abstract
Minimal hepatic encephalopathy (MHE) is diagnosed using PHES battery, but other tests are more sensitive, and a simple tool for early MHE detection is required. Assessment of saccadic eye movements is useful for early detection of cognitive alterations in different pathologies. We characterized the alterations in saccadic eye movements in MHE patients, its relationship with cognitive alterations and its utility for MHE diagnosis. One-hundred and eighteen cirrhotic patients (86 without and 32 with MHE) and 35 controls performed PHES and Stroop test and an eye movements test battery by OSCANN system: visual saccades, antisaccades, memory-guided saccades, fixation test and smooth pursuit. We analyzed 177 parameters of eye movements, assessed their diagnostic capacity for MHE, and correlated with cognitive alterations. MHE patients showed alterations in 56 of the 177 variables of eye movements compared to NMHE patients. MHE patients showed longer latencies and worse performance in most eye movements tests, which correlated with mental processing speed and attention impairments. The best correlations found were for antisaccades and memory-guided saccades, and some parameters in these tests could be useful for discriminating MHE and NMHE patients. Eye movements analysis could be a new, rapid, reliable, objective, and reproducible tool for early diagnose MHE.
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Affiliation(s)
- Franc Casanova-Ferrer
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Cecilia E García-Cena
- Centre for Automation and Robotics, Universidad Politecnica de Madrid, Madrid, Spain
| | - Juan-Jose Gallego
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Alessandra Fiorillo
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Amparo Urios
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Alberto Calvo-Córdoba
- Centre for Automation and Robotics, Universidad Politecnica de Madrid, Madrid, Spain
| | - Maria-Pilar Ballester
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain.,Servicio de Medicina Digestiva, Hospital Clínico Universitario de Valencia, 46010, Valencia, Spain
| | - María Pilar Ríos
- Servicio de Medicina Digestiva, Hospital Arnau de Vilanova, 46015, Valencia, Spain
| | - Lucía Durbán
- Servicio de Medicina Digestiva, Hospital Arnau de Vilanova, 46015, Valencia, Spain
| | - Marta R Hidalgo
- Bioinformatics and Biostatistics Unit, Centro Investigación Príncipe Felipe, 46012, Valencia, Spain
| | - Francisco García
- Bioinformatics and Biostatistics Unit, Centro Investigación Príncipe Felipe, 46012, Valencia, Spain
| | - Vicente Felipo
- Laboratory of Neurobiology, Centro Investigación Príncipe Felipe, 46012, Valencia, Spain
| | - Carmina Montoliu
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain. .,Department of Pathology, Faculty of Medicine, University of Valencia/INCLIVA-Health Research Institute, Avda. Blasco Ibañez, 17, 46010, Valencia, Spain.
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Arenas YM, Martínez-García M, Llansola M, Felipo V. Enhanced BDNF and TrkB Activation Enhance GABA Neurotransmission in Cerebellum in Hyperammonemia. Int J Mol Sci 2022; 23:ijms231911770. [PMID: 36233065 PMCID: PMC9570361 DOI: 10.3390/ijms231911770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 11/28/2022] Open
Abstract
Background: Hyperammonemia is a main contributor to minimal hepatic encephalopathy (MHE) in cirrhotic patients. Hyperammonemic rats reproduce the motor incoordination of MHE patients, which is due to enhanced GABAergic neurotransmission in the cerebellum as a consequence of neuroinflammation. In hyperammonemic rats, neuroinflammation increases BDNF by activating the TNFR1–S1PR2–CCR2 pathway. (1) Identify mechanisms enhancing GABAergic neurotransmission in hyperammonemia; (2) assess the role of enhanced activation of TrkB; and (3) assess the role of the TNFR1–S1PR2–CCR2–BDNF pathway. In the cerebellum of hyperammonemic rats, increased BDNF levels enhance TrkB activation in Purkinje neurons, leading to increased GAD65, GAD67 and GABA levels. Enhanced TrkB activation also increases the membrane expression of the γ2, α2 and β3 subunits of GABAA receptors and of KCC2. Moreover, enhanced TrkB activation in activated astrocytes increases the membrane expression of GAT3 and NKCC1. These changes are reversed by blocking TrkB or the TNFR1–SP1PR2–CCL2–CCR2–BDNF–TrkB pathway. Hyperammonemia-induced neuroinflammation increases BDNF and TrkB activation, leading to increased synthesis and extracellular GABA, and the amount of GABAA receptors in the membrane and chloride gradient. These factors enhance GABAergic neurotransmission in the cerebellum. Blocking TrkB or the TNFR1–SP1PR2–CCL2–CCR2–BDNF–TrkB pathway would improve motor function in patients with hepatic encephalopathy and likely with other pathologies associated with neuroinflammation.
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Montagnese S, Rautou PE, Romero-Gómez M, Larsen FS, Shawcross DL, Thabut D, Vilstrup H, Weissenborn K. EASL Clinical Practice Guidelines on the management of hepatic encephalopathy. J Hepatol 2022; 77:807-824. [PMID: 35724930 DOI: 10.1016/j.jhep.2022.06.001] [Citation(s) in RCA: 97] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/01/2022] [Indexed: 12/12/2022]
Abstract
The EASL Clinical Practice Guidelines (CPGs) on the management of hepatic encephalopathy (HE) present evidence-based answers to a set of relevant questions (where possible, formulated in PICO [patient/population, intervention, comparison and outcomes] format) on the definition, diagnosis, differential diagnosis and treatment of HE. The document does not cover the pathophysiology of HE and does not cover all available treatment options. The methods through which it was developed and any information relevant to its interpretation are also provided.
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Acharya C, McGeorge S, Fagan A, Wade JB, Lee H, Luketic V, Sterling RK, Thacker L, Bajaj JS. Substance‐use simulation impairs driving capability in patients with cirrhosis regardless of hepatic encephalopathy. Hepatol Commun 2022; 6:2867-2875. [PMID: 35842916 PMCID: PMC9512458 DOI: 10.1002/hep4.2028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/16/2022] [Accepted: 06/11/2022] [Indexed: 11/07/2022] Open
Abstract
Driving is independently affected by cirrhosis and hepatic encephalopathy (HE) and alcohol/substance use, but their concomitant impact is unclear. We aimed to determine the impact of alcohol and other substances on driving‐simulator performance in cirrhosis with and without HE. Outpatients with cirrhosis and controls underwent cognitive testing and driving simulation for the following three conditions: baseline, wearing goggles simulating alcohol intoxication, and wearing goggles simulating opioid/benzodiazepine abuse. Outcomes were number of centerline crossings (CCs) and road‐edge excursions (REEs). We compared controls versus patients with cirrhosis then subjects with cirrhosis with and without HE for all conditions, using generalized linear modeling (GLM). Sixty subjects (17 controls, 43 with cirrhosis [Model for End‐Stage Liver Disease score, 10; 21 subjects with prior HE]) were included. Simulations showed higher CCs and REEs at baseline in patients with cirrhosis with and without HE versus controls. With alcohol‐ and substance abuse‐impairment goggles, CCs increased but REEs decreased in cirrhosis. In the GLM, a time and group interaction was seen (p < 0.001) for CCs and REEs. Patients with cirrhosis showed higher CCs and REEs at baseline than controls (CCs, p = 0.003; REEs, p = 0.0001) and higher CCs (p = 0.03) and lower REEs (p = 0.001) with alcohol‐simulating goggles. All groups were equally impaired with opioid/benzodiazepine‐simulating goggles (CCs, p = 0.49; REEs, p = 0.46). Controls with alcohol‐simulating goggles had similar CCs as the baseline of patients with cirrhosis (p = 0.98). conclusions: Simulating alcohol intake induces greater driving impairment in patients with cirrhosis versus controls, but similar patterns were seen with opioid/benzodiazepine‐simulating goggles. At baseline, patients with cirrhosis have simulator outcomes equivalent to intoxicated controls. Driving simulation with goggles modeling substance abuse could improve insight into driving errors and enhance driving rehabilitation in patients with cirrhosis.
