Prevalence of and Factors Associated With Minimal Hepatic Encephalopathy in Patients With Cirrhosis of Liver

Relationship between Sarcopenia and minimal hepatic encephalopathy in patients with cirrhosis: a prospective observational study

BACKGROUND

Sarcopenia, characterized by loss of muscle mass and function, has gained importance in the evaluation of cirrhotic patients. Evidence suggests its role in adverse clinical outcomes, including minimal hepatic encephalopathy (MHE). This study aimed to investigate the association between sarcopenia and MHE in patients with cirrhosis.

METHODS

We prospectively enrolled outpatients with cirrhosis to assess sarcopenia using the 2019 criteria from the Asian Working Group for Sarcopenia. MHE was diagnosed through the Psychometric Hepatic Encephalopathy Score.

RESULTS

Of the 210 cirrhotic patients (57.1% male, mean age 62.7 ± 9.6 years), 54 (25.7%) had sarcopenia, with 26 (12.3%) classified as severe. Thirty-seven patients (17.6%) were diagnosed with MHE. Sarcopenia prevalence was significantly higher in patients with MHE compared to those without MHE (45.9% vs. 21.4%). MHE was significantly associated with age, education level, Mini-Mental State Examination score, and a history of hepatic decompensation. No significant associations were found regarding gender, body mass index, comorbidities, sleep quality, and the etiology of cirrhosis. Multivariable logistic regression showed that MHE was significantly associated with age (adjusted odds ratio [aOR] 1.08, 95% CI 1.02-1.13), sarcopenia (aOR 3.29, 95% CI 1.44-7.50), history of overt hepatic encephalopathy (aOR 7.40, 95% CI 1.20-45.56), and variceal bleeding (aOR 3.13, 95% CI 1.38-7.10). Severe sarcopenia was also independently associated with MHE (aOR 3.64, 95% CI 1.32-10.05).

CONCLUSIONS

Sarcopenia is prevalent in cirrhotic patients and is associated with an increased risk of MHE. Our findings emphasize the importance of assessing sarcopenia to potentially mitigate MHE risk in managing patients with cirrhosis.

The role of multifocal visual evoked potential in detection of minimal hepatic encephalopathy in patients with compensated liver cirrhosis

BACKGROUND

Minimal hepatic encephalopathy (MHE) is one of the most debilitating complications of hepatic cirrhosis, and visual electrophysiology, visual evoked potential (VEP) has long been used for MHE diagnosis. This technique only produces a summed response that is greatly dominated by the macular region. Multifocal visual evoked potential (mfVEP) imaging minimizes these limitations because it allows topographic recording of the optic nerve and visual cortex. The aim of this study was to detect minimal hepatic encephalopathy among cirrhotic patients using the mfVEP in comparison to the validated psychometric hepatic encephalopathy score (PHES), paired associative learning (PAL) and the Benton visual retention test (BVRT).

METHODS

Forty-five patients with compensated hepatic cirrhosis were enrolled in our study and compared to 45 normal controls who were matched for age, sex and educational level. Both groups underwent psychological tests (PHES, PAL, BVRT) and neurophysiological tests (mfVEP).

RESULTS

1According to the validated PHES, 14 patients were found to have MHE, 15 patients were found to have abnormal mfVEP, and abnormalities in the BVRT and PAL were found in 11 and 10 patients, respectively. 2-mfVEP showed the highest sensitivity in the detection of MHE in reference to the PHES. 3- The mfVEP test and potentially the BVRT have the advantage of detecting subtle abnormalities in non-MHE cirrhotic patients, for further research and follow-up are needed.

CONCLUSION

mfVEP demonstates promising results for objective early detection of MHE, with a sensitivity of approximately 92.9%.

Analysis of independent risk factors for hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients with cirrhosis combined with diabetes

OBJECTIVE

This study aimed to reveal the independent risk factors for overt hepatic encephalopathy (OHE) after transjugular intrahepatic portosystemic shunt (TIPS) in patients with decompensated cirrhosis complicated with diabetes.

PATIENTS AND METHODS

This study retrospectively analyzed 126 consecutive patients with cirrhosis combined with diabetes who underwent TIPS in our department from January 2016 to June 2022. The patients were divided into two groups according to the presence or absence of OHE after TIPS. Data were analyzed using the χ 2 -tests, unpaired t -tests, logistic regression, receiver operating characteristic curves, and Kaplan-Meier curves.

