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Matsuda T, Namisaki T, Shibamoto A, Asada S, Tomooka F, Kubo T, Koizumi A, Tanaka M, Iwai S, Inoue T, Tsuji Y, Fujinaga Y, Nishimura N, Sato S, Kitagawa K, Kaji K, Mitoro A, Asada K, Takaya H, Noguchi R, Akahane T, Yoshiji H. Clinical Significance of Marginal Zinc Deficiency as a Predictor of Covert Hepatic Encephalopathy in Patients with Liver Cirrhosis. Int J Mol Sci 2025; 26:4184. [PMID: 40362419 PMCID: PMC12071699 DOI: 10.3390/ijms26094184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2025] [Revised: 04/26/2025] [Accepted: 04/26/2025] [Indexed: 05/15/2025] Open
Abstract
Covert hepatic encephalopathy (CHE) can worsen the quality of life and prognosis of patients with cirrhosis. We analyzed the risk factors of CHE and identified patients at high risk for overt hepatic encephalopathy (HE) who would benefit from therapeutic interventions. We included 145 patients without a history of or treatment for overt HE. Patients were divided into the CHE and no-CHE groups (n = 91 and 54, respectively). CHE had a score above the age-based cutoff value of one of the neuropsychological tests, such as the Stroop and number connection tests. CHE prevalence was 62.8% (n = 91). Compared with the no-CHE group, the CHE group had significantly lower serum zinc and albumin levels. Multiple logistic regression analysis identified serum zinc levels at a cutoff value of 74 µg/dL. Subclinical zinc deficiency showed a diagnostic performance of 55.6% sensitivity and 81.5% specificity for CHE. Blood ammonia levels and liver functional reserves were not predictive of CHE. Compared with patients with zinc levels < 74 µg/dL (n = 102), those with ≥74 µg/dL (n = 43) had significantly lower CHE prevalence and better hepatic functional reserve. Subclinical zinc deficiency was associated with CHE occurrence in patients with cirrhosis without a history of or treatment for overt HE. Measurement of zinc levels facilitates early detection of CHE by neuropsychological testing.
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Affiliation(s)
- Takuya Matsuda
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
| | - Tadashi Namisaki
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
| | - Akihiko Shibamoto
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
| | - Shohei Asada
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
| | - Fumimasa Tomooka
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
| | - Takahiro Kubo
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
| | - Aritoshi Koizumi
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
| | - Misako Tanaka
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
| | - Satoshi Iwai
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
| | - Takashi Inoue
- Department of Evidence-Based Medicine, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan;
| | - Yuki Tsuji
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
| | - Yukihisa Fujinaga
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
| | - Norihisa Nishimura
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
| | - Shinya Sato
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
| | - Koh Kitagawa
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
| | - Kosuke Kaji
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
| | - Akira Mitoro
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
| | - Kiyoshi Asada
- Clinical Research Center, Nara Medical University, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan;
| | - Hiroaki Takaya
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
| | - Ryuichi Noguchi
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
| | - Takemi Akahane
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
| | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.M.); (A.S.); (S.A.); (F.T.); (T.K.); (A.K.); (M.T.); (S.I.); (Y.T.); (Y.F.); (N.N.); (S.S.); (K.K.); (K.K.); (A.M.); (H.T.); (R.N.); (T.A.); (H.Y.)
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Koyano K, Atsukawa M, Tsubota A, Kondo C, Miwa T, Namisaki T, Hiraoka A, Toyoda H, Tada T, Kobayashi Y, Kawata K, Matsuura K, Mikami S, Kawabe N, Oikawa T, Suzuki K, Kawano T, Okubo T, Arai T, Tani J, Morishita A, Iwasa M, Ishikawa T, Ikegami T, Tanaka Y, Shimizu M, Yoshiji H, Iwakiri K. Association Between Laboratory Values and Covert Hepatic Encephalopathy in Patients with Liver Cirrhosis: A Multicenter, Retrospective Study. J Clin Med 2025; 14:1858. [PMID: 40142666 PMCID: PMC11942637 DOI: 10.3390/jcm14061858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2025] [Revised: 02/24/2025] [Accepted: 03/07/2025] [Indexed: 03/28/2025] Open
Abstract
Background/Objective: Recently, there has been an increasing need to implement the diagnosis of the presence of covert hepatic encephalopathy (CHE) in patients with cirrhosis. The aim of this study was to identify novel factors associated with CHE in clinical practice. Methods: This retrospective study enrolled a total of 402 patients with cirrhosis at 17 institutions. The Stroop test was performed to diagnose CHE at each center. Results: The patients comprised 233 males and 169 females, with a median age of 69 (IQR, 61-75) years. The median albumin and 25(OH)D3 levels were 3.9 (3.5-4.3) g/dL and 15.4 (11.0-21.0) ng/mL, respectively. This cohort included 181 patients with esophageal varices (EV). Multivariate analysis revealed that low 25(OH)D3 (p < 0.05) and EV (p < 0.05) were independent risk factors for CHE. When limited to only laboratory factors, low albumin (p < 0.01) and low 25(OH)D3 (p < 0.05) were independent factors for CHE. The optimal cut-off values of albumin and 25(OH)D3 for predicting CHE were 3.7 g/dL and 16.5 ng/mL, respectively. The prevalence of CHE was 59.2% for 25(OH)D3 < 16.5 ng/mL and EV, 53.8% for albumin < 3.7 g/dL and 25(OH)D3 < 16.5 ng/mL, and 66.7% for albumin < 3.7 g/dL, EV, and 25(OH)D3 < 16.5 ng/mL. Conclusions: Low 25(OH)D3 and albumin levels, and the EV were positively associated with CHE in patients with cirrhosis. Specifically, the prevalence of CHE increased with a decrease in 25(OH)D3 levels. Patients with such risk factors should be actively and carefully examined for the presence of CHE.
