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Llansola M, Arenas YM, Sancho-Alonso M, Mincheva G, Palomares-Rodriguez A, Doverskog M, Izquierdo-Altarejos P, Felipo V. Neuroinflammation alters GABAergic neurotransmission in hyperammonemia and hepatic encephalopathy, leading to motor incoordination. Mechanisms and therapeutic implications. Front Pharmacol 2024; 15:1358323. [PMID: 38560359 PMCID: PMC10978603 DOI: 10.3389/fphar.2024.1358323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
Enhanced GABAergic neurotransmission contributes to impairment of motor coordination and gait and of cognitive function in different pathologies, including hyperammonemia and hepatic encephalopathy. Neuroinflammation is a main contributor to enhancement of GABAergic neurotransmission through increased activation of different pathways. For example, enhanced activation of the TNFα-TNFR1-NF-κB-glutaminase-GAT3 pathway and the TNFα-TNFR1-S1PR2-CCL2-BDNF-TrkB pathway in cerebellum of hyperammonemic rats enhances GABAergic neurotransmission. This is mediated by mechanisms affecting GABA synthesizing enzymes GAD67 and GAD65, total and extracellular GABA levels, membrane expression of GABAA receptor subunits, of GABA transporters GAT1 and GAT three and of chloride co-transporters. Reducing neuroinflammation reverses these changes, normalizes GABAergic neurotransmission and restores motor coordination. There is an interplay between GABAergic neurotransmission and neuroinflammation, which modulate each other and altogether modulate motor coordination and cognitive function. In this way, neuroinflammation may be also reduced by reducing GABAergic neurotransmission, which may also improve cognitive and motor function in pathologies associated to neuroinflammation and enhanced GABAergic neurotransmission such as hyperammonemia, hepatic encephalopathy or Parkinson's disease. This provides therapeutic targets that may be modulated to improve cognitive and motor function and other alterations such as fatigue in a wide range of pathologies. As a proof of concept it has been shown that antagonists of GABAA receptors such as bicuculline reduces neuroinflammation and improves cognitive and motor function impairment in rat models of hyperammonemia and hepatic encephalopathy. Antagonists of GABAA receptors are not ideal therapeutic tools because they can induce secondary effects. As a more effective treatment to reduce GABAergic neurotransmission new compounds modulating it by other mechanisms are being developed. Golexanolone reduces GABAergic neurotransmission by reducing the potentiation of GABAA receptor activation by neurosteroids such as allopregnanolone. Golexanolone reduces neuroinflammation and GABAergic neurotransmission in animal models of hyperammonemia, hepatic encephalopathy and cholestasis and this is associated with improvement of fatigue, cognitive impairment and motor incoordination. This type of compounds may be useful therapeutic tools to improve cognitive and motor function in different pathologies associated with neuroinflammation and increased GABAergic neurotransmission.