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Affiliation(s)
- Chathur Acharya
- Division of Gastroenterology, Hepatology, and NutritionVirginia Commonwealth University and Richmond VA Medical CenterRichmondVirginiaUSA
| | - Sara McGeorge
- Division of Gastroenterology, Hepatology, and NutritionVirginia Commonwealth University and Richmond VA Medical CenterRichmondVirginiaUSA
| | - Andrew Fagan
- Division of Gastroenterology, Hepatology, and NutritionVirginia Commonwealth University and Richmond VA Medical CenterRichmondVirginiaUSA
| | - James B. Wade
- Department of PsychiatryVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Hannah Lee
- Division of Gastroenterology, Hepatology, and NutritionVirginia Commonwealth University and Richmond VA Medical CenterRichmondVirginiaUSA
| | - Velimir Luketic
- Division of Gastroenterology, Hepatology, and NutritionVirginia Commonwealth University and Richmond VA Medical CenterRichmondVirginiaUSA
| | - Richard K. Sterling
- Division of Gastroenterology, Hepatology, and NutritionVirginia Commonwealth University and Richmond VA Medical CenterRichmondVirginiaUSA
| | - Leroy Thacker
- Department of BiostatisticsVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Jasmohan S. Bajaj
- Division of Gastroenterology, Hepatology, and NutritionVirginia Commonwealth University and Richmond VA Medical CenterRichmondVirginiaUSA
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Gairing SJ, Müller L, Kloeckner R, Galle PR, Labenz C. Review article: post-TIPSS hepatic encephalopathy-current knowledge and future perspectives. Aliment Pharmacol Ther 2022; 55:1265-1276. [PMID: 35181894 DOI: 10.1111/apt.16825] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/23/2022] [Accepted: 02/02/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND In light of the global rise in the burden of chronic liver diseases and liver cirrhosis, the number of patients suffering from decompensation events is expected to increase. Transjugular intrahepatic portosystemic shunts (TIPSS) provide effective long-term symptom control and may prolong transplant-free survival in portal hypertension-driven recurrent ascites and variceal bleeding. New-onset or recurrent hepatic encephalopathy (HE) after TIPSS insertion (post-TIPSS HE) represents the most severe post-interventional complication. AIMS To provide insight into the epidemiology and risk factors for post-TIPSS HE and scrutinize the current state of the art in treatment and drug therapy options. METHODS We conducted a literature search on post-TIPSS HE in patients with liver cirrhosis. RESULTS Post-TIPSS HE occurs in up to 54.5% of cases and particularly early recurrent HE is associated with a dismal prognosis. In recent years, several risk factors for the development of post-TIPSS HE have been identified. These include not only parameters reflecting liver function (model for end-stage liver disease score/Child-Pugh score) as well as cognitive dysfunction caused by minimal HE but also extrahepatic factors such as sarcopenia and common medications such as proton pump inhibitors. In addition, new data on the benefit of rifaximin and of smaller stent grafts emerged and may improve the prevention of post-TIPSS HE. CONCLUSIONS Careful selection of TIPSS candidates is of utmost importance to reduce the risk of post-TIPSS HE. In this narrative review, we provide a concise overview of the current epidemiology and risk factors of the treatment options for post-TIPSS HE.
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Affiliation(s)
- Simon Johannes Gairing
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Lukas Müller
- Department of Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Roman Kloeckner
- Department of Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Peter R Galle
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Christian Labenz
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
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Zhu L, Zhang W, Chen L, Ren Y, Cao Y, Sun T, Sun B, Liu J, Wang J, Zheng C. Brain Gray Matter Alterations in Hepatic Encephalopathy: A Voxel-Based Meta-Analysis of Whole-Brain Studies. Front Hum Neurosci 2022; 16:838666. [PMID: 35517986 PMCID: PMC9062230 DOI: 10.3389/fnhum.2022.838666] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 02/28/2022] [Indexed: 12/03/2022] Open
Abstract
Background Previous studies on voxel-based morphometry (VBM) have found that there were gray matter alterations in patients with hepatic encephalopathy (HE). However, the reported results were inconsistent and lack a quantitative review. Therefore, this study aims for a quantitative meta-analysis of VBM analysis on patients with HE. Methods The studies in our meta-analysis were collected from Pubmed, Web of Science, and Embase, which were published from January 1947 to October 2021. The seed-based d mapping (SDM) method was applied to quantitatively estimate the regional gray matter abnormalities in patients with HE. A meta-regression analysis was applied to evaluate the relationship between plasma ammonia and gray matter alteration. Results There were nine studies, with sixteen datasets consisting of 333 participants with HE and 429 healthy controls. The pooled and subgroup meta-analyses showed an increase in gray matter volume (GMV) in the bilateral thalamus and the calcarine fissure but a decrease in the GMV in the bilateral insula, the basal ganglia, the anterior cingulate gyrus, and the cerebellum. The meta-regression showed that plasma ammonia was positively associated with the GMV in the left thalamus but was negatively associated with the GMV in the cerebellum and the bilateral striatum. Conclusion Gray matter volume in patients with HE largely varied and could be affected by plasma ammonia. The findings of this study could help us to better understand the pathophysiology of cognitive dysfunction in patients with HE.
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Affiliation(s)
- Licheng Zhu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Weihua Zhang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lei Chen
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanqiao Ren
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanyan Cao
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tao Sun
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bo Sun
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Jing Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chuansheng Zheng
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
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Kaps L, Hildebrand K, Nagel M, Michel M, Kremer WM, Hilscher M, Galle PR, Schattenberg JM, Wörns MA, Labenz C. Validation of EncephalApp_Stroop as screening tool for the detection of minimal hepatic encephalopathy in German patients with liver cirrhosis. Clin Res Hepatol Gastroenterol 2022; 46:101873. [PMID: 35124289 DOI: 10.1016/j.clinre.2022.101873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 12/14/2021] [Accepted: 01/17/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND In contrast to overt hepatic encephalopathy (OHE), the diagnosis of minimal HE (MHE) is challenging in patients with cirrhosis requiring elaborate, specialized testing. The EncephalApp_Stroop is a smartphone-based application established as screening tool for the diagnosis of MHE but has not yet been validated in a German cohort and country specific cut-offs are currently missing. METHODS 93 patients with cirrhosis were enroled into this study. Psychometric hepatic encephalopathy score (PHES) was used to detect MHE, and a subset of the patients was tested with critical flicker frequency (CFF). All patients underwent testing with EncephalApp_Stroop. Cut-off thresholds for EncephalApp_Stroop were calculated according to Youden's Index and a separate cut-off was determined with focus on sensitivity. RESULTS 24 (26%) patients had MHE according to PHES. EncephalApp_Stroop had a strong correlation with PHES (r=-0.76, p<0.001), while there was only a modest correlation with CFF (r=-0.51, <0.001). On time as well as on+off time discriminated best between patients with and without MHE with AUROCS of 0.87 for both measures. According to Youden's index, a cut-off of >224.7 s (sec) (on+off time) discriminated best between patients with and without MHE with a sensitivity of 71% and a specificity of 88%. The adjusted cut-off value for on+off time with focus on sensitivity (sensitivity:specificity weighed 2:1) was 185.1 s, yielding an optimized sensitivity of 92% and a negative predictive value of 96%. By using this cut-off as a pre-screening test in a stepwise diagnosis algorithm, elaborate testing with PHES could have been avoided in 49% of all patients. CONCLUSION EncephalApp_Stroop may be useful in a stepwise diagnosis algorithm or even as a stand-alone screening tool to detect MHE in German patients with cirrhosis.
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Affiliation(s)
- Leonard Kaps
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany.
| | - Katharina Hildebrand
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Michael Nagel
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Maurice Michel
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Wolfgang Maximilian Kremer
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Max Hilscher
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Peter R Galle
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Jörn M Schattenberg
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Marcus-Alexander Wörns
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Department of Gastroenterology, Hematology, Oncology and Endocrinology, Klinikum Dortmund, Germany
| | - Christian Labenz
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany.