RESULTS

Age and ascites were independent risk factors for OHE after TIPS in patients with cirrhosis and diabetes. Elder patients had a higher risk of postoperative OHE than younger patients [odds ratio (OR): 1.040; 95% confidence interval (CI): 1.003-1.079]. Compared with patients without ascites, patients with ascites were significantly more likely to develop OHE (OR: 3.757; 95% CI: 1.274-11.080; OR: 4.338; 95% CI: 1.069-17.603).

CONCLUSION

Age and ascites are independent risk factors of post-TIPS OHE in cirrhotic patients with diabetes.

Etiological Spectrum of Cirrhosis in India: A Systematic Review and Meta-analysis

BACKGROUND

Cirrhosis is a significant cause of morbidity and mortality globally and in India. This systematic review and meta-analysis aimed to ascertain the etiological spectrum and changing trends of cirrhosis in India.

METHODS

We searched electronic databases, including Pubmed/Medline, Scopus, and Embase. We included original studies that reported the etiology of cirrhosis in the Indian population.

RESULTS

We included 158 studies (adults: 147, children: 11). The overall pooled estimate of alcohol as a cause of cirrhosis in adults was 43.2% (95% confidence interval (CI) 39.8-46.6%; I2 = 97.8%), followed by nonalcoholic fatty liver disease (NAFLD)/cryptogenic in 14.4%, 95% CI (11.7-17.3%; I2 = 98.4%), hepatitis B virus (HBV) in 11.5%, 95% CI (9.8-13.3%; I2 = 96.6%), and hepatitis C virus (HCV) in 6.2%, 95% CI (4.8-7.8%; I2 = 97.2%) of the included patients. The most common cause of cirrhosis in all zones was alcohol-related. Comparison of etiologies over time revealed a reduction in the viral hepatitis-related and an increase in the proportion of alcohol-related and NAFLD/cryptogenic-related cirrhosis. The overall pooled estimates of various etiologies in children were: HBV in 10.7%, 95% CI (4.6-18.7%; I2 = 91.0%), NAFLD/Cryptogenic in 22.3%, 95% CI (9.0-39.2%; I2 = 96.7%), and HCV in 2.0%, 95% CI (0.0-8.5%; I2 = 94.6%).

CONCLUSIONS

Alcohol is the most common etiology of cirrhosis in adults in India. The proportions of alcohol and NAFLD-related cirrhosis are increasing, and those of viral hepatitis-related cirrhosis are reducing. The results of our meta-analysis will help formulate health policies and the allocation of resources.

Covert hepatic encephalopathy is associated with aggressive disease progression and poor survival in patients with cirrhosis

OBJECTIVES

Covert hepatic encephalopathy (CHE) negatively affects the health-related quality of life and increases the risk of overt HE (OHE) in patients with liver cirrhosis. However, the impact of CHE on long-term patient outcomes remains controversial. This study aimed to explore the association between CHE and disease progression and survival among cirrhotic patients.

METHODS

This was a single-center prospective study that enrolled 132 hospitalized patients with cirrhosis, with an average follow-up period of 45.02 ± 23.06 months. CHE was diagnosed using the validated Chinese standardized psychometric hepatic encephalopathy score.

RESULTS

CHE was detected in 35.61% cirrhotic patients. During the follow-up, patients with CHE had a higher risk of developing OHE (log-rank 5.840, P = 0.016), exacerbation of ascites (log-rank 4.789, P = 0.029), and portal vein thrombosis (PVT) (log-rank 8.738, P = 0.003). Cox multivariate regression analyses revealed that CHE was independently associated with the occurrence of OHE, exacerbation of ascites, and PVT. Furthermore, patients with progression of cirrhosis were more likely to be diagnosed as CHE (log-rank 4.462, P = 0.035). At the end of the follow-up, patients with CHE had a lower survival rate compared to those without CHE (log-rank 8.151, P = 0.004). CHE diagnosis (hazard ratio 2.530, P = 0.008), together with elder age and higher Child-Pugh score, were risk factors for impaired survival in cirrhotic patients.

CONCLUSION

CHE is associated with disease progression and poor survival in patients with cirrhosis, indicating that CHE may serve as an independent predictor of poor prognosis among these patients.

A modified Child-Turcotte-Pugh score based on plasma ammonia predicts survival for patients with decompensated cirrhosis

BACKGROUND

Plasma ammonia has been shown to be an independent prognostic factor for patients with liver cirrhosis.

AIM

We aimed to investigate the discrimination and calibration of a new prognostic model (aCTP) based on plasma ammonia (Amm) replacing hepatic encephalopathy (HE) in the Child-Turcotte-Pugh (CTP) score.