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Affiliation(s)
- Marta Llansola
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Yaiza M. Arenas
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - María Sancho-Alonso
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Gergana Mincheva
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | | | | | | | - Vicente Felipo
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
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2
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Casanova-Ferrer F, Gallego JJ, Fiorillo A, Urios A, Ríos MP, León JL, Ballester MP, Escudero-García D, Kosenko E, Belloch V, Montoliu C. Improved cognition after rifaximin treatment is associated with changes in intra- and inter-brain network functional connectivity. J Transl Med 2024; 22:49. [PMID: 38217008 PMCID: PMC10787503 DOI: 10.1186/s12967-023-04844-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 12/29/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Rifaximin is a non-reabsorbable antibiotic which acts at gut level, and improves cognition and inflammatory parameters in minimal hepatic encephalopathy (MHE) patients, but not all patients show the same level of response. This study aims to assess brain activity, both within and between brain networks, following rifaximin treatment, considering the differences between response groups as well. METHODS Twenty-two healthy controls and 53 patients with cirrhosis (22 without and 31 with MHE, diagnosed by Psychometric Hepatic Encephalopathy Score, PHES) performed psychometric, attention and coordination tests, and blood inflammatory parameters were measured. Resting-state functional magnetic resonance imaging (fMRI) acquisitions were performed on controls and MHE patients. Eighteen MHE patients underwent a rifaximin treatment for 6 months, after which all measures were repeated. fMRI images were analysed and changes after treatment were assessed. RESULTS After rifaximin treatment, 13 patients improved their PHES score (Responder patients) while 5 did not (Non-responder patients). No significant decrease in blood ammonia was observed after rifaximin treatment, but there was a decrease in plasma inflammatory cytokines in responder patients. A global effect of rifaximin was detected on the sensorimotor and fronto-parietal networks. Responder patients showed a relative increase of thalamic network connectivity in comparison to non-responder patients. Before treatment, responder and non-responder patients showed connectivity differences in basal ganglia network. The connection of the sensorimotor and thalamic networks between them and with other networks suffered changes after treatment. These connections between networks mostly decreased after treatment. All changes and differences showed a significant level of correlation with the performance of psychometric tests and the blood levels of inflammatory biomarkers. CONCLUSIONS There was an improvement of the communication between executive, motor and attention-related brain areas, and their functional independence following rifaximin treatment. Patients who respond also show a less deteriorated connection involved in these functions before treatment. Results suggest that the improved inflammatory state of MHE patients, following rifaximin treatment would favour the observed changes in brain function and enhanced cognitive performance.
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Affiliation(s)
- Franc Casanova-Ferrer
- Fundacion de Investigación Hospital Clinico Universitario de Valencia-INCLIVA, Valencia, Spain
| | - Juan-José Gallego
- Fundacion de Investigación Hospital Clinico Universitario de Valencia-INCLIVA, Valencia, Spain
| | - Alessandra Fiorillo
- Fundacion de Investigación Hospital Clinico Universitario de Valencia-INCLIVA, Valencia, Spain
| | - Amparo Urios
- Fundacion de Investigación Hospital Clinico Universitario de Valencia-INCLIVA, Valencia, Spain
| | - María-Pilar Ríos
- Servicio de Medicina Digestiva, Hospital Arnau de Vilanova de Valencia, Valencia, Spain
| | - José Luis León
- Universitats Neurorradiology Unit, Ascires Biomedical Group, Valencia, Spain
| | - María-Pilar Ballester
- Servicio de Medicina Digestiva, Hospital Clinico Universitario de Valencia, Valencia, Spain
| | - Desamparados Escudero-García
- Servicio de Medicina Digestiva, Hospital Clinico Universitario de Valencia, Valencia, Spain
- Departamento de Medicina, University of Valencia, Valencia, Spain
| | - Elena Kosenko
- Institute of Theoretical and Experimental Biophysics of Russian Academy of Sciences, Pushchino, Russia
| | - Vicente Belloch
- Universitats Neurorradiology Unit, Ascires Biomedical Group, Valencia, Spain
| | - Carmina Montoliu
- Fundacion de Investigación Hospital Clinico Universitario de Valencia-INCLIVA, Valencia, Spain.
- Department of Pathology, Faculty of Medicine, University of Valencia, Av Blasco Ibáñez, 15, 46010, Valencia, Spain.
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3
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Minimal Hepatic Encephalopathy Affects Daily Life of Cirrhotic Patients: A Viewpoint on Clinical Consequences and Therapeutic Opportunities. J Clin Med 2022; 11:jcm11237246. [PMID: 36498820 PMCID: PMC9736966 DOI: 10.3390/jcm11237246] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/21/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022] Open
Abstract
Minimal hepatic encephalopathy (MHE) is a frequent complication of hepatic encephalopathy (HE) and can affect up to 80% of patients with liver cirrhosis. It is characterized by the lack of obvious clinical signs and the presence of alterations detectable using psychometric or electrophysiological testing focused on attention, working memory, psychomotor speed and visuospatial ability. Ideally, each patient should be tested for this condition because, despite the absence of symptoms, it has severe repercussions on daily life activities. It may be responsible for an inability to drive, sleep disturbances, risk of falls and inability to work. Some studies have highlighted its prognostically unfavorable role on mortality and risk of "overt" HE (OHE). Finally, MHE severely affects the lives of patients and caregivers, altering their quality of life and their socioeconomic status. Several treatments have been proposed for MHE treatment, including non-absorbable disaccharides, poorly absorbable antibiotics, such as rifaximin, probiotics and branched-chain amino acids, with promising results. For this reason, early diagnosis and intervention with appropriate measures is essential, with the aim of improving both performance on psychometric tests, as well as clinical aspects related to this condition.