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Devabhaktuni S, Patkar P, Pooja V, Dhamija S, Gupta N, Chaudhury S, Saldanha D. Differentiation of hepatic encephalopathy from delirium tremens: A case series and review. Ind Psychiatry J 2021; 30:S214-S220. [PMID: 34908693 PMCID: PMC8611582 DOI: 10.4103/0972-6748.328865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/18/2021] [Accepted: 06/03/2021] [Indexed: 11/04/2022] Open
Abstract
Hepatic encephalopathy (HE) is an important and potentially life threatening complication in alcoholic patients with decompensated liver function that develop even as they continue drinking. Delirium tremens, on the other hand, is an acute condition resulting from alcohol abstinence in a person dependent on alcohol, making it a life threatening diagnosis that requires intensive care and successful management of the withdrawal. Often in medical wards, these two conditions are mistaken and so is the management plan confused with each other. Making the right diagnosis early on during the hospital course is extremely important in these critical conditions so as to make an appropriate schedule for treatment and a better outcome for the same. A case series of patients who presented with a diagnostic dilemma is reported. Clinical examinations, diagnostic tools to measure the levels of ammonia and liver function tests and hemogram, West Haven criteria and Child-Pugh grading, and clinical scales of these patients are reported. Increased levels of ammonia were present in all the cases. The subtle similarities in the presentation of the two conditions often make it confusing for the clinician to distinguish between them. Using a simple test of measuring ammonia levels in the blood helps in such situations. The detection of raised levels of ammonia in cases of chronic liver disease helps in not just the diagnosis but also is an important prognostic indicator for development of HE.
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Affiliation(s)
- Spandana Devabhaktuni
- Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Prajakta Patkar
- Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - V Pooja
- Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Sana Dhamija
- Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Nishtha Gupta
- Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Suprakash Chaudhury
- Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Daniel Saldanha
- Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
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Qu Y, Li T, Lin C, Liu F, Wu S, Wang L, Ye Q. Animal naming test for the assessment of minimal hepatic encephalopathy in Asian cirrhotic populations. Clin Res Hepatol Gastroenterol 2021; 45:101729. [PMID: 34091081 DOI: 10.1016/j.clinre.2021.101729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/01/2021] [Accepted: 05/06/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM To evaluate the diagnostic performance of simplified animal naming test (S-ANT1) for minimal hepatic encephalopathy (MHE) in patients with cirrhosis from a Chinese tertiary centre and to optimize the application strategy of S-ANT1 in clinical practice. METHODS The Animal Naming Test 1 (ANT1) was performed in all included cirrhotic patients and healthy volunteers. S-ANT1 was calculated to adjust for age and education. Psychometric Hepatic Encephalopathy Score (PHES) was also performed in patients with cirrhosis. RESULTS 88 cirrhotic patients and 34 healthy control subjects were included. Cirrhotic patients were characterized with lower S-ANT1 scores (P = 0.001). In patients with cirrhosis, score of S-ANT1 was correlated with PHES score, age, school education period, and blood ammonia (all P values <0.05). With ≤20 animals as the cut-off value, S-ANT1 could distinguish MHE and no MHE with a sensitivity of 77.5% and a specificity of 58.3%. A three-step screening strategy, with 90% as a threshold for sensitivity and specificity and two cut-off values "≤12 animals" and ">23 animals", was then formulated to rule out patients with high possibility of MHE and with high possibility of no MHE. The remaining "ruled-in" patients should be further evaluated for MHE using PHES. CONCLUSIONS S-ANT1 is an important screening tool for MHE in cirrhotic patients. The three-step screening strategy based on S-ANT1 and PHES is conducive to the identification of MHE in clinical practice.
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Affiliation(s)
- Yundong Qu
- Department of Infectious Disease and Hepatology, The Second Hospital, Cheeloo College of Medicine, Shandong University, China
| | - Tao Li
- Department of Infectious Disease and Hepatology, The Second Hospital, Cheeloo College of Medicine, Shandong University, China
| | - Chunlei Lin
- Department of Infectious Disease and Hepatology, The Second Hospital, Cheeloo College of Medicine, Shandong University, China
| | - Feng Liu
- Department of Hepatology, Tianjin Second People's Hospital, China; Tianjin Institute of Hepatology, China
| | - Shuo Wu
- Department of Infectious Disease and Hepatology, The Second Hospital, Cheeloo College of Medicine, Shandong University, China; Hospital of Traditional Chinese Medicine of Linyi City, China
| | - Lei Wang
- Department of Infectious Disease and Hepatology, The Second Hospital, Cheeloo College of Medicine, Shandong University, China
| | - Qian Ye
- Department of Infectious Disease and Hepatology, The Second Hospital, Cheeloo College of Medicine, Shandong University, China.
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Luo M, Li XF, Hu SJ, Bai FH. Clinical efficiency of inhibitory control test for the diagnosis of minimal hepatic encephalopathy: A systematic review with meta-analysis. Hepatol Res 2021; 51:839-849. [PMID: 34185942 DOI: 10.1111/hepr.13682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/22/2021] [Accepted: 06/06/2021] [Indexed: 01/01/2023]
Abstract
AIM Minimal hepatic encephalopathy (MHE) is a common neuropsychiatric complication of liver cirrhosis and portosystemic shunt. The inhibitory control test (ICT) is a novel computerized psychometric test for MHE diagnosis, but its efficiency has yet to be confirmed. This study aimed to systematically review the existing evidence concerning the ICT application and then evaluate the efficiency of ICT for MHE diagnosis in clinical practice. METHODS A comprehensive search of published works was carried out to identify reports concerning the ICT for MHE diagnosis between January 2000 and December 2020. The pooled sensitivity, specificity, and diagnostic odds ratio of ICT for MHE diagnosis were calculated using a random or fixed effect model. The summary receiver operator characteristic (sROC) curve was constructed, and the area under the sROC curve was calculated. Metaregression and subgroup analyses were used to identify the source of heterogeneity. Publication bias was evaluated using the Deeks funnel plot asymmetry test. RESULTS Twelve studies were included in this systematic review, and nine studies enrolling 1022 patients were included in the final meta-analysis. The ICT had a pooled sensitivity, specificity, and DOR of 83%, 64%, and 9, respectively. The area under the sROC curve was 0.79. The metaregression analysis indicated that different locations of studies (relative diagnostic odds ratio, 12.65; p = 0.02) were identified as the source of heterogeneity. No significant publication bias was observed. CONCLUSIONS The ICT has a high sensitivity and moderate specificity for MHE diagnosis, and it can be used as a primary diagnostic method for MHE.
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Affiliation(s)
- Ming Luo
- Department of Gastroenterology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, Ningxia Hui Autonomous Region, China
| | - Xiao-Fei Li
- Department of Gastroenterology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, Ningxia Hui Autonomous Region, China
| | - Sheng-Juan Hu
- Department of Gastroenterology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, Ningxia Hui Autonomous Region, China
| | - Fei-Hu Bai
- Department of Gastroenterology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, Ningxia Hui Autonomous Region, China
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Miwa T, Hanai T, Nishimura K, Maeda T, Ogiso Y, Imai K, Suetsugu A, Takai K, Shiraki M, Shimizu M. Handgrip strength stratifies the risk of covert and overt hepatic encephalopathy in patients with cirrhosis. JPEN J Parenter Enteral Nutr 2021; 46:858-866. [PMID: 34287991 DOI: 10.1002/jpen.2222] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Handgrip strength (HGS) is a simple and convenient method to assess nutrition status in patients with cirrhosis. This retrospective study aimed to investigate the utility of HGS for predicting patients with covert hepatic encephalopathy (CHE) and patients at high risk of overt hepatic encephalopathy (OHE). METHODS We reviewed 963 patients with cirrhosis and consequently enrolled eligible 270 patients. HGS was measured using a digital grip dynamometer. CHE was diagnosed using a computer-aided neuropsychiatric test. Factors associated with CHE were estimated using the logistic regression model. Predictors associated with OHE occurrence were analyzed using the Fine-Gray competing risk regression model. RESULTS Of the 270 eligible patients, reduced HGS was observed in 102 (38%), reduced muscle mass in 107 (40%), and CHE in 53 (20%). Multivariate analysis showed that serum ammonia levels (odds ratio [OR], 2.23; 95% CI, 1.14-4.36; P = 0.014) and reduced HGS (OR, 3.68; 95% CI, 1.93-7.03; P < 0.001) were independently associated with CHE. During the median follow-up period of 24.5 months, 43 (16%) patients experienced OHE. After adjusting for possible confounding factors, multivariate analysis showed that reduced HGS (subdistribution hazard ratio, 2.36; 95% CI, 1.27-4.38; P = 0.007) was a significant predictor in the development of OHE. CONCLUSION Patients with reduced HGS had a higher prevalence of CHE and a higher risk for OHE occurrence than those with normal HGS. The measurement of HGS could be a simple bedside modality to stratify the patients' risk for CHE and OHE.