DESIGN

Diagnostic test, paired design.

METHODS

Baseline Amm levels were corrected to the upper limit of normal (Amm-ULN). We designed the new model based on the cut-off value of Amm-ULN in the observational cohort of 554 clinically stable cirrhotic patients from January 2012 to July 2019. External validation was carried out using prospective data from 185 patients with liver cirrhosis.

RESULTS

Our analysis showed that each 1-point increase in Amm-ULN was associated with a 2-fold increase in the likelihood of mortality [hazard ratio (HR), 2.06; 95% CI: 1.81-2.36, P < 0.001]. In the aCTP score, Amm-ULN < 1.0 was defined as a score of 1, 1.0 ≤ Amm-ULN < 1.4 as 2 and ≥1.4 as 3. The survival curves among three aCTP grades were significantly different (P < 0.0001). The aCTP score showed the better agreements between predicted and observed events in the validating cohorts than the CTP score (C-statistics: 0.75 and 0.69, P < 0.001). The aCTP score showed inspiring power to predict acute decompensation (C-statistics: 0.76; 95% CI: 0.71-0.81) and acute-on-chronic liver failure (C-statistics: 0.81; 95% CI: 0.77-0.86).

CONCLUSION

This study demonstrates the feasibility and the potential for plasma Amm replacing HE (aCTP) to enhance the prognostication of transplant-free survival provided by the CTP score for patients with decompensated cirrhosis.

Elevated levels of soluble glycoprotein V - The plasma marker of platelet activation by thrombin in patients with early stage primary biliary cholangitis (PBC)

PURPOSE

There is a growing body of evidence for a prothrombotic tendency in patients with primary biliary cholangitis (PBC). The aim of the study was to evaluate coagulation disorders in patients with early stage PBC compared to healthy controls and evaluation of their relationship with clinical data, with particular emphasis on minimal hepatic encephalopathy (MHE).

PATIENTS AND METHODS

Fifty-one participants (PBC group - 38 patients, all patients but one Child-Pugh A; control group - 13 healthy controls) were included in our prospective, single center study. We assessed the plasma levels of sGPV, plasma procoagulant phospholipids (PPL) and rotational thromboelastometry (ROTEM) profiles in all study participants. Porto-systemic encephalopathy syndrome test was used to assess MHE.

RESULTS

The sGPV levels were higher in the PBC group compared to the controls: 36.07 ​± ​11.32 ​ng/mL vs 27.04 ​± ​11.72 ​ng/mL, p ​= ​0.031. The PPL level was lower in the PBC group compared to controls resulting in increased clotting time in a factor Xa-based coagulation assay: 54.65 (47.83-58.83) sec. vs 45.90 (43.3-50.5) sec., p ​= ​0.0065. PPL levels were correlated with platelet count (rho ​= ​-0.46, p ​= ​0.001). ROTEM parameters did not differ significantly between groups. Coagulation parameters did not differ significantly between patients with and without MHE.

CONCLUSIONS

We have showed increased levels of sGPV - a plasma marker of platelet activation by thrombin in patients with early stage PBC compared to healthy controls. We found no relationship between the coagulation disorders and the occurrence of MHE. The PPL level was lower in the PBC group.

Prediction of Patient Hepatic Encephalopathy Risk with Freiburg Index of Post-TIPS Survival Score Following Transjugular Intrahepatic Portosystemic Shunts: A Retrospective Study

Background

Hepatic encephalopathy is a complication of portal hypertension. The Freiburg index of transjugular portosystemic shunt (TIPS) and patient outcomes have recently been described. This retrospective study was conducted at a single center in China and included 241 patients with portal hypertension who underwent TIPS implantation to evaluate the Freiburg index of post-TIPS survival score (FIPS) to predict hepatic encephalopathy.

Methods

A single-center retrospective study including 241 patients who underwent TIPS operation between April 2015 and July 2019 was conducted. Clinical demographics and relevant clinical parameters within 24h after admission were collected. The prediction performances of FIPS, Child–Pugh and the model for end-stage liver disease (MELD) scores were compared by decision curve analysis and receiver operating characteristic (ROC) curve analysis. In addition, multivariate analyses were performed to identify independent predictors.