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Affiliation(s)
- Kaori Koyano
- Division of Gastroenterology and Hepatology, Nippon Medical School, Tokyo 113-8602, Japan; (K.K.); (C.K.); (K.S.); (T.K.); (T.A.); (K.I.)
| | - Masanori Atsukawa
- Division of Gastroenterology and Hepatology, Nippon Medical School, Tokyo 113-8602, Japan; (K.K.); (C.K.); (K.S.); (T.K.); (T.A.); (K.I.)
| | - Akihito Tsubota
- Project Research Units, Research Center for Medical Science, The Jikei University School of Medicine, Tokyo 105-8461, Japan; (A.T.); (T.O.)
| | - Chisa Kondo
- Division of Gastroenterology and Hepatology, Nippon Medical School, Tokyo 113-8602, Japan; (K.K.); (C.K.); (K.S.); (T.K.); (T.A.); (K.I.)
| | - Takao Miwa
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, Gifu 501-1193, Japan (M.S.)
| | - Tadashi Namisaki
- Department of Gastroenterology, Nara Medical University, Nara 634-8521, Japan; (T.N.); (H.Y.)
| | - Atsushi Hiraoka
- Gastroenterology Center, Ehime Prefectural Central Hospital, Matsuyama 790-0024, Japan;
| | - Hidenori Toyoda
- Department of Gastroenterology, Ogaki Municipal Hospital, Gifu 503-8502, Japan;
| | - Toshifumi Tada
- Department of Internal Medicine, Japanese Red Cross Himeji Hospital, Himeji 670-8540, Japan;
| | - Yuji Kobayashi
- Department of Hepatology, Saiseikai Niigata Hospital, Niigata 950-1104, Japan; (Y.K.); (T.I.)
| | - Kazuhito Kawata
- Hepatology Division, Department of Internal Medicine II, Hamamatsu University School of Medicine, Hamamatsu 431-3125, Japan;
| | - Kentaro Matsuura
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya 464-0083, Japan;
| | - Shigeru Mikami
- Department of Internal Medicine, Division of Gastroenterology, Kikkoman General Hospital, Noda 278-0005, Japan;
| | - Naoto Kawabe
- Department of Gastroenterology and Hepatology, School of Medicine, Fujita Health University, Toyoake 470-1192, Japan;
| | - Tsunekazu Oikawa
- Project Research Units, Research Center for Medical Science, The Jikei University School of Medicine, Tokyo 105-8461, Japan; (A.T.); (T.O.)
| | - Kenta Suzuki
- Division of Gastroenterology and Hepatology, Nippon Medical School, Tokyo 113-8602, Japan; (K.K.); (C.K.); (K.S.); (T.K.); (T.A.); (K.I.)
| | - Tadamichi Kawano
- Division of Gastroenterology and Hepatology, Nippon Medical School, Tokyo 113-8602, Japan; (K.K.); (C.K.); (K.S.); (T.K.); (T.A.); (K.I.)
| | - Tomomi Okubo
- Department of Gastroenterology, Nippon Medical School Chiba Hokusoh Hospital, Inzai 270-1694, Japan;
| | - Taeang Arai
- Division of Gastroenterology and Hepatology, Nippon Medical School, Tokyo 113-8602, Japan; (K.K.); (C.K.); (K.S.); (T.K.); (T.A.); (K.I.)
| | - Joji Tani
- Department of Gastroenterology, Kagawa University Graduate School of Medicine, Kagawa 761-0793, Japan; (J.T.); (A.M.)
| | - Asahiro Morishita
- Department of Gastroenterology, Kagawa University Graduate School of Medicine, Kagawa 761-0793, Japan; (J.T.); (A.M.)
| | - Motoh Iwasa
- Department of Gastroenterology and Hepatology, Mie University School of Medicine, Tsu 514-8507, Japan;
| | - Toru Ishikawa
- Department of Hepatology, Saiseikai Niigata Hospital, Niigata 950-1104, Japan; (Y.K.); (T.I.)
| | - Tadashi Ikegami
- Division of Hepatology and Gastroenterology, Department of Internal Medicine, Tokyo Medical University Ibaraki Medical Center, Ibaraki 300-0332, Japan;
| | - Yasuhito Tanaka
- Department of Gastroenterology and Hepatology, Faculty of Life Sciences, Kumamoto University, Kumamoto 860-8555, Japan;
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, Gifu 501-1193, Japan (M.S.)
| | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, Nara 634-8521, Japan; (T.N.); (H.Y.)
| | - Katsuhiko Iwakiri
- Division of Gastroenterology and Hepatology, Nippon Medical School, Tokyo 113-8602, Japan; (K.K.); (C.K.); (K.S.); (T.K.); (T.A.); (K.I.)
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Miwa T, Tsuruoka M, Ueda H, Abe T, Inada H, Yukawa-Muto Y, Ohara M, Arai T, Tamai Y, Isoda H, Tadokoro T, Hanai T, Ito T, Tamaki N, Sakamaki A, Aoki Y, Tada F, Yoshio S, Takahashi H, Morishita A, Ishikawa T, Inoue J, Suda G, Ogawa C, Atsukawa M, Hiraoka A, Kuroda H, Namisaki T, Honda T, Kawaguchi T, Tanaka Y, Terai S, Ikegami T, Yoshiji H, Iwasa M, Shimizu M. Current management and future perspectives of covert hepatic encephalopathy in Japan: a nationwide survey. J Gastroenterol 2025:10.1007/s00535-025-02232-0. [PMID: 40053108 DOI: 10.1007/s00535-025-02232-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2025] [Accepted: 02/16/2025] [Indexed: 04/20/2025]
Abstract
BACKGROUND Covert hepatic encephalopathy (CHE) leads to devastating outcomes in patients with cirrhosis. This study aims to elucidate the current management and future perspectives of CHE in Japan. METHODS A questionnaire-based cross-sectional study was conducted among physicians involved in managing cirrhosis in Japan. The primary aim was to elucidate the real-world management of CHE, including testing and treatment. Factors influencing the implementation of CHE testing were analyzed using a logistic regression model. Limitations and future perspectives for improving the management of CHE were also evaluated. RESULTS Of 511 physicians surveyed, 93.9% recognized CHE as a significant problem, and 86.9% agreed that it should be tested. Overall, 62.8% of physicians tested for CHE, whereas 37.2% did not. Multivariable analysis identified institutional factors and certifying board as significant determinants of CHE test implementation. The Stroop (68.2%) and neuropsychiatric tests (57.5%) were the most commonly used methods of identifying CHE. Among those who tested for CHE, 87.7% treated CHE; the most common treatments were lactulose (81.5%), rifaximin (76.3%), and branched-chain amino acids (70.4%). Among non-testers, the primary barrier was the time requirement for testing. Proposals to encourage CHE testing included the development of simple tests and integration of multidisciplinary teams. CONCLUSIONS Most physicians involved in cirrhosis care in Japan recognize CHE as a significant problem that warrants testing. However, testing for CHE remains limited by institutional factors and physician specialties. Time requirements for CHE testing are the primary barrier, and simple tests and multidisciplinary teams are recommended to enhance CHE management.