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Affiliation(s)
- Takao Miwa
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Tatsunori Hanai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan.,Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Kayoko Nishimura
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Toshihide Maeda
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yui Ogiso
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kenji Imai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Atsushi Suetsugu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Koji Takai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan.,Division for Regional Cancer Control, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Makoto Shiraki
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
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Giménez-Garzó C, Fiorillo A, Ballester-Ferré MP, Gallego JJ, Casanova-Ferrer F, Urios A, Benlloch S, Martí-Aguado D, San-Miguel T, Tosca J, Ríos MP, Montón C, Durbán L, Escudero-García D, Aparicio L, Felipo V, Montoliu C. A New Score Unveils a High Prevalence of Mild Cognitive Impairment in Patients with Nonalcoholic Fatty Liver Disease. J Clin Med 2021; 10:2806. [PMID: 34202269 PMCID: PMC8268962 DOI: 10.3390/jcm10132806] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/21/2021] [Accepted: 06/24/2021] [Indexed: 01/10/2023] Open
Abstract
Patients with nonalcoholic fatty liver disease (NAFLD) may show mild cognitive impairment (MCI). The neurological functions affected remain unclear. The aims were to: (1) Characterize the neuropsychological alterations in NAFLD patients; (2) assess the prevalence of impairment of neurological functions evaluated; (3) develop a new score for sensitive and rapid MCI detection in NAFLD; (4) assess differences in MCI features between patients with nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH); and (5) compare neuropsychological alterations in NAFLD patients with cirrhotic patients with MCI. Fifty-nine NAFLD patients and 53 controls performed psychometric tests assessing different neurological functions: PHES (Psychometric Hepatic Encephalopathy Score) battery, d2, Stroop, Oral SDMT (Symbol Digit Modalities Test), Digit Span, number-letter test, and bimanual and visual-motor coordination tests. NAFLD patients show impairment in attention, mental concentration, psychomotor speed, cognitive flexibility, inhibitory mental control, and working memory. We developed a new, rapid, and sensitive score based on the most affected parameters in NAFLD patients, unveiling that 32% of NAFLD show MCI. Prevalence was similar in NAFL (36%) or NASH (27%) patients, but lower in NAFLD than in cirrhosis (65%). MCI prevalence is significant in NAFLD patients. Psychometric testing is warranted in these patients to unveil MCI and take appropriate measures to reverse and prevent its progression.
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Affiliation(s)
- Carla Giménez-Garzó
- Laboratory of Neurobiology, Centro Investigación Príncipe Felipe, 46012 Valencia, Spain; (C.G.-G.); (A.U.)
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
| | - Alessandra Fiorillo
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
| | - María-Pilar Ballester-Ferré
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
- Servicio de Medicina Digestiva, Hospital Clínico Valencia, 46010 Valencia, Spain
| | - Juan-José Gallego
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
| | - Franc Casanova-Ferrer
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
| | - Amparo Urios
- Laboratory of Neurobiology, Centro Investigación Príncipe Felipe, 46012 Valencia, Spain; (C.G.-G.); (A.U.)
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
| | - Salvador Benlloch
- Servicio de Digestivo, Hospital Arnau de Vilanova, 46015 Valencia, Spain; (S.B.); (M.-P.R.); (L.D.)
- CIBERehd, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - David Martí-Aguado
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
- Servicio de Medicina Digestiva, Hospital Clínico Valencia, 46010 Valencia, Spain
| | - Teresa San-Miguel
- Departamento de Patología, Universidad Valencia, 46010 Valencia, Spain;
| | - Joan Tosca
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
- Servicio de Medicina Digestiva, Hospital Clínico Valencia, 46010 Valencia, Spain
| | - María-Pilar Ríos
- Servicio de Digestivo, Hospital Arnau de Vilanova, 46015 Valencia, Spain; (S.B.); (M.-P.R.); (L.D.)
| | - Cristina Montón
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
- Servicio de Medicina Digestiva, Hospital Clínico Valencia, 46010 Valencia, Spain
| | - Lucía Durbán
- Servicio de Digestivo, Hospital Arnau de Vilanova, 46015 Valencia, Spain; (S.B.); (M.-P.R.); (L.D.)
| | - Desamparados Escudero-García
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
- Servicio de Medicina Digestiva, Hospital Clínico Valencia, 46010 Valencia, Spain
- Departamento de Medicina, Universidad Valencia, 46010 Valencia, Spain
| | - Luis Aparicio
- Departamento de Anatomía y Embriología, Universidad Valencia, 46010 Valencia, Spain;
| | - Vicente Felipo
- Laboratory of Neurobiology, Centro Investigación Príncipe Felipe, 46012 Valencia, Spain; (C.G.-G.); (A.U.)
| | - Carmina Montoliu
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
- Departamento de Patología, Universidad Valencia, 46010 Valencia, Spain;
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Moran S, López-Sánchez M, Milke-García MDP, Rodríguez-Leal G. Current approach to treatment of minimal hepatic encephalopathy in patients with liver cirrhosis. World J Gastroenterol 2021; 27:3050-3063. [PMID: 34168407 PMCID: PMC8192295 DOI: 10.3748/wjg.v27.i22.3050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/01/2021] [Accepted: 04/21/2021] [Indexed: 02/06/2023] Open
Abstract
Minimal hepatic encephalopathy (MHE) corresponds to the earliest stage of hepatic encephalopathy (HE). MHE does not present clinically detectable neurological-psychiatric abnormalities but is characterized by imperceptible neurocognitive alterations detected during routine clinical examination via neuropsychological or psychometrical tests. MHE may affect daily activities and reduce job performance and quality of life. MHE can increase the risk of accidents and may develop into overt encephalopathy, worsening the prognosis of patients with liver cirrhosis. Despite a lack of consensus on the therapeutic indication, interest in finding novel strategies for prevention or reversion has led to numerous clinical trials; their results are the main objective of this review. Many studies address the treatment of MHE, which is mainly based on the strategies and previous management of overt HE. Current alternatives for the management of MHE include measures to maintain nutritional status while avoiding sarcopenia, and manipulation of intestinal microbiota with non-absorbable disaccharides such as lactulose, antibiotics such as rifaximin, and administration of different probiotics. This review analyzes the results of clinical studies that evaluated the effects of different treatments for MHE.
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Affiliation(s)
- Segundo Moran
- Laboratory of Hepatology Research, Centro Médico Nacional, Siglo XXI, Mexican Institute of Social Security, Mexico City 06720, Mexico
| | - Marlene López-Sánchez
- Laboratory of Hepatology Research, Centro Médico Nacional, Siglo XXI, Mexican Institute of Social Security, Mexico City 06720, Mexico
| | | | - Gustavo Rodríguez-Leal
- Laboratory of Hepatology Research, Centro Médico Nacional, Siglo XXI, Mexican Institute of Social Security, Mexico City 06720, Mexico
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Miwa T, Hanai T, Toshihide M, Ogiso Y, Imai K, Suetsugu A, Takai K, Shiraki M, Katsumura N, Shimizu M. Zinc deficiency predicts overt hepatic encephalopathy and mortality in liver cirrhosis patients with minimal hepatic encephalopathy. Hepatol Res 2021; 51:662-673. [PMID: 33242359 DOI: 10.1111/hepr.13601] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 11/07/2020] [Accepted: 11/15/2021] [Indexed: 12/13/2022]
Abstract
AIM Minimal hepatic encephalopathy (MHE) is associated with poor outcomes and the development of overt hepatic encephalopathy (OHE) in patients with liver cirrhosis (LC). Zinc plays a key role in the detoxification of ammonia, a risk factor of hepatic encephalopathy. This study aimed to investigate whether zinc deficiency predicts OHE occurrence and mortality in LC patients with MHE. METHOD This retrospective study included 100 LC patients with MHE. MHE was diagnosed using a computer-aided neuropsychiatric test. Predictors associated with the development of OHE were analyzed using the Fine-Gray competing risk regression model. Cox proportional hazards regression analysis was carried out to evaluate the risk factors of mortality. Survival rates were analyzed using the Kaplan-Meier method and log-rank test. RESULTS Of the 100 LC patients with MHE, 41% had zinc deficiency (<60 μg/dl). Zinc deficiency was observed more frequently in the patients with reduced liver function reserve. During the median follow-up period of 9.9 months, 16% of the patients with MHE developed OHE. The patients with zinc deficiency had a higher risk of OHE than those without zinc deficiency (p = 0.03). Zinc deficiency was also associated with poor survival (p = 0.004). Multivariate analyses showed that zinc predicts the development of OHE (subdistribution hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.92-0.99; p = 0.008) and mortality (HR, 0.96; 95% CI, 0.93-0.99; p = 0.02), independently of liver function reserves. CONCLUSION Zinc deficiency is likely to be a predictor of both OHE development and mortality in LC patients with MHE.