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4
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Ha A, Saleh ZM, Serper M, Tapper EB. Falls are an underappreciated driver of morbidity and mortality in cirrhosis. Clin Liver Dis (Hoboken) 2022; 20:146-150. [PMID: 36447902 PMCID: PMC9700049 DOI: 10.1002/cld.1246] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/11/2022] [Accepted: 06/19/2022] [Indexed: 11/27/2022] Open
Abstract
Content available: Author Interview and Audio Recording.
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Affiliation(s)
- Albert Ha
- Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Zachary M. Saleh
- Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Marina Serper
- Division of Gastroenterology and HepatologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Elliot B. Tapper
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMichiganUSA
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5
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Casanova-Ferrer F, García-Cena CE, Gallego JJ, Fiorillo A, Urios A, Calvo-Córdoba A, Ballester MP, Ríos MP, Durbán L, Hidalgo MR, García F, Felipo V, Montoliu C. Minimal hepatic encephalopathy is associated to alterations in eye movements. Sci Rep 2022; 12:16837. [PMID: 36207472 PMCID: PMC9547018 DOI: 10.1038/s41598-022-21230-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 09/23/2022] [Indexed: 11/09/2022] Open
Abstract
Minimal hepatic encephalopathy (MHE) is diagnosed using PHES battery, but other tests are more sensitive, and a simple tool for early MHE detection is required. Assessment of saccadic eye movements is useful for early detection of cognitive alterations in different pathologies. We characterized the alterations in saccadic eye movements in MHE patients, its relationship with cognitive alterations and its utility for MHE diagnosis. One-hundred and eighteen cirrhotic patients (86 without and 32 with MHE) and 35 controls performed PHES and Stroop test and an eye movements test battery by OSCANN system: visual saccades, antisaccades, memory-guided saccades, fixation test and smooth pursuit. We analyzed 177 parameters of eye movements, assessed their diagnostic capacity for MHE, and correlated with cognitive alterations. MHE patients showed alterations in 56 of the 177 variables of eye movements compared to NMHE patients. MHE patients showed longer latencies and worse performance in most eye movements tests, which correlated with mental processing speed and attention impairments. The best correlations found were for antisaccades and memory-guided saccades, and some parameters in these tests could be useful for discriminating MHE and NMHE patients. Eye movements analysis could be a new, rapid, reliable, objective, and reproducible tool for early diagnose MHE.
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Affiliation(s)
- Franc Casanova-Ferrer
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Cecilia E García-Cena
- Centre for Automation and Robotics, Universidad Politecnica de Madrid, Madrid, Spain
| | - Juan-Jose Gallego
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Alessandra Fiorillo
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Amparo Urios
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Alberto Calvo-Córdoba
- Centre for Automation and Robotics, Universidad Politecnica de Madrid, Madrid, Spain
| | - Maria-Pilar Ballester
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain.,Servicio de Medicina Digestiva, Hospital Clínico Universitario de Valencia, 46010, Valencia, Spain
| | - María Pilar Ríos
- Servicio de Medicina Digestiva, Hospital Arnau de Vilanova, 46015, Valencia, Spain
| | - Lucía Durbán
- Servicio de Medicina Digestiva, Hospital Arnau de Vilanova, 46015, Valencia, Spain
| | - Marta R Hidalgo
- Bioinformatics and Biostatistics Unit, Centro