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Affiliation(s)
- Takao Miwa
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan.
| | - Mio Tsuruoka
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, 980-8574, Japan
| | - Hajime Ueda
- Division of Gastroenterology and Hepatology, Tokyo Medical University Ibaraki Medical Center, 3-20-1 Chuo, Ami-Machi, Inashiki-Gun, Ibaraki, 300-3095, Japan
| | - Tamami Abe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate Medical University School of Medicine, Nishitokuta 2-1-1, Yahaba-Cho, Shiwa-Gun, Yahaba, Iwate, 028-3694, Japan
| | - Hiroki Inada
- Department of Gastroenterology and Hepatology, Faculty of Life Sciences, Kumamoto University, Kumamoto University, 1-1-1, Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Yoshimi Yukawa-Muto
- Department of Hepatology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahimachi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Masatsugu Ohara
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Kita-15 Nishi-7, Kita-Ku, Sapporo-Shi, Hokkaido, 060-8638, Japan
| | - Taeang Arai
- Division of Gastroenterology and Hepatology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Yasuyuki Tamai
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Hiroshi Isoda
- Liver Center, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Tomoko Tadokoro
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki, Kita, Takamatsu, Kagawa, 761-0793, Japan
| | - Tatsunori Hanai
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Takanori Ito
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa, Nagoya, 466-8550, Japan
| | - Nobuharu Tamaki
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, 1-26-1Kyonan-Cho, Musashino-Shi, Tokyo, 180-8610, Japan
| | - Akira Sakamaki
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachidori, Chuo-Ku, Niigata, 951-8510, Japan
| | - Yoshihiko Aoki
- Kohnodai Hospital, National Center for Global Health and Medicine, 1-7-1, Kohnodai, Ichikawa, 272-8516, Japan
| | - Fujimasa Tada
- Gastroenterology Center, Ehime Prefectural Central Hospital, 83 Kasuga-Cho, Matsuyama, Ehime, 790-0024, Japan
| | - Sachiyo Yoshio
- Department of Human Immunology and Translational Research, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Hirokazu Takahashi
- Liver Center, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Asahiro Morishita
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki, Kita, Takamatsu, Kagawa, 761-0793, Japan
| | - Tsuyoshi Ishikawa
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube-Yamaguchi, 7558505, Japan
| | - Jun Inoue
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, 980-8574, Japan
| | - Goki Suda
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Kita-15 Nishi-7, Kita-Ku, Sapporo-Shi, Hokkaido, 060-8638, Japan
| | - Chikara Ogawa
- Department of Gastroenterology and Hepatology, Takamatsu Red Cross Hospital, Takamatsu, 4-1-3 Bancho, Takamatsu City, Kagawa Prefecture, 760-0017, Japan
| | - Masanori Atsukawa
- Division of Gastroenterology and Hepatology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Atsushi Hiraoka
- Gastroenterology Center, Ehime Prefectural Central Hospital, 83 Kasuga-Cho, Matsuyama, Ehime, 790-0024, Japan
| | - Hidekatsu Kuroda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate Medical University School of Medicine, Nishitokuta 2-1-1, Yahaba-Cho, Shiwa-Gun, Yahaba, Iwate, 028-3694, Japan
| | - Tadashi Namisaki
- Department of Gastroenterology, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Takashi Honda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa, Nagoya, 466-8550, Japan
| | - Takumi Kawaguchi
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, 830-0011, Japan
| | - Yasuhito Tanaka
- Department of Gastroenterology and Hepatology, Faculty of Life Sciences, Kumamoto University, Kumamoto University, 1-1-1, Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachidori, Chuo-Ku, Niigata, 951-8510, Japan
| | - Tadashi Ikegami
- Division of Gastroenterology and Hepatology, Tokyo Medical University Ibaraki Medical Center, 3-20-1 Chuo, Ami-Machi, Inashiki-Gun, Ibaraki, 300-3095, Japan
| | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Motoh Iwasa
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
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Herting EC, Jensen MD, Jepsen P. Lactulose use among patients with alcohol-related liver cirrhosis as a surrogate marker of hepatic encephalopathy: prevalence and association with mortality - a Danish nationwide cohort study. Metab Brain Dis 2025; 40:107. [PMID: 39826057 PMCID: PMC11742859 DOI: 10.1007/s11011-025-01533-w] [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: 08/14/2024] [Accepted: 01/10/2025] [Indexed: 01/20/2025]
Abstract
BACKGROUND & AIMS Hepatic encephalopathy (HE), one of the most serious prognostic factors for mortality in alcohol-related cirrhosis (ALD cirrhosis), is not recorded in Danish healthcare registries. However, treatment of HE with lactulose, the universal first-line treatment, can be identified through data on filled prescriptions. This study aimed to investigate if lactulose can be used as a surrogate marker of HE. METHODS We used Danish healthcare registries to establish a cohort of patients with ALD cirrhosis diagnosed in 2000-2018. Lactulose users were identified using data on filled prescriptions. We computed the prevalence and cumulative incidence of lactulose use, and then matched lactulose users with cohort members who were not using lactulose. This matched dataset was used to identify predictors of lactulose initiation, and to examine the association between lactulose use and all-cause mortality. RESULTS We included 23,089 patients, among whom we identified 4,789 first-time lactulose users. The prevalence of lactulose usage rose to 11% within the first 6 months after ALD diagnosis and reached 19% 5 years after inclusion. The 1-year cumulative incidence of lactulose use was 31%, and predictors of initiating lactulose use were history of severe liver disease (ascites, portal hypertension, spontaneous bacterial peritonitis or gastrointestinal bleeding) or hepatocellular carcinoma. Lactulose use was associated with higher mortality (adjusted hazard ratio 1.61 [95% confidence interval 1.53; 1.69]). CONCLUSIONS Lactulose is used by 10-20% of patients with ALD cirrhosis, primarily those with severe cirrhosis, and lactulose users have a markedly higher mortality than nonusers. We conclude that lactulose use can be used to estimate the prevalence of HE and to reduce confounding from HE, but it should not be used as a surrogate for HE in studies with HE as an outcome.