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Affiliation(s)
- Takao Miwa
- Department of Gastroenterology, Chuno Kosei Hospital, Seki, Japan.,Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Tatsunori Hanai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan.,Division for Regional Cancer Control, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Maeda Toshihide
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yui Ogiso
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kenji Imai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Atsushi Suetsugu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Koji Takai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan.,Division for Regional Cancer Control, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Makoto Shiraki
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Naoki Katsumura
- Department of Gastroenterology, Chuno Kosei Hospital, Seki, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
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Minimal Hepatic Encephalopathy and Biejia-Ruangan Are Associated with First Hospital Readmission in Nonalcoholic Cirrhosis Patients. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:6652858. [PMID: 34055016 PMCID: PMC8123979 DOI: 10.1155/2021/6652858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 04/06/2021] [Accepted: 04/19/2021] [Indexed: 11/17/2022]
Abstract
Introductionand Aim. Patients with cirrhosis are often hospitalized repeatedly for a variety of complications. This retrospective study aimed to assess the effects of minimal hepatic encephalopathy (MHE) and Biejia-Ruangan (BR) on first hospital readmission in nonalcoholic cirrhosis patients without previous overt hepatic encephalopathy (OHE) or hepatocellular carcinoma (HCC). Materials and Methods. A total of 176 hospitalized patients with nonalcoholic cirrhosis were included in this retrospective study. Patients who were first admitted to Beijing Ditan Hospital of Capital Medical University from January 2017 to September 2019 were enrolled. The primary endpoint was their first liver-related hospital readmission. The risk factors for readmission were analyzed by Cox proportional hazard regression analysis. Results. A total of 176 nonalcoholic cirrhosis patients without previous OHE or HCC were included; 57 patients (32.4%) were diagnosed with MHE, and 63 patients (35.8%) were administered BR (2 g, three times a day). Multivariate analysis revealed that nonalcoholic cirrhosis patients with MHE (HR, 5.805; 95% CI, 3.007-11.206; x, P < 0.001) and a higher Model for End-Stage Liver Disease (MELD) score (HR, 1.145; 95% CI, 1.068-1.227; P < 0.001) had an increased risk of first hospital readmission, and patients treated with BR (HR, 0.318; 95% CI, 0.151-0.670; P=0.003) had a decreased risk of first hospital readmission. Conclusion. MHE increased the risk of hospital readmission in nonalcoholic cirrhosis patients without previous OHE or HCC, and this risk was decreased by BR administration.
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Kondo Y, Iwasa M, Kawaratani H, Miyaaki H, Hanai T, Kon K, Hirano H, Shimizu M, Yoshiji H, Okita K, Koike K. Proposal of Stroop test cut-off values as screening for neuropsychological impairments in cirrhosis: A Japanese multicenter study. Hepatol Res 2021; 51:674-681. [PMID: 33615662 DOI: 10.1111/hepr.13629] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/01/2021] [Accepted: 02/10/2021] [Indexed: 12/13/2022]
Abstract
AIM Despite its relevant clinical impact and high prevalence, covert hepatic encephalopathy (HE) still remains underdiagnosed. As patients with liver cirrhosis tend to be older in Japan, more suitable tests for the elderly and cut-off values based on this attribute are needed. Recently, a Stroop test has been developed and validated for the screening and diagnosis of covert HE in the United States. The present study aims to establish the cut-off values of the Stroop test to screen covert HE. METHODS This study was a prospective multicenter cross-sectional endeavor. We undertook a survey of 311 cirrhotic patients, administering the number connection test (NCT)-A and -B and the Stroop-off and -on test. RESULTS We determined the cut-off values of Stroop test results for cirrhotic patients in a variety of age ranges. The cut-off value of the Stroop test was strongly correlated with age. There was a significant correlation between the results of NCT-B and age, and Stroop-on test results showed a correlation with serum albumin (Alb) levels. Serum Alb ≤3.2 g/dl could have the potential to be an objective biomarker of covert HE. In addition, stepwise logistic regression analysis revealed a relationship between the results of the Stroop-on test and plasma ammonia levels. CONCLUSIONS We established the cut-off values of Stroop test results and confirmed the efficacy of the Stroop test as a simple tool for assessing cognitive alterations. The Stroop test could be suitable as a necessary minimum for the diagnosis of covert HE.
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Affiliation(s)
- Yasuteru Kondo
- Department of Hepatology, Sendai Kousei Hospital, Sendai, Japan
| | - Motoh Iwasa
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Mie, Japan
| | - Hideto Kawaratani
- Department of Gastroenterology, Nara Medical University, Nara, Japan
| | - Hisamitsu Miyaaki
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tatsunori Hanai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kazuyoshi Kon
- Department of Gastroenterology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hirotaka Hirano
- Department of Gastroenterology, Yodogawa Christian Hospital, Osaka, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, Nara, Japan
| | | | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Development and Validation of a Clinical-Genetic Risk Score to Predict Hepatic Encephalopathy in Patients With Liver Cirrhosis. Am J Gastroenterol 2021; 116:1238-1247. [PMID: 33852451 DOI: 10.14309/ajg.0000000000001164] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/30/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION We aimed to define the impact of the genetic background on overt hepatic encephalopathy (HE) in patients with liver cirrhosis by developing a combined clinical-genetic risk score. METHODS Patients suffering from liver cirrhosis from the outpatient clinics of 4 hospitals (n = 600) were included and followed up for at least 5 years until HE bouts, liver transplant, or death. Patients were genotyped for 60 candidate single nucleotide polymorphisms together with the microsatellite in the promoter region of the gene GLS. RESULTS Single nucleotide polymorphisms rs601338 (FUT2), rs5743836 (TRL9), rs2562582 (SLC1A3), rs313853 (SLC1A5), and GLS microsatellite did predict independently the incidence and severity of overt HE and were included as genetic score. Competing risk analysis revealed that bilirubin (subhazard ratio [sHR] 1.30 [1.15-1.48], P < 0.001), albumin (sHR 0.90 [0.86-0.93], P < 0.001), genetic score (sHR 1.90 [1.57-2.30], P < 0.001), and previous episodes of overt HE (sHR 2.60 [1.57-4.29], P < 0.001) were independently associated to HE bouts during the follow-up with an internal (C-index 0.83) and external validation (C-index 0.74). Patients in the low-risk group had 5% and 12% risk of HE at 1 (log-rank 92.1; P < 0.001) and 5 (log-rank 124.1; P < 0.001) years, respectively, whereas 36% and 48% in the high-risk group. DISCUSSION The genetic background influenced overt HE risk and severity. The clinical-genetic HE Risk score, which combined genetic background together with albumin, bilirubin, and previous episodes of overt HE, could be a useful tool to predict overt HE in patients with cirrhosis.