Results

Eighty-three out of 241 patients (34.4%) finally developed post-TIPS hepatic encephalopathy. The area under the ROC curve of FIPS was 0.744 (95% confidence interval: 0.684–0.798). FIPS was identified as an independent risk factor for post-TIPS hepatic encephalopathy (hazard ratio: 2.23, 95% confidence interval: 1.71–2.90, p<0.001). Moreover, we further grouped the FIPS scores into two categories (FIPS ≤-0.97, low-risk; FIPS >-0.97, high risk) to improve its applicability. Patients with high FIPS scores had a significantly higher incidence of hepatic encephalopathy than patients with low FIPS scores (P<0.05).

Conclusion

This study showed that FIPS could be used to evaluate the risk of hepatic encephalopathy in this patient group with improved predictive performance when compared with the Child–Pugh and MELD scores.

Psychometric methods for diagnosing and monitoring minimal hepatic encephalopathy -current validation level and practical use

Hepatic encephalopathy (HE) is cerebral dysfunction caused by liver failure and inflicts 30-40% of patients with liver cirrhosis during their disease course. Clinically manifest HE is often preceded by minimal HE (MHE) - a clinically undetectable cognitive disturbance closely associated with loss of quality of life. Accordingly, detecting and treating MHE improve the patients' daily functioning and prevent HE-related hospital admissions. The scope of this review article is to create an overview of the validation level and usage of psychometric tests used to detect MHE: Portosystemic hepatic encephalopathy test, continuous reaction time test, Stroop EncephalApp, animal naming test, critical flicker frequency test, and inhibitory control test. Our work is aimed at the clinician or scientist who is about to decide on which psychometric test would fit best in their clinic, cohort, or study. First, we outline psychometric test validation obstacles and requirements. Then, we systematically approach the literature on each test and select well-conducted studies to answer the following questions:• Which percentage of patients with cirrhosis does the test deem as having MHE?• Is the test able to predict clinically manifest HE?• Is there a well-known test-retest variation and inter-observer variation?• Is the test able to detect a treatment response?• Is the test result affected by age, educational level, gender, or comorbidities?

Psoas Muscle Density Predicts Occurrences of Hepatic Encephalopathy in Patients Receiving Transjugular Intrahepatic Portosystemic Shunts within 1 year

PURPOSE

We aimed to assess the efficacy of psoas density (PD) for predicting hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) procedures.

METHODS

Data were collected from patients who underwent TIPS procedures at a single institution between 2013 and 2019. PD was manually measured using software on unenhanced CT scans at the level of third lumbar vertebra. Laboratory and physical examination data were collected within 24 h after admission in order to compare the differences between patients with and without post-TIPS HE.

RESULTS

A total of 251 patients were included in this study. Among these patients, 77 (30.7%) developed post-TIPS HE within one year after TIPS creation. The threshold of PD for predicting HE was 51.24 Hounsfield unit (HU). PD values less than this threshold were correlated with an increased risk of HE (hazard ratio 0.92; 95% CI 0.89-0.95, P < 0.001). The area under the receiver operating characteristic curve (AUROC) of PD was 0.743 (95% CI 0.685-0.796), which was superior to Model for End-stage Liver Disease (MELD) (0.569, P = 0.007), albumin-bilirubin score (ALBI) (0.641, P = 0.018), and Child-Pugh score (0.583, P = 0.003).

CONCLUSION

PD measurement showed good HE predictive value in cirrhotic patients who underwent TIPS. This measure also performed better than MELD, ALBI and Child-Pugh.

Minimal hepatic encephalopathy may be present despite the absence of non-invasive and elastography evidence of cirrhosis in patients with primary biliary cholangitis

PURPOSE

Minimal hepatic encephalopathy (MHE) is an important complication of chronic liver disease (CLD); however, MHE burden in patients with primary biliary cholangitis (PBC) has not been determined yet. Therefore, our study aimed to assess the prevalence of MHE in a typical cohort of middle-aged, patients with PBC suspicion of liver fibrosis and to investigate the relationship between MHE, basic laboratory tests and the stage of liver fibrosis.

PATIENTS AND METHODS

Fifty-one patients (38 with PBC and 13 controls), were prospectively enrolled. Portosystemic Encephalopathy-Syndrome test was used to diagnose MHE. Elastography point qualification (ElastPQ) and non-invasive markers (APRI and FIB-4) were used to assess liver fibrosis. The severity of CLD was assessed using the Model of End-Stage Liver Disease (MELD) and Child-Pugh score.