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Affiliation(s)
- Emma Celia Herting
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus N, Denmark.
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark.
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, C116, DK-8200, Aarhus N, Denmark.
| | - Morten Daniel Jensen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus N, Denmark
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus N, Denmark
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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5
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Albillos A, Bañares R, Hernández-Gea V. Portal hypertension: recommendations for diagnosis and treatment. Consensus document sponsored by the Spanish Association for the Study of the Liver (AEEH) and the Biomedical Research Network Centre for Liver and Digestive Diseases (CIBERehd). GASTROENTEROLOGIA Y HEPATOLOGIA 2025; 48:502208. [PMID: 39756832 DOI: 10.1016/j.gastrohep.2024.502208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/07/2024] [Accepted: 04/09/2024] [Indexed: 01/07/2025]
Abstract
Portal hypertension is a hemodynamic abnormality that complicates the course of cirrhosis, as well as other diseases that affect the portal venous circulation. The development of portal hypertension compromises prognosis, especially when it rises above a certain threshold known as clinically significant portal hypertension (CSPH). In the consensus conference on Portal Hypertension promoted by the Spanish Association for the Study of the Liver and the Hepatic and Digestive diseases area of the Biomedical Research Networking Center (CIBERehd), different aspects of the diagnosis and treatment of portal hypertension caused by cirrhosis or other diseases were discussed. The outcome of this discussion was a set of recommendations that achieved varying degrees of consensus among panelists and are reflected in this consensus document. The six areas under discussion were: the relevance of CSPH and the non-invasive methods used for its diagnosis and that of cirrhosis, the prevention of the first episode of decompensation and its recurrence, the treatment of acute variceal bleeding and other complications of portal hypertension, the indications for the use of TIPS, and finally, the diagnosis and treatment of liver vascular diseases.
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Affiliation(s)
- Agustín Albillos
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
| | - Rafael Bañares
- Servicio de Medicina de Aparato Digestivo, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Universidad Complutense, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
| | - Virginia Hernández-Gea
- Servicio de Hepatología, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, España.
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6
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Albillos A, Bañares R, Hernández-Gea V. Portal hypertension: recommendations for diagnosis and treatment. Consensus document sponsored by the Spanish Association for the Study of the Liver (AEEH) and the Biomedical Research Network Center for Liver and Digestive Diseases (CIBERehd). REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2025; 117:14-57. [PMID: 39350672 DOI: 10.17235/reed.2024.10805/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2025]
Abstract
Portal hypertension is a hemodynamic abnormality that complicates the course of cirrhosis, as well as other diseases that affect the portal venous circulation. The development of portal hypertension compromises prognosis, especially when it rises above a certain threshold known as clinically significant portal hypertension (CSPH). In the consensus conference on Portal Hypertension promoted by the Spanish Association for the Study of the Liver and the Hepatic and Digestive diseases area of the Biomedical Research Networking Center (CIBERehd), different aspects of the diagnosis and treatment of portal hypertension caused by cirrhosis or other diseases were discussed. The outcome of this discussion was a set of recommendations that achieved varying degrees of consensus among panelists and are reflected in this consensus document. The six areas under discussion were: the relevance of clinically significant portal hypertension and the non-invasive methods used for its diagnosis and that of cirrhosis, the prevention of the first episode of decompensation and its recurrence, the treatment of acute variceal bleeding and other complications of portal hypertension, the indications for the use of TIPS, and finally, the diagnosis and treatment of liver vascular diseases.
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Affiliation(s)
- Agustín Albillos
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, España
| | - Rafael Bañares
- Servicio de Medicina de Aparato Digestivo, Hospital General Universitario Gregorio Marañón
| | - Virginia Hernández-Gea
- Servicio de Hepatología, Hospital Clínic. Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)
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7
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Salama MM, Bayoumi EM, Sayed MM, Abdul-Rahman SA, Saleh SAB, Zaky AS, Mohamed GA. Evaluation of handgrip strength as a predictor of sarcopenia in patients with HCV-related cirrhosis. EGYPTIAN LIVER JOURNAL 2023; 13:24. [DOI: 10.1186/s43066-023-00261-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 05/06/2023] [Indexed: 01/03/2025] Open
Abstract
Abstract
Background
Sarcopenia, characterised by a loss of muscle strength, quantity/quality, and physical performance, is associated with increased mortality and poor clinical outcomes in patients with liver cirrhosis. The use of the currently accepted methods for estimating muscle mass, such as computed tomography, dual-energy X-ray absorptiometry, and bioelectrical impedance analysis, in routine clinical practice is restricted because of limited availability, radiation exposure, time consumption, or high cost. Therefore, an alternative, simple, safe, reproducible, and financially accessible method for the routine assessment of sarcopenia is needed. Hence, we aim to assess the utility of handgrip strength (HGS) in diagnosing sarcopenia in patients with HCV-related cirrhosis compared to appendicular skeletal muscle index assessed by dual-energy X-ray absorptiometry (DEXA-ASMI). A total of 64 participants older than 18 years were consecutively recruited. The subjects were divided into the following groups: Control group included 32 healthy control subjects, and the HCV-related liver cirrhosis group included 32 patients who were subdivided equally into two subgroups (Child A and Child C) with 16 patients each. All participants were subjected to dominant hand dynamometer and DEXA scan.