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Ochoa-Sanchez R, Oliveira MM, Tremblay M, Petrazzo G, Pant A, Bosoi CR, Perreault M, Querbes W, Kurtz CB, Rose CF. Genetically engineered E. coli Nissle attenuates hyperammonemia and prevents memory impairment in bile-duct ligated rats. Liver Int 2021; 41:1020-1032. [PMID: 33548108 DOI: 10.1111/liv.14815] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 12/30/2020] [Accepted: 01/28/2021] [Indexed: 12/12/2022]
Abstract
UNLABELLED Hyperammonemia associated with chronic liver disease (CLD) is implicated in the pathogenesis of hepatic encephalopathy (HE). The gut is a major source of ammonia production that contributes to hyperammonemia in CLD and HE and remains the primary therapeutic target for lowering hyperammonemia. As an ammonia-lowering strategy, Escherichia coli Nissle 1917 bacterium was genetically modified to consume and convert ammonia to arginine (S-ARG). S-ARG was further modified to additionally synthesize butyrate (S-ARG + BUT). Both strains were evaluated in bile-duct ligated (BDL) rats; experimental model of CLD and HE. METHODS One-week post-surgery, BDLs received non-modified EcN (EcN), S-ARG, S-ARG + BUT (3x1011 CFU/day) or vehicle until sacrifice at 3 or 5 weeks. Plasma (ammonia/pro-inflammatory/liver function), liver fibrosis (hydroxyproline), liver mRNA (pro-inflammatory/fibrogenic/anti-apoptotic) and colon mRNA (pro-inflammatory) biomarkers were measured post-sacrifice. Memory, motor-coordination, muscle-strength and locomotion were assessed at 5 weeks. RESULTS In BDL-Veh rats, hyperammonemia developed at 3 and further increased at 5 weeks. This rise was prevented by S-ARG and S-ARG + BUT, whereas EcN was ineffective. Memory impairment was prevented only in S-ARG + BUT vs BDL-Veh. Systemic inflammation (IL-10/MCP-1/endotoxin) increased at 3 and 5 weeks in BDL-Veh. S-ARG + BUT attenuated inflammation at both timepoints (except 5-week endotoxin) vs BDL-Veh, whereas S-ARG only attenuated IP-10 and MCP-1 at 3 weeks. Circulating ALT/AST/ALP/GGT/albumin/bilirubin and gene expression of liver function markers (IL-10/IL-6/IL-1β/TGF-β/α-SMA/collagen-1α1/Bcl-2) were not normalized by either strain. Colonic mRNA (TNF-α/IL-1β/occludin) markers were attenuated by synthetic strains at both timepoints vs BDL-Veh. CONCLUSION S-ARG and S-ARG + BUT attenuated hyperammonemia, with S-ARG + BUT additional memory protection likely due to greater anti-inflammatory effect. These innovative strategies, particularly S-ARG + BUT, have potential to prevent HE.
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Affiliation(s)
| | - Mariana M Oliveira
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | - Mélanie Tremblay
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | - Grégory Petrazzo
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | | | - Cristina R Bosoi
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | | | | | | | - Christopher F Rose
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
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Madsen M, Kimer N, Bendtsen F, Petersen AM. Fecal microbiota transplantation in hepatic encephalopathy: a systematic review. Scand J Gastroenterol 2021; 56:560-569. [PMID: 33840331 DOI: 10.1080/00365521.2021.1899277] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Hepatic encephalopathy (HE) is a reversible neurocognitive dysfunction that ranges in severity from subclinical alterations to coma. Patients with chronic liver disease are predisposed to HE due to metabolic failure and portosystemic shunting of toxins, of which ammonia is believed to be the main toxic chemical. Fecal microbiota transplantation (FMT) may reduce ammonia synthesis by altering the gut microbiota composition to a taxon low in urease, diminish uptake of ammonia by reestablishing the integrity of the intestinal barrier and increase ammonia clearance by improving liver function. In this systematic review, we summarize the insights of the current literature examining FMT as a treatment for HE.PubMed and EMBASE were searched on 08 February 2021 using the MeSH terms 'fecal microbiota transplantation & hepatic encephalopathy' and the abbreviations 'FMT & HE'.Eight studies fulfilled our inclusion criteria, comprising two randomized clinical trials, three case reports and three rodent studies. Thirty-nine patients with HE were treated with FMT. Thirty-nine rodents received FMT in laboratory tests. FMT improved neurocognitive test results in four human studies and two rodent studies. Microbiota originating from donors was found in human recipients one year post-FMT. Readmission of patients was lower after treatment with FMT compared to standard of care.FMT may improve neurocognitive function and reduce serious adverse events in patients with HE, but the studies conducted so far have been small and their long-term follow-up is limited. Large-scale, randomized and controlled trials are needed to validate and help standardize the clinical application of FMT in cases of HE.
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Affiliation(s)
- Mathias Madsen
- Gastro Unit, Medical Division, Hvidovre University Hospital, Copenhagen, Denmark
| | - Nina Kimer
- Gastro Unit, Medical Division, Hvidovre University Hospital, Copenhagen, Denmark.,Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Bendtsen
- Gastro Unit, Medical Division, Hvidovre University Hospital, Copenhagen, Denmark
| | - Andreas Munk Petersen
- Gastro Unit, Medical Division, Hvidovre University Hospital, Copenhagen, Denmark.,Department of Clinical Microbiology, Hvidovre University Hospital, Copenhagen, Denmark
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Lu B, Wu C, Azami NLB, Xie D, Zhao C, Xu W, Hui D, Chen X, Sun R, Song J, An Y, Li K, Wang H, Ye G, Sun M. Babao Dan improves neurocognitive function by inhibiting inflammation in clinical minimal hepatic encephalopathy. Biomed Pharmacother 2021; 135:111084. [PMID: 33383371 DOI: 10.1016/j.biopha.2020.111084] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/22/2020] [Accepted: 11/28/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Inflammation has been considered a precipitating event that contributes to neurocognitive dysfunction in minimal hepatic encephalopathy (MHE). Inhibition TLR-4 related inflammation can effectively improve neurocognitive dysfunction of MHE. Our previous study showed that Babao Dan (BBD) effectively inhibited inflammation and ameliorated neurocognitive function in rats with acute hepatic encephalopathy (HE) and chronic HE. The mechanism may lie in the regulation of TLR4 signaling pathway. Therefore, this study aimed to evaluate the role of BBD in the treatment of MHE patients with cirrhosis and to elucidate the underlying mechanism by which BBD regulated TLR4 pathway to alleviate inflammation. METHODS A randomized controlled trial (n = 62) was conducted to evaluate the clinical efficacy between BBD plus lactulose (n = 31) and lactulose alone (n = 31) in MHE patients by testing neurocognitive function (NCT-A and DST), blood ammonia, liver function (ALT, AST and TBIL) and blood inflammation (IL-1β, IL-6 and TNF-α). Afterward, we detected NO, inflammatory cytokines (IL-1β, IL-6 and TNF-α) and the phosphorylation of P65, JNK, ERK as well as P38 in LPS-activated rat primary bone marrow-derived macrophages (BMDMs), peritoneal macrophages (PMs), and mouse primary BMDMs/PMs/microglia/astrocytes, to investigate the underlying mechanism of BBD inhibiting inflammation through TLR4 pathway. Also, the survival rate of mice, liver function (ALT, AST), blood inflammation (IL-1β, IL-6 and TNF-α), inflammatory cytokines (IL-1β, IL-6 and TNF-α) and histopathological changes in the liver, brain and lung were measured to assess the anti-inflammatory effect of BBD on neurocognitive function in endotoxin shock/endotoxemia mice. RESULTS BBD combined with lactulose significantly ameliorated neurocognitive function by decreasing NCT-A (p<0.001) and increasing DST (p<0.001); inhibited systemic inflammation by decreasing IL-1β (p<0.001), IL-6(p<0.001) and TNF-α (p<0.001); reduced ammonia level (p = 0.005), and improved liver function by decreasing ALT(p = 0.043), AST(p = 0.003) and TBIL (p = 0.026) in MHE patients. Furthermore, BBD inhibited gene and protein expression of IL-1β, IL-6 and TNF-α as well as NO in rat primary BMDMs/PMs, and mouse primary BMDMs/PMs/microglia/astrocytes in a dose-dependent manner. BBD inhibited the activation of mouse primary BMDMs/PMs/microglia/astrocytes by regulating TLR4 pathway involving the phosphorylation of P65, JNK, ERK and P38. Also, BBD reduced the mortality of mice with endotoxin shock/endotoxemia; serum levels of ALT, AST, IL-1β, IL-6 and TNF-α; gene expression of IL-1β, IL-6 and TNF-α in the liver, brain and lung, and tissue damage in the liver and lung. CONCLUSION Our study provided for the first time clinical and experimental evidence supporting the use of BBD in MHE, and revealed that BBD could play a crucial role in targeting and regulating TLR4 inflammatory pathway to improve neurocognitive function in MHE patients.