RESULTS

MHE was diagnosed in 9 patients (24.3%) with PBC and none in the control group. As many as 44.4% of the patients with MHE had neither advanced fibrosis nor cirrhosis, as demonstrated using non-invasive markers of liver fibrosis or ElastPQ. The MELD score was the only predictor of MHE with cut-off value 8.5 [AUC ​= ​0.753, CI_95% ​= ​0.569 to 0.938)] with sensitivity of 56%, specificity of 85% and accuracy of the test of 78%. Non-invasive markers of liver fibrosis and ElastPQ did not predict MHE.

CONCLUSIONS

MHE may occur in PBC despite no evidence of advanced liver fibrosis or cirrhosis. The slightly elevated MELD score may indicate a substantially increased risk of MHE in patients with PBC.

Normalisation of the psychometric encephalopathy score within the Cameroonian population

Background

Minimal hepatic encephalopathy (MHE) is the presence of neuropsychological abnormalities detectable by psychometric tests. Psychometric Hepatic Encephalopathy Score (PHES) is a gold standard test for the early diagnosis of MHE in cirrhotic patients. The aim of this study was to standardize the PHES in a healthy Cameroonian population and to evaluate the prevalence of MHE among cirrhotic patients.

Methods

This was a prospective, multicentric study from 1 December 2018 to 31 July 2019 in two groups: healthy volunteers and cirrhotic patients without clinical signs of hepatic encephalopathy. The results of the number connection test-A, number connection test-B, serial dotting test, line tracing test were expressed in seconds and those of the digit symbol test in points.

Results

A total of 102 healthy volunteers (54 men, 48 women) and 50 cirrhotic patients (29 men, 31 women) were included. The mean age was 38.1 ± 12.55 years in healthy volunteers and 49.3 ± 15.6 years in cirrhotic patients. The mean years of education level was 11.63 ± 4.20 years in healthy volunteers and 9.62 ± 3.9 years in cirrhotic patients. The PHES of the healthy volunteer group was − 0.08 ± 1.28 and the cut-off between normal and pathological values was set at − 3 points. PHES of the cirrhotic patients was − 7.66 ± 5.62 points and significantly lower than that of volunteers (p < 0.001). Prevalence of MHE was 74% among cirrhotic patients. Age and education level were associated with MHE.

Conclusion

PHES cut-off value in Cameroonians is − 3, with MHE prevalence of 74% among cirrhotic patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-021-01858-7.

Recompensation factors for patients with decompensated cirrhosis: a multicentre retrospective case-control study

OBJECTIVES

We aimed to evaluate recompensation factors among patients with decompensated cirrhosis.

DESIGN

A multicentre retrospective case-control study was conducted. Data were collected from and compared between groups of patients with recompensated and acute decompensated cirrhosis. Univariable and multivariable logistic regressions were used to select indicators associated with recompensation among patients with decompensated cirrhosis with different complications. A decision tree with 10-fold cross-validation was used to develop the model to identify patients with recompensation. We followed the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) guideline for development and reporting of the new model.

SETTING

The study was conducted in six tertiary public hospitals in Chongqing, China.

PARTICIPANTS

This study included 3953 patients with decompensated cirrhosis.

RESULTS

In the total sample of included patients, there were 553 patients with recompensation and 3400 patients with acute decompensation, including 1158 patients with gastrointestinal bleeding, 1715 patients with a bacterial infection, 104 patients with hepatic encephalopathy and 423 patients with ascites. The most relevant indicator of recompensation selected by the decision tree model was albumin, with a threshold of 40 g/L. Total protein, haemoglobin, basophil percentage, alanine aminotransferase, neutrophil-to-lymphocyte ratio and diabetes were also selected to subsequently distinguish patients. The terminal nodes with a probability of recompensation was 0.89. The overall accuracy rate of the model was 0.92 (0.91-0.93), and it exhibited high specificity (86.9%) and sensitivity (92.6%).

CONCLUSIONS

The occurrence of recompensated cirrhosis could be identified by albumin, total protein, haemoglobin, basophil percentage, alanine aminotransferase, neutrophil-to-lymphocyte ratio and diabetes. These simple variables may help clinicians develop a treatment plan to encourage patients with decompensated cirrhosis to recompensate.

Minimal Hepatic Encephalopathy and Biejia-Ruangan Are Associated with First Hospital Readmission in Nonalcoholic Cirrhosis Patients

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.

Efficacy of albumin-bilirubin score to predict hepatic encephalopathy in patients underwent transjugular intrahepatic portosystemic shunt

BACKGROUND AND AIMS

The occurrence of hepatic encephalopathy is one of the main factors limiting the development and application of transjugular intrahepatic portosystemic shunt (TIPS). Our study aimed to verify the efficacy of the albumin-bilirubin score, an objective and simple scoring system, to predict post-TIPS hepatic encephalopathy.