Results
The prevalence of sarcopenia was significantly higher in the cirrhosis group than in the control group (7.75 ± 1.35 vs. 8.29 ± 1.25 kg/m2, P < 0.001), with increasing prevalence in the Child C class group (P < 0.001). HGS was significantly lower in the Child C group compared to other groups (P < 0.001). Regarding the differentiation of sarcopenic patients, defining HGS using a cutoff of ≤ 28.6 kg has an AUC of 0.879, sensitivity of 100%, specificity of 66.7%, PPV of 61.1%, and NPV of 100% (95% CI = 0.715 to 0.967; P < 0.0001).
Conclusion
Given the low cost, reproducibility, and safety of handgrip strength dynamometry, this is a promising method for both the diagnosis of sarcopenia as well as serial monitoring of muscle function in patients with HCV-related cirrhosis.
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Kim MJ, Kim JH, Jung JH, Kim SE, Kim HS, Jang MK, Park SH, Lee MS, Suk KT, Kim DJ, Choi EK, Park JW. Serum S100B Levels in Patients with Liver Cirrhosis and Hepatic Encephalopathy. Diagnostics (Basel) 2023; 13:333. [PMID: 36766438 PMCID: PMC9914222 DOI: 10.3390/diagnostics13030333] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/08/2023] [Accepted: 01/13/2023] [Indexed: 01/18/2023] Open
Abstract
Hepatic encephalopathy (HE) is one of the main complications of liver cirrhosis (LC) and is classified into minimal hepatic encephalopathy (MHE) and overt hepatic encephalopathy (overt HE). S100B is expressed mainly in astrocytes and other glial cells, and S100B has been reported to be associated with various neurological disorders. The present study aimed to investigate the diagnostic ability of serum S100B to discriminate the grade of HE and the parameters correlated with serum S100B levels. Additionally, we investigated whether serum S100B levels can be used to predict 1-year mortality in cirrhotic patients. In total, 95 cirrhotic patients were consecutively enrolled and divided into the following three groups: (i) without any types of HEs; (ii) with MHE; and (iii) with overt HE. The diagnosis of MHE was made by the Mini-Mental State Examination (MMSE) and Psychometric Hepatic Encephalopathy Score (PHES). Among the three groups, there were no significant differences in serum S100B levels regardless of HE severity. The clinical parameters correlated with serum S100B levels were age, serum bilirubin, and creatinine levels. The Model for End-Stage Liver Disease (MELD) score showed a significant positive correlation with serum S100B levels. The relationship between serum S100B levels and MELD score was maintained in 48 patients without any type of HE. Additionally, hyperammonemia, low cholesterol levels, and the combination of serum S100B levels ≥ 35 pg/mL with MELD score ≥ 13 were factors for predicting 1- year mortality. In conclusion, serum S100B level was not useful for differentiating the severity of HE. However, we found that serum S100B levels can be affected by age, serum bilirubin, and creatinine in cirrhotic patients and are associated with MELD scores. Additionally, serum S100B levels showed the possibility of predicting 1-year mortality in cirrhotic patients. These findings suggest that serum S100B levels may reflect liver dysfunction and prognosis in liver disease.
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Affiliation(s)
- Mo-Jong Kim
- Ilsong Institute of Life Science, Hallym University, Seoul 07247, Republic of Korea
- Department of Biomedical Gerontology, Graduate School of Hallym University, Chuncheon-si 24252, Republic of Korea
| | - Jung-Hee Kim
- Department of Internal Medicine, Dongtan Sacred Heart Hospital of Hallym University Medical Center, 7, Keunjaebong-gil, Hwaseong-si 18450, Republic of Korea
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
| | - Jang-Han Jung
- Department of Internal Medicine, Dongtan Sacred Heart Hospital of Hallym University Medical Center, 7, Keunjaebong-gil, Hwaseong-si 18450, Republic of Korea
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
| | - Sung-Eun Kim
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
- Department of Internal Medicine, Hallym University Sacred Heart Hospital of Hallym University Medical Center, 22, Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang-si 14068, Republic of Korea
| | - Hyoung-Su Kim
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
- Department of Internal Medicine, Kangdong Sacred Heart Hospital of Hallym University Medical Center, 18, Cheonho-daero 173-gil, Gangdong-gu, Seoul 05355, Republic of Korea
| | - Myoung-Kuk Jang
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
- Department of Internal Medicine, Kangdong Sacred Heart Hospital of Hallym University Medical Center, 18, Cheonho-daero 173-gil, Gangdong-gu, Seoul 05355, Republic of Korea
| | - Sang-Hoon Park
- Department of Internal Medicine, Kangnam Sacred Heart Hospital of Hallym University Medical Center, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Myung-Seok Lee
- Department of Internal Medicine, Kangnam Sacred Heart Hospital of Hallym University Medical Center, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Ki Tae Suk
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital of Hallym University Medical Center, 77, Sakju-ro, Chuncheon-si 24253, Republic of Korea
| | - Dong Joon Kim
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital of Hallym University Medical Center, 77, Sakju-ro, Chuncheon-si 24253, Republic of Korea
| | - Eun-Kyoung Choi
- Ilsong Institute of Life Science, Hallym University, Seoul 07247, Republic of Korea
- Department of Biomedical Gerontology, Graduate School of Hallym University, Chuncheon-si 24252, Republic of Korea
| | - Ji-Won Park
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
- Department of Internal Medicine, Hallym University Sacred Heart Hospital of Hallym University Medical Center, 22, Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang-si 14068, Republic of Korea
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9
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Miwa T, Hanai T, Imai K, Takai K, Shiraki M, Hayashi H, Shimizu S, Nishigaki Y, Tomita E, Shimizu M. Effects of Rifaximin on Circulating Albumin Structures and Serum Ammonia Levels in Patients with Liver Cirrhosis: A Preliminary Study. J Clin Med 2022; 11:jcm11247318. [PMID: 36555935 PMCID: PMC9784744 DOI: 10.3390/jcm11247318] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/05/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022] Open
Abstract
Circulating albumin structures, including their oxidized and reduced forms, are involved in hepatic encephalopathy (HE) development. However, the effects of rifaximin, a key drug in HE treatment, on the circulating albumin structure in patients with liver cirrhosis remain unclear. In this multicenter prospective study, eight patients with hyperammonemia (≥80 μg/dL) were enrolled. The circulating albumin structure was evaluated using the ratio of oxidized albumin (human nonmercaptalbumin, HNA). Patients were administered 400 mg rifaximin 3 times/day for 3 months, and laboratory data were assessed at baseline and during observation. Among the eight patients, three were men; the median age and body mass index were 70 years and 26.4 kg/m2, respectively. The median HNA and serum ammonia levels at baseline were 41% and 143 μg/dL, respectively. After rifaximin therapy, HNA showed a decreasing tendency (median; from 41% to 36%, p = 0.321), but serum albumin levels showed no significant change (from 3.5 g/dL to 3.5 g/dL, p = 1.00); serum ammonia levels significantly reduced (median: 143 μg/dL to 76 μg/dL, p = 0.015). Thus, rifaximin reduces serum ammonia levels and may improve circulating albumin structure in patients with cirrhosis. Further large-scale studies are required to confirm these preliminary results.