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Affiliation(s)
- Bingjie Lu
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Chao Wu
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Nisma Lena Bahaji Azami
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Dong Xie
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Changqing Zhao
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Wan Xu
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Dengcheng Hui
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Xi Chen
- Shanghai Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai, 200082, China.
| | - Runfei Sun
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Jingru Song
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Yongtong An
- Central Research Institute, Shanghai Pharmaceuticals Holding Co., Ltd., Shanghai, 201203, China.
| | - Kun Li
- The MOE Key Laboratory for Standardization of Chinese Medicines and the SATCM Key Laboratory for New Resources and Quality Evaluation of Chinese Medicines, Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Huijun Wang
- The MOE Key Laboratory for Standardization of Chinese Medicines and the SATCM Key Laboratory for New Resources and Quality Evaluation of Chinese Medicines, Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Guan Ye
- Central Research Institute, Shanghai Pharmaceuticals Holding Co., Ltd., Shanghai, 201203, China.
| | - Mingyu Sun
- Shuguang Hospital, Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
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Williams S, Louissaint J, Nikirk S, Bajaj JS, Tapper EB. Deprescribing medications that may increase the risk of hepatic encephalopathy: A qualitative study of patients with cirrhosis and their doctors. United European Gastroenterol J 2021; 9:193-202. [PMID: 33226300 PMCID: PMC8259255 DOI: 10.1177/2050640620975224] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/25/2020] [Indexed: 12/19/2022] Open
Abstract
Background and Aims Multiple medications are associated with an increased risk of incident hepatic encephalopathy. Despite this known risk, medications such as opioids, benzodiazepines, gabapentin/pregabalin, and/or proton pump inhibitors are increasingly prescribed to persons with cirrhosis. Deprescribing is a promising intervention to reduce the burden of hepatic encephalopathy. Given that deprescribing has not been trialed in cirrhosis, we evaluated the barriers and facilitators to safe and successful deprescribing in cirrhosis. Methods We conducted, transcribed, and analyzed semi‐structured interviews using qualitative methodology with 22 subjects. This included eight patients with cirrhosis and recent use of opiates, benzodiazepines, gabapentin/Lyrica, and/or proton pump inhibitors as well as 14 providers (primary care, transplant surgery, transplant hepatology). Interviews explored opinions, behaviors, and understanding surrounding the risks and benefits of deprescribing. Results Major provider‐specific barriers included deferred responsibility of the deprescribing process, knowledge gaps regarding the risk of hepatic encephalopathy associated with medications (e.g., proton pump inhibitors) as well as the safe method of deprescription (i.e., benzodiazepines), and time constraints. Patient‐specific barriers included knowledge gaps regarding the cirrhosis‐specific risks of their medications and anxiety about the recurrence of symptoms after medication discontinuation. Patients uniformly reported trust in their provider's opinions on risks and wished for more comprehensive education during or after visits. Providers uniformly reported support for deprescription resources including pharmacist or nurse outreach. Conclusion Given knowledge of medication risks related to hepatic encephalopathy in patients with cirrhosis, deprescribing is universally seen as important. Knowledge gaps, inaction, and uncertainty regarding feasible alternatives prevent meaningful implementation of deprescription. Trials of protocolized pharmacy‐based deprescribing outreach and patient‐facing education on risks are warranted.
Summarize the established knowledge on this subject
Hepatic encephalopathy (HE) is a morbid complication of cirrhosis. The risk of HE may be increased by psychoactive medications and proton pump inhibitors. Deprescribing is felt to be a promising approach to HE prevention.
What are the significant and/or new findings of this study?
Patients are unaware of how their medications influence the risk of HE. Patients are willing to follow physician recommendations regarding deprescribing but are afraid of worsening symptoms. Physicians do not feel comfortable deprescribing opioids or benzodiazepines. Physicians do not feel responsible or equipped with the resources for deprescribing.
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Affiliation(s)
- Sydni Williams
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jeremy Louissaint
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Sam Nikirk
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA.,Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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Abstract
Type C hepatic encephalopathy (HE) is a brain dysfunction caused by severe hepatocellular failure or presence of portal-systemic shunts in patients with liver cirrhosis. In its subclinical form, called “minimal hepatic encephalopathy (MHE), only psychometric tests or electrophysiological evaluation can reveal alterations in attention, working memory, psychomotor speed and visuospatial ability, while clinical neurological signs are lacking. The term “covert” (CHE) has been recently used to unify MHE and Grade I HE in order to refer to a condition that is not unapparent but also non overt. “Overt” HE (OHE) is characterized by personality changes, progressive disorientation in time and space, acute confusional state, stupor and coma. Based on its time course, OHE can be divided in Episodic, Recurrent or Persistent. Episodic HE is generally triggered by one or more precipitant factors that should be found and treated. Unlike MHE, clinical examination and clinical decision are crucial for OHE diagnosis and West Haven criteria are widely used to assess the severity of neurological dysfunction. Primary prophylaxis of OHE is indicated only in the patient with gastrointestinal bleeding using non-absorbable antibiotics (Rifaximin) or non-absorbable disaccharides (Lactulose). Treatment of OHE is based on the identification and correction of precipitating factors and starting empirical ammonia-lowering treatment with Rifaximin and Lactulose (per os and enemas). The latter should be used for secondary prophylaxis, adding Rifaximin if HE becomes recurrent. In recurrent/persistent HE, the treatment options include fecal transplantation, TIPS revision and closure of eventual splenorenal shunts. Treatment of MHE should be individualized on a case-by-case basis.
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Rega D, Aiko M, Peñaranda N, Urios A, Gallego JJ, Giménez-Garzó C, Casanova F, Fiorillo A, Cabrera-Pastor A, San-Miguel T, Ipiens C, Escudero-García D, Tosca J, Montón C, Ballester MP, Ballester J, Aparicio L, Ríos MP, Durbán L, Mir A, Kosenko E, Cases P, Felipo V, Montoliu C. Patients with Minimal Hepatic Encephalopathy Show Altered Thermal Sensitivity and Autonomic Function. J Clin Med 2021; 10:jcm10020239. [PMID: 33440769 PMCID: PMC7826803 DOI: 10.3390/jcm10020239] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/30/2020] [Accepted: 01/05/2021] [Indexed: 12/21/2022] Open
Abstract
Cirrhotic patients may experience alterations in the peripheral nervous system and in somatosensory perception. Impairment of the somatosensory system could contribute to cognitive and motor alterations characteristic of minimal hepatic encephalopathy (MHE), which affects up to 40% of cirrhotic patients. We assessed the relationship between MHE and alterations in thermal, vibration, and/or heat pain sensitivity in 58 cirrhotic patients (38 without and 20 with MHE according to Psychometric Hepatic Encephalopathy Score) and 39 controls. All participants underwent attention and coordination tests, a nerve conduction study, autonomic function testing, and evaluation of sensory thresholds (vibration, cooling, and heat pain detection) by electromyography and quantitative sensory testing. The detection thresholds for cold and heat pain on the foot were higher in patients with, than those without MHE. This hyposensitivity was correlated with attention deficits. Reaction times in the foot were longer in patients with, than without MHE. Patients with normal sural nerve amplitude showed altered thermal sensitivity and autonomic function, with stronger alterations in patients with, than in those without MHE. MHE patients show a general decrease in cognitive and sensory abilities. Small fibers of the autonomic nervous system and thermal sensitivity are altered early on in MHE, before large sensory fibers. Quantitative sensory testing could be used as a marker of MHE.
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Affiliation(s)
- Dalia Rega
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
| | - Mika Aiko
- Servicio de Neurofisiología, Hospital Clínico de Valencia, 46010 Valencia, Spain; (M.A.); (N.P.); (C.I.); (P.C.)
| | - Nicolás Peñaranda
- Servicio de Neurofisiología, Hospital Clínico de Valencia, 46010 Valencia, Spain; (M.A.); (N.P.); (C.I.); (P.C.)
| | - Amparo Urios
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
| | - Juan-José Gallego
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
| | - Carla Giménez-Garzó
- Laboratorio de Neurobiología. Centro Investigación Príncipe Felipe, 46012 Valencia, Spain; (C.G.-G.); (V.F.)
| | - Franc Casanova
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
| | - Alessandra Fiorillo
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
| | - Andrea Cabrera-Pastor
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
| | - Teresa San-Miguel
- Departamento de Patología, Facultad de Medicina, Universidad de Valencia, 46010 Valencia, Spain;
| | - Cristina Ipiens
- Servicio de Neurofisiología, Hospital Clínico de Valencia, 46010 Valencia, Spain; (M.A.); (N.P.); (C.I.); (P.C.)
| | - Desamparados Escudero-García
- Servicio de Medicina Digestiva, Hospital Clinico de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.); (J.B.)