METHODS

From February 2014 to July 2019, a total of 224 patients who underwent TIPS procedure were entered into the study. All patients were followed up after TIPS placement. Relevant clinical data within 24 h after admission were collected to compare the differences between patients with and without hepatic encephalopathy after TIPS placement.

RESULTS

A total of 82 (36.6%) patients developed post-TIPS hepatic encephalopathy. Age and albumin-bilirubin score was found to be independent risk factors for post-TIPS hepatic encephalopathy. The albumin-bilirubin score shows a good ability to predict the occurrence of hepatic encephalopathy within 1 year after TIPS. The area under the receiver operating characteristic curve is 0.74 (95% confidence interval: 0.673-0.806). In addition, in order to improve its feasibility, we regrouped the albumin-bilirubin score into three levels (albumin-bilirubin≤ -1.95, low risk; 1.95 <albumin-bilirubin ≤1.45, intermediate risk; albumin-bilirubin > -1.45, high risk).

CONCLUSION

The albumin-bilirubin score has a good predictive value for the possibility of post-TIPS hepatic encephalopathy, which is better than the model for end-stage liver disease and Child-Pugh score.

Proposal of Stroop test cut-off values as screening for neuropsychological impairments in cirrhosis: A Japanese multicenter study

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.

Animal Naming Test - a simple and accurate test for diagnosis of minimal hepatic encephalopathy and prediction of overt hepatic encephalopathy

Aim of the study

Minimal hepatic encephalopathy (MHE) is the mildest form in the spectrum of hepatic encepha-lopathy (HE). We compared the usefulness of the Psychometric Hepatic Encephalopathy Score (PHES) and Animal Naming Test (ANT) for the diagnosis of MHE and the prediction of the development of overt episodes of HE.

Material and methods

103 consecutive patients with liver cirrhosis without overt HE were subjected to PHES and ANT evaluation. The receiver-operating characteristic curve was used to determine the optimum cut-off of the ANT value for the diagnosis of MHE.

Results

Thirty-seven (35.9%) patients had MHE as assessed by altered PHES. ANT (< 14) was positive in 36 (34.95%) patients with MHE with a sensitivity of 89.19% and specificity of 95.7%, positive predictive value (PPV) of 91.67%, negative predictive value (NPV) of 94.03% and diagnostic accuracy of 93.20%. The area under the curve for diagnosis of MHE was 0.978 (95% CI: 0.954-1.0). MHE patients had significantly lower ANT as compared to non-MHE patients and controls (10.81 ±0.324 vs. 15.27 ±0.147 vs. 15.78 ±0.192, respectively, p = 0.01). ANT correlated with PHES (r = 0.752, p = 0.001) and also with Child-Pugh (r = –0.408, p = 0.001) and MELD (r = –0.318, p = 0.001) scores. During follow-up, 14 patients in the MHE group and 4 in the non-MHE group developed overt episodes of HE (p = 0.001).

Conclusions

ANT is simple and accurate for the diagnosis of MHE and prediction of overt episodes of HE in patients with cirrhosis and correlates well with the Child-Pugh and MELD scores.

A nomogram to predict the risk of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in Cirrhotic Patients

BACKGROUND AND AIM

Hepatic encephalopathy (HE) is a serious complication of decompensated liver cirrhosis, affecting the prognosis of patients underwent transjugular intrahepatic portosystemic shunts (TIPS). We aim to create a nomogram to predict hepatic encephalopathy- free survivals (HEFS) after TIPS in cirrhotic patients and select appropriate candidates for TIPS.

METHODS

Cirrhotic patients underwent TIPS from 2015 to 2018 in our department were included. Multivariable Cox regression was conducted to estimate the predictors of overt HE (OHE) after TIPS within one year. A nomogram based on the Cox proportional hazard model using data from a retrospective training cohort (70% of the patients) was developed. Then the prediction model was validated in the remaining 30% patients by Harrell's C-indexes, ROC curves and calibration plots.

RESULTS

Of 373 patients, 117 developed postoperative OHE (31.4%). The training and validation groups comprised 83 (31.4%) and 34 (31.2%) patients, respectively. The cumulative survival rates of patients with HE at 1, 2 and 3 years were 90%, 83% and 76%, respectively. The nomogram included the following variables: age, Child-Turcotte-Pugh class (CTP class), diabetes mellitus (DM), serum creatinine and serum sodium (C-index = 0.772). The C-index for HEFS prediction was 0.773 for the validation cohort. The ROC for predicting HEFS was 0.809 and 0.783, respectively.