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Affiliation(s)
- Takao Miwa
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, Gifu 501-1194, Japan
- Health Administration Center, Gifu University, Gifu 501-1193, Japan
- Correspondence: ; Tel.: +81-(58)-230-6308
| | - Tatsunori Hanai
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, Gifu 501-1194, Japan
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu 501-1194, Japan
| | - Kenji Imai
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, Gifu 501-1194, Japan
| | - Koji Takai
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, Gifu 501-1194, Japan
- Division for Regional Cancer Control, Graduate School of Medicine, Gifu University, Gifu 501-1193, Japan
| | - Makoto Shiraki
- Department of Gastroenterology, Chuno Kosei Hospital, Gifu 501-3802, Japan
| | - Hideki Hayashi
- Department of Gastroenterology and Hepatology, Gifu Municipal Hospital, Gifu 500-8513, Japan
| | - Shogo Shimizu
- Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu 500-8717, Japan
| | - Yoichi Nishigaki
- Department of Gastroenterology and Hepatology, Gifu Municipal Hospital, Gifu 500-8513, Japan
| | - Eiichi Tomita
- Department of Gastroenterology and Hepatology, Gifu Municipal Hospital, Gifu 500-8513, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, Gifu 501-1194, Japan
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10
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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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11
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Zhou YF, Xu Y, Ding YF, Yu XJ, Wu YL, Chen P, Zou DW. Novel nomogram model for predicting 6-week mortality in liver cirrhosis patients with acute upper gastrointestinal bleeding. J Dig Dis 2022; 23:516-526. [PMID: 36208036 DOI: 10.1111/1751-2980.13137] [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: 06/16/2022] [Revised: 09/27/2022] [Accepted: 10/06/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To develop and validate a nomogram for predicting 6-week mortality in patients with liver cirrhosis and acute upper gastrointestinal bleeding (UGIB) and to compare it with other commonly used scoring systems. METHODS This retrospective study included cirrhotic patients with acute UGIB hospitalized between January 2013 and December 2020. Random sampling was used to divide patients into the training (n = 676) and validation cohorts (n = 291) at a 7:3 ratio. Multivariate logistic stepwise regression was used to establish a model for predicting 6-week mortality. Multiple indicators were used to validate the nomogram, including the area under the receiver operating characteristic curve (AUROC), calibration curve, and decision curve analysis (DCA). RESULTS In the training cohort, total bilirubin (TBIL) (odds ratio [OR] 1.75, 95% confidence interval [CI] 1.22-2.50), hemoglobin (Hb) (OR 0.97, 95% CI 0.95-0.99), C-reactive protein (OR 2.79, 95% CI 1.30-6.07), prothrombin time (OR 1.17, 95% CI 1.05-1.30), and hepatic encephalopathy (stage I-II: OR 4.15, 95% CI 1.73-9.61; stage III-IV: OR 19.6, 95% CI 5.33-76.8) were identified as independent factors of 6-week mortality. The AUROC of the UGIB-LC score was 0.873 (95% CI 0.820-0.927), which was higher than that of the Child-Pugh score (0.781), model for end-stage liver disease score (0.766), and neutrophil-to-lymphocyte ratio (0.716). CONCLUSION The UGIB-LC score is useful for predicting 6-week mortality in patients with liver cirrhosis and acute UGIB, which is superior to the other three scoring systems.
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Affiliation(s)
- Yu Fen Zhou
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ying Xu
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yan Fei Ding
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiao Jun Yu
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yun Lin Wu
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ping Chen
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Duo Wu Zou
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Efficacy of rifaximin against covert hepatic encephalopathy and hyperammonemia in Japanese patients. PLoS One 2022; 17:e0270786. [PMID: 35776720 PMCID: PMC9249214 DOI: 10.1371/journal.pone.0270786] [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: 03/30/2022] [Accepted: 06/20/2022] [Indexed: 11/23/2022] Open
Abstract
Covert hepatic encephalopathy (CHE) impairs patient quality of life and occurs in approximately 30% of liver cirrhosis (LC) cases. Japanese clinical practice guidelines recommend rifaximin to treat overt HE (OHE). However, the usefulness of rifaximin against CHE is not thoroughly investigated in Japanese patients. We aimed to investigate the efficacy of rifaximin against hyperammonemia and CHE in Japan. We observed 102 patients with HE showing hyperammonemia secondary to LC and examined various biochemical and behavioral parameters following rifaximin treatment. CHE was diagnosed when the patients exhibited two or more abnormal neuropsychological test (NPT) scores but did not indicate OHE symptoms. In the 102 cases, a significant therapeutic effect of rifaximin on hyperammonemia was observed from 2 to 48 weeks after starting treatment. Excluding 10 patients diagnosed with OHE upon starting rifaximin treatment, 12 of the 92 remaining patients (11.8%) transitioned to OHE within 1 year. The 1 year cumulative OHE transition rate was 14.5%. Among the 24 patients with CHE diagnosed by the NPT for whom NPT results could be evaluated at 4 and 12 weeks after starting treatment, 10 (41.6%) had recovered from CHE at 12 weeks. When the factors contributing to recovery from CHE were examined by multivariate analysis, an ammonia level <129 μg/dL was a significant factor. Rifaximin was thus significantly effective against both hyperammonemia and CHE in Japanese patients.