- Departamento de Medicina, Universidad de Valencia, 46010 Valencia, Spain;
| | - Joan Tosca
- Servicio de Medicina Digestiva, Hospital Clinico de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.); (J.B.)
| | - Cristina Montón
- Servicio de Medicina Digestiva, Hospital Clinico de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.); (J.B.)
| | - María-Pilar Ballester
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
- Servicio de Medicina Digestiva, Hospital Clinico de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.); (J.B.)
| | - José Ballester
- Servicio de Medicina Digestiva, Hospital Clinico de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.); (J.B.)
| | - Luis Aparicio
- Departamento de Anatomía y Embriología, Universidad Valencia, 46010 Valencia, Spain;
| | - María-Pilar Ríos
- Servicio de Digestivo, Hospital Arnau de Vilanova, 46015 Valencia, Spain; (M.-P.R.); (L.D.)
| | - Lucía Durbán
- Servicio de Digestivo, Hospital Arnau de Vilanova, 46015 Valencia, Spain; (M.-P.R.); (L.D.)
| | - Amparo Mir
- Departamento de Medicina, Universidad de Valencia, 46010 Valencia, Spain;
| | - Elena Kosenko
- Institute of Theoretical and Experimental Biophysics of Russian Academy of Sciences, 142290 Pushchino, Russia;
| | - Paula Cases
- Servicio de Neurofisiología, Hospital Clínico de Valencia, 46010 Valencia, Spain; (M.A.); (N.P.); (C.I.); (P.C.)
| | - Vicente Felipo
- Laboratorio de Neurobiología. Centro Investigación Príncipe Felipe, 46012 Valencia, Spain; (C.G.-G.); (V.F.)
| | - Carmina Montoliu
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
- Departamento de Patología, Facultad de Medicina, Universidad de Valencia, 46010 Valencia, Spain;
- Correspondence: ; Tel.: +34-963-864-381
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Characterization of brain microstructural abnormalities in cirrhotic patients without overt hepatic encephalopathy using diffusion kurtosis imaging. Brain Imaging Behav 2021; 14:627-638. [PMID: 31538276 PMCID: PMC7160080 DOI: 10.1007/s11682-019-00141-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cirrhosis is a major public health concern. However, little is known about the neurobiological mechanisms underlying brain microstructure alterations in cirrhotic patients. The purpose of this prospective study was to investigate brain microstructural alterations in cirrhosis with or without minimal hepatic encephalopathy (MHE) and their relationship with patients’ neurocognitive performance and disease duration using voxel-based analysis of diffusion kurtosis imaging (DKI). DKI data were acquired from 30 cirrhotic patients with MHE, 31 patients without MHE (NMHE) and 59 healthy controls. All DKI-derived parametric maps were compared across the three groups to investigate their group differences. Correlation analyses were further performed to assess relationships between altered imaging parameters and clinical data. Voxel-based analysis of DKI data results showed that MHE/NMHE patients had increased radial diffusivity, axial diffusivity (AD) and mean diffusivity in addition to decreased axial kurtosis (AK) and fractional anisotropy of kurtosis in several regions. Compared to controls, these regions were primarily the cingulum, temporal and frontal cortices. The DKI metrics (i.e., AK and AD) were correlated with clinical variables in the two patient groups. In conclusion, DKI is useful for detecting brain microstructural abnormalities in MHE and NMHE patients. Abnormal DKI parameters suggest alterations in brain microstructural complexity in cirrhotic patients, which may contribute to the neurobiological basis of neurocognitive impairment. These results may provide additional information on the pathophysiology of cirrhosis.
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Incidence and Bedside Predictors of the First Episode of Overt Hepatic Encephalopathy in Patients With Cirrhosis. Am J Gastroenterol 2020; 115:2017-2025. [PMID: 32773463 PMCID: PMC7853725 DOI: 10.14309/ajg.0000000000000762] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Hepatic encephalopathy (HE) is associated with marked increases in morbidity and mortality for patients with cirrhosis. We aimed to determine the risk of and predictors for HE in contemporary patients. METHODS We prospectively enrolled 294 subjects with Child A-B (70% Child A) cirrhosis and portal hypertension without previous HE from July 2016 to August 2018. The primary outcome was the development of overt HE (grade >2). We assessed the predictive power of model for end-stage liver disease-sodium (MELD-Na) score, the Inhibitory Control Test, the Sickness Impact Profile score, and the Bilirubin-Albumin-Beta-Blocker-Statin score. We also derived a novel predictive model incorporating MELD-Na score, impact of cirrhosis on daily activity (Likert 1-9), frailty (chair-stands per 30 seconds), and health-related quality of life (Short-Form 8, 0-100). RESULTS The cohort's median age was 60 years, 56% were men, and the median MELD-Na score was 9. During a follow-up of 548 ± 281 days, 62 (21%) had incident overt HE with 1-year probability of 14% ± 2%, 10% ± 2%, and 25% ± 5% for Child A and B. The best model for predicting the risk of overt HE included MELD-Na, Short-Form 8, impact on activity rating, and chair-stands within 30 seconds. This model-MELDNa-Actvity-Chairstands-Quality of Life Hepatic Encephalopathy Score-offered an area under the receiver operating curve (AUROC) for HE development at 12 months of 0.82 compared with 0.55, 0.61, 0.70, and 0.72 for the Inhibitory Control Test, Sickness Impact Profile, Bilirubin-Albumin-Beta-Blocker-Statin, and MELD-Na, respectively. The AUROC for HE-related hospitalization was 0.92. DISCUSSION This study provides the incidence of HE in a well-characterized cohort of contemporary patients. Bedside measures such as activity, quality of life, and physical function accurately stratified the patient's risk for overt HE.
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Greinert R, Zipprich A, Simón-Talero M, Stangl F, Ludwig C, Wienke A, Praktiknjo M, Höhne K, Trebicka J, Genescà J, Ripoll C. Covert hepatic encephalopathy and spontaneous portosystemic shunts increase the risk of developing overt hepatic encephalopathy. Liver Int 2020; 40:3093-3102. [PMID: 32890428 DOI: 10.1111/liv.14660] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 08/14/2020] [Accepted: 08/20/2020] [Indexed: 12/13/2022]
Abstract
AIM The aim of the study was to evaluate the presence of covert hepatic encephalopathy (cHE) and its characteristics according to the presence of spontaneous portosystemic shunts (SPSS) and their influence on the development of overt hepatic encephalopathy. METHODS Secondary analysis of a multicentre study, which evaluated the association between SPSS and complications of cirrhosis. The present study population includes those patients who also underwent cHE diagnostic evaluation. Presence of SPSS was evaluated by cross-sectional imaging and quantified by total SPSS-area. Logistic and Cox-regression competing risk analyses were performed. RESULTS About 65 patients were included of age 58 (IQR 50-66), MELD 15 (IQR 10-20), with alcoholic liver disease 63%. Thirty-two patients (49%) had cHE, had higher MELD [16 (IQR 12-24) vs 13 (IQR 9-17), P = .027], a greater proportion of SPSS [n = 18 (56%) vs n = 8 (24%); P = .008] and a higher total cross-sectional SPSS-area [28.3 (0-94.2) vs 0 (0-14.1); P = .005]. On multivariate analysis MELD [OR 1.11 (95% CI 1.01-1.21)] and presence of SPSS [OR 3.95 (95% CI 1.22-12.80)] were independently associated to cHE at baseline. During follow-up cHE was an independent predictor of oHE [cHE: HR 6.93 (95% CI 2.64-18.20). The effect of cHE on the development of oHE was greater in patients with SPSS [only cHE: HR 5.66 (95% CI 1.82-17.62), cHE and SPSS: HR 8.63 (95% CI 3.15-23.65)]. CONCLUSIONS cHE is independently associated to the presence of SPSS (and total cross-sectional SPSS-area) and MELD. Furthermore, the presence of SPSS seems to increase the risk of cHE of developing of overt hepatic encephalopathy.
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Affiliation(s)
- Robin Greinert
- First Department of Internal Medicine, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - Alexander Zipprich
- First Department of Internal Medicine, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - Macarena Simón-Talero
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), CIBEREHD, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Franz Stangl
- Department of Radiology, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - Christiane Ludwig
- First Department of Internal Medicine, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - Andreas Wienke
- Institute of Medical Epidemiology, Biostatistics, and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | | | - Kevin Höhne
- First Department of Internal Medicine, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - Jonel Trebicka
- Medizinische Klinik 1, Universitätsklinikum Frankfurt. Goethe Universität, Frankfurt, Germany
| | - Joan Genescà
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), CIBEREHD, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cristina Ripoll
- First Department of Internal Medicine, Martin-Luther University Halle-Wittenberg, Halle, Germany
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