CONCLUSIONS

We created a nomogram of predicting postoperative HEFS in cirrhotic patients received TIPS. This nomogram could be an important tool of HE risk prediction before TIPS to guide the therapeutic strategy in cirrhotic patients.

Nonpharmacologic Management of Hepatic Encephalopathy: An Update

Research increasingly shows that the gut-liver-brain axis is a crucial component in the pathophysiology of hepatic encephalopathy (HE). Due to the limitations of current standard-of-care medications, non-pharmacological treatments that target gut dysbiosis, including probiotics, nutritional management, and fecal microbiota transplants, are being considered as alternative and adjunct therapies. Meta-analyses note that probiotics could offer benefits in HE treatment, but have not shown superiority over lactulose. Emerging literature suggests that fecal microbiota transplants could offer a novel strategy to treat gut dysbiosis and favorably impact HE. Finally, liver support devices and liver transplantation could offer a last-resort treatment option for persistent HE.

Association of serum albumin level with incidence and mortality of overt hepatic encephalopathy in cirrhosis during hospitalization

BACKGROUND

Hepatic encephalopathy (HE) is a serious complication of cirrhosis. Decreased serum albumin (ALB) level may facilitate the development of HE and accelerate the death of cirrhotic patients with HE. Recent evidence also suggests that human albumin infusion may reduce the incidence of HE and improve the outcomes of cirrhotic patients. This study aimed to explore the association of serum ALB level with the development of overt HE and HE-associated mortality during hospitalization.

METHODS

Cirrhotic patients admitted to our hospital between January 2010 and February 2019 were screened. Independent predictors for HE were identified by logistic regression analyses. Odds ratio (OR) with 95% confidence interval (95% CI) was calculated. Area under curve (AUC) was calculated by receiver operator characteristic curve analyses.

RESULTS

Of the 2376 included patients with cirrhosis but without HE at admission, 113 (4.8%) developed overt HE during hospitalizations. ALB level (OR = 0.878, 95% CI = 0.834-0.924) was an independent risk factor for development of overt HE. AUC of ALB level for predicting the development of overt HE was 0.770 (95% CI = 0.752-0.787, p < 0.0001), and the best cut-off value was ⩽31.6 g/l. Of the 183 included patients with cirrhosis and overt HE at admission, 20 (10.9%) died during hospitalizations. ALB level (OR = 0.864, 95% CI = 0.771-0.967) was an independent risk factor for death from overt HE. The AUC of ALB level for predicting death from overt HE was 0.737 (95% CI = 0.667-0.799, p = 0.0001), and the best cut-off value was ⩽22.8 g/l.

CONCLUSIONS

Decreased serum ALB level may be associated with higher risk of overt HE and HE-associated mortality during hospitalizations in cirrhosis.

Diabetes mellitus increases the risk of hepatic encephalopathy after a transjugular intrahepatic portosystemic shunt in cirrhotic patients

OBJECTIVE

The aim of this study was to examine the effect of diabetes mellitus (DM) on the rate of hepatic encephalopathy (HE) in patients with decompensated liver cirrhosis after the creation of a transjugular intrahepatic portosystemic shunt (TIPS).

PATIENTS AND METHODS

This study retrospectively reviewed 436 consecutive patients with cirrhosis receiving TIPS in our department from 2008 to 2016. By comparing two groups of patients, with or without DM, the incidence of developing overt HE after TIPS, as well as the correlation between diabetes and HE, was analyzed. Data were analyzed using the χ-tests, unpaired t-tests, logistic regression, and Kaplan-Meier curves. After the initial data processing, we used a regression model to analyze whether or not DM is associated with the development of HE after TIPS.

RESULTS

Of the 436 patients who underwent TIPS, 85 (19.5%) had diabetes at admission and 126 (28.9%) had HE after TIPS. Patients with DM more frequently had HE compared with those without DM (44.7 vs. 25.1%; P = 0.000). The logistic regression analysis showed that DM (P = 0.015) and age (P = 0.002) were independent risk factors for HE after TIPS. Finally, using the Kaplan-Meier curves, we found that diabetes significantly increases the incidence of overt HE (log-rank P = 0.026).

CONCLUSION

Similar to old age, DM may increase the risk of HE in cirrhotic patients after the creation of TIPS.

Zinc supplementation in patients with cirrhosis and hepatic encephalopathy: a systematic review and meta-analysis

BACKGROUND

Low serum zinc level is associated with hepatic encephalopathy (HE), but the efficacy of zinc supplementation remains uncertain. This study aimed to investigate the effects of zinc supplementation on HE treatment in patients with cirrhosis.

METHODS

We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (Cochrane CENTRAL) and Scopus from inception to December 2018; without publication date or language restrictions. Randomized controlled trials of zinc supplementation versus placebo or other treatment for the management of HE in adult patients with cirrhosis were selected. The primary outcome was the degree of HE as assessed by clinical signs or specialized psychometric tests. The secondary outcomes included serum ammonia levels, adverse events, or the length of hospital stay and costs. We carried out a meta-analysis with random effects model and summarized continuous outcomes using standardized mean differences (SMD) or mean differences (MD) with 95% confidence intervals (95% CI). The risk of bias was assessed using the Cochrane risk of bias tool, and the certainty of evidence for each outcome was evaluated with the Grading of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

Four trials with 247 patients were included. In patients with cirrhosis who had mild HE (≤ grade II), the available evidence suggested that the combination treatment of zinc supplementation and lactulose over 3 to 6 months significantly improved performance in the number connection test (SMD: -0.97; 95% CI: - 1.75 to - 0.19; P = 0.01; moderate certainty), reported in three trials (n = 227). However, compared with lactulose therapy alone, additional zinc supplementation demonstrated no significant difference in the digit symbol test (SMD: 0.44; 95% CI: - 0.12 to 1.00; P = 0.12; very low certainty) or serum ammonia levels (MD: -10.86; 95% CI: - 25.73 to 4.01; P = 0.15; very low certainty), reported in two trials (n = 137). None of the included trials reported adverse events or effects on hospitalization.

CONCLUSIONS

In conclusion, a combination of zinc supplementation and lactulose over 3 to 6 months may improve the number connection test in cirrhotic patients with low grade HE, compared with lactulose only.

TRIAL REGISTRATION

PROSPERO: CRD42017080955 . Registered 23 November 2017.

Development and Validation of a Prognostic Score to Predict Covert Hepatic Encephalopathy in Patients With Cirrhosis

OBJECTIVES

Diagnosis of covert hepatic encephalopathy (CHE) is challenging and often neglected in clinical practice. The aim of this study was to develop an easy-to-perform score to predict CHE in patients with cirrhosis.

METHODS

For the development or validation cohort of the proposed clinical CHE score, 142 or 96 consecutive patients with cirrhosis were prospectively enrolled. The Psychometric Hepatic Encephalopathy Score was used to detect minimal hepatic encephalopathy. All patients were examined with the simplified animal naming test and were asked to complete the Chronic Liver Disease Questionnaire. We followed the TRIPOD guideline for development, validation, and reporting of the proposed score.

RESULTS

The clinical covert hepatic encephalopathy score containing the variables-clinically detectable ascites, history of overt hepatic encephalopathy (OHE), albumin serum level, activity subdomain of the Chronic Liver Disease Questionnaire, and simplified animal naming test-discriminated best between patients with and without CHE. We generated 2 cutoff values for the identification of the high-, intermediate- (with need for additional specialized testing), and low-risk groups for CHE. By applying these cutoffs, the sensitivity, specificity, positive predictive value, and negative predictive value were 90%, 91%, 85%, and 94%, respectively. The AUC was 0.908 or 0.872 for the development or the validation cohort, respectively. Higher scores were further associated with poorer quality of life, and the high-risk group was predictive for first-time OHE within 180 days.

CONCLUSIONS

We developed an easy-to-perform score to identify patients with cirrhosis at risk of CHE, which correlates with quality of life and risk of first-time OHE.

Why Do Individuals with Cirrhosis Fall? A Mechanistic Model for Fall Assessment, Treatment, and Research

Falls are prevalent for people with cirrhosis and commonly lead to loss of independence, reduced quality of life, and mortality. Despite a critical need for fall prevention in this population, cirrhosis-specific fall-related mechanisms are not well understood. We posit that most falls in this patient population are due to a coalescence of discrete subclinical impairments that are not typically detected at the point of care. The combined effect of these subtle age- and disease-related neurocognitive and muscular impairments leads to the inability to respond successfully to a postural perturbation within the available 300 to 400 ms. This article provides a conceptual model of physiological resilience to avoid a fall that focuses on attributes that underlie the ability to withstand a postural perturbation and their clinical evaluation. Evidence supporting this model in cirrhosis and other high fall risk conditions will be synthesized and suggestions for fall assessment and treatment will be discussed.