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Ibáñez-Samaniego L, Bañares R. Evaluation of the Role of Minimal Perihepatic Ascites, Minimal Hepatic Encephalopathy, and Bleeding Due to Portal Hypertensive Gastroenteropathy in the Definition of Decompensation. PORTAL HYPERTENSION VII 2022:363-392. [DOI: 10.1007/978-3-031-08552-9_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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Hanai T, Shiraki M, Nishimura K, Miwa T, Maeda T, Ogiso Y, Imai K, Suetsugu A, Takai K, Shimizu M. Usefulness of the Stroop Test in Diagnosing Minimal Hepatic Encephalopathy and Predicting Overt Hepatic Encephalopathy. Hepatol Commun 2021; 5:1518-1526. [PMID: 34510827 PMCID: PMC8435282 DOI: 10.1002/hep4.1738] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/07/2021] [Accepted: 04/11/2021] [Indexed: 02/04/2023] Open
Abstract
Minimal hepatic encephalopathy (MHE) adversely affects the clinical outcomes of patients with liver cirrhosis. This prospective study aimed to evaluate the utility of the Stroop test in the diagnosis of MHE and prediction of overt hepatic encephalopathy (OHE) in Japanese patients with cirrhosis. We enrolled 152 patients who underwent the Stroop test between November 2018 and February 2020. MHE was diagnosed using a combination of neuropsychological tests as the gold standard. The enrolled patients were followed up prospectively until the occurrence of OHE or August 2020. The optimal cutoff value of the Stroop test measurements was determined by receiver operating characteristic (ROC) curve analysis, and its predictive ability was assessed using the area under the ROC curve (AUC). Among the 139 eligible patients, 50 (36%) were diagnosed with MHE. The OffTime+OnTime cutoff value of 218.3 seconds had the best discriminative ability for MHE diagnosis, with an AUC of 0.77, a sensitivity of 74%, and a specificity of 75%. During a median follow-up of 10.8 months, 6 (4%) patients developed OHE. The OffTime+OnTime cutoff value of 305.6 seconds had the highest predictive ability for OHE, with an AUC of 0.79, a sensitivity of 67%, and a specificity of 92%. This value predicted OHE occurrence independent of liver functional reserve and prior OHE (hazard ratio, 19.8; P = 0.003). These two cutoff values remained statistically significant even when patients with prior OHE were excluded from the analysis. Conclusion: The Stroop test was useful for diagnosing patients with MHE and predicting OHE in Japanese patients with cirrhosis.
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Affiliation(s)
- Tatsunori Hanai
- Department of Gastroenterology/Internal MedicineGifu University Graduate School of MedicineGifuJapan
| | - Makoto Shiraki
- Department of Gastroenterology/Internal MedicineGifu University Graduate School of MedicineGifuJapan
| | - Kayoko Nishimura
- Center for Nutrition Support and Infection ControlGifu University HospitalGifuJapan
| | - Takao Miwa
- Department of Gastroenterology/Internal MedicineGifu University Graduate School of MedicineGifuJapan
| | - Toshihide Maeda
- Department of Gastroenterology/Internal MedicineGifu University Graduate School of MedicineGifuJapan
| | - Yui Ogiso
- Department of Gastroenterology/Internal MedicineGifu University Graduate School of MedicineGifuJapan
| | - Kenji Imai
- Department of Gastroenterology/Internal MedicineGifu University Graduate School of MedicineGifuJapan
| | - Atsushi Suetsugu
- Department of Gastroenterology/Internal MedicineGifu University Graduate School of MedicineGifuJapan
| | - Koji Takai
- Department of Gastroenterology/Internal MedicineGifu University Graduate School of MedicineGifuJapan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal MedicineGifu University Graduate School of MedicineGifuJapan
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15
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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: 18] [Impact Index Per Article: 4.5] [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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16
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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: 24] [Impact Index Per Article: 6.0] [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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17
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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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18
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Formentin C, Zarantonello L, Mangini C, Frigo AC, Montagnese S, Merkel C. Clinical, neuropsychological and neurophysiological indices and predictors of hepatic encephalopathy (HE). Liver Int 2021; 41:1070-1082. [PMID: 33411388 DOI: 10.1111/liv.14785] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/30/2020] [Accepted: 01/01/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS The occurrence of overt hepatic encephalopathy (HE) marks a significant progression in the natural history of liver disease. The aims of the present study were to: 1) describe a large cohort of patients with cirrhosis in terms of neuropsychological or neurophysiological HE indices, and 2) test if the severity of liver disease and/or any such indices [Psychometric Hepatic Encephalopathy Score (PHES), Scan test, electroencephalography (EEG)] predicted mortality/HE risk in a subgroup of such cohort. METHOD Four hundred and sixty-one patients with cirrhosis (59 ± 10 years; 345 males) were included; information on previous overt HE episodes was available in 407. Follow-up information on mortality/HE-related hospitalization in 134/127 respectively. Information on previous overt HE episodes and both mortality and HE-related hospitalization over the follow-up in 124. RESULTS Patients with a history of overt HE (60%) had poorer liver function, worse neuropsychiatric indices, higher ammonia levels and higher prevalence of portal-systemic shunt. The risk of HE-related hospitalization over the follow-up was higher in patients with higher MELD score and worse Scan performance. Mortality was higher in those with higher MELD. Among patients without a history of overt HE, those with worse PHES had higher HE risk. Among patients with a history, those with higher MELD, better PHES and worse Scan performance had higher HE risk. CONCLUSIONS In patients without previous overt HE episodes, neuropsychological and neurophysiological tests predict HE, while in those with previous overt HE episodes, HE development largely depends on the severity of liver dysfunction.
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Affiliation(s)
- Chiara Formentin
- Department of Medicine, and Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Lisa Zarantonello
- Department of Medicine, and Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Chiara Mangini
- Department of Medicine, and Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Anna C Frigo
- Department of Medicine, and Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Sara Montagnese
- Department of Medicine, and Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Carlo Merkel
- Department of Medicine, and Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
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19
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Hiramine Y, Uto H, Mawatari S, Kanmura S, Imamura Y, Hiwaki T, Saishoji A, Kakihara A, Maenohara S, Tokushige K, Ido A. Efficacy of rifaximin, a poorly absorbed rifamycin antimicrobial agent, for hepatic encephalopathy in Japanese patients. Hepatol Res 2021; 51:445-460. [PMID: 33533150 DOI: 10.1111/hepr.13622] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 12/27/2020] [Accepted: 01/15/2021] [Indexed: 12/21/2022]
Abstract
AIM Rifaximin is recommended as treatment for hepatic encephalopathy (HE) that targets intestinal bacterial flora. Although combined use with synthetic disaccharides is the standard of care worldwide, the therapeutic effects of rifaximin for overt encephalopathy (OHE) in Japanese patients have not been examined sufficiently. We examined the therapeutic effects of rifaximin for OHE in Japanese patients. METHODS A total of 76 patients who developed OHE of West Haven grade II or higher at least once within the 12 months before starting rifaximin were included. Blood ammonia levels and the incidence of OHE during the 12 months before and after starting rifaximin therapy were compared in a before-and-after study. Rifaximin efficacy and predictors of efficacy were also examined. RESULTS Post-treatment blood ammonia levels were significantly lower than pretreatment levels. The mean annual number of OHE incidents and intravenous branched-chain amino acid preparations used per patient were significantly lower after starting rifaximin therapy (2.51 vs. 0.76 times/year, p < 0.001; and 71.9 vs. 20.7 preparations/year, p = 0.003, respectively). The cumulative incidence of hospitalizations associated with HE significantly decreased after rifaximin therapy (hazard ratio 0.187; p < 0.001). The efficacy rate, defined as the proportion of patients without OHE during the administration of rifaximin for 1 year after starting rifaximin therapy, was 65.8%. Serum albumin ≥2.7 g/dl was an independent predictor of efficacy. CONCLUSION Rifaximin was associated with decreased blood ammonia levels, lower incidence of OHE, and fewer hospitalizations in Japanese patients with HE. In addition, serum albumin level was an important predictor on efficacy of rifaximin.
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Affiliation(s)
- Yasunari Hiramine
- Department of Internal Medicine, Kagoshima Kouseiren Hospital, Kagoshima, Japan
| | - Hirofumi Uto
- Center for Digestive and Liver Diseases, Miyazaki Medical Center Hospital, Miyazaki, Japan.,Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Seiichi Mawatari
- Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Shuji Kanmura
- Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Yasushi Imamura
- Department of Internal Medicine, Kagoshima Kouseiren Hospital, Kagoshima, Japan
| | - Takuya Hiwaki
- Department of Internal Medicine, Kagoshima Kouseiren Hospital, Kagoshima, Japan
| | - Akiko Saishoji
- Department of Internal Medicine, Kagoshima Kouseiren Hospital, Kagoshima, Japan.,Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Atsuko Kakihara
- Department of Internal Medicine, Kagoshima Kouseiren Hospital, Kagoshima, Japan.,Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Shigeho Maenohara
- Department of Surgery, Kagoshima Kouseiren Hospital, Kagoshima, Japan
| | - Koichi Tokushige
- Department of Internal Medicine, Kagoshima Kouseiren Hospital, Kagoshima, Japan
| | - Akio Ido
- Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
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20
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Akahane T, Yoshiji H. Role of serum albumin in hepatic encephalopathy. Hepatol Res 2021; 51:353-354. [PMID: 33797845 DOI: 10.1111/hepr.13632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Takemi Akahane
- Department of Gastroenterology, Nara Medical University, Kashihara, Japan
| | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, Kashihara, Japan
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21
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Impaired brain function improved by L-carnitine in patients with cirrhosis: evaluation using near-infrared spectroscopy. Sci Rep 2020; 10:13566. [PMID: 32782294 PMCID: PMC7419306 DOI: 10.1038/s41598-020-70585-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/20/2020] [Indexed: 02/07/2023] Open
Abstract
To evaluate the effects of l-carnitine on impaired brain function in patients with liver cirrhosis. We conducted a retrospective cohort study that included sequential 80 liver cirrhosis patients with impaired brain function evaluated using near-infrared spectroscopy (NIRS). Among them, l-carnitine was administered to 48 patients. The NIRS data and blood ammonia level at baseline and after 8 weeks of treatment were compared between patients administered with l-carnitine (l-carnitine group) and those who were not (control group). The NIRS data at baseline were similar between the l-carnitine and control groups (0.04 ± 0.04 vs. 0.04 ± 0.05 mMmm, p = n.s), whereas those in the l-carnitine group (n = 48) were significantly better than that of the control group at 8 weeks of treatment (n = 32) (0.103 ± 0.081 vs. 0.040 ± 0.048 mMmm, p < 0.001). In the l-carnitine group, 35.4% (17/48) of patients had hyperammonemia. The NIRS data of the l-carnitine group at 8 weeks of treatment were significantly improved than that of the control group, irrespective of baseline ammonia levels (0.11 ± 0.09 vs. 0.04 ± 0.05 mMmm, p = 0.005, and 0.10 ± 0.06 vs. 0.02 ± 0.03 mMmm, p = 0.003, for normal baseline ammonia and elevated ammonia levels, respectively). In the multivariate analysis, l-carnitine administration (odds ratio [OR] 3.51, 95% confidence interval [CI] 1.23–9.99, p = 0.019) and baseline NIRS data of ≤ 0.07 mMmm (OR 5.21, 95% CI 1.69–16.0, p = 0.0041) were found as independent significant factors. l-carnitine improves impaired brain function in patients with liver cirrhosis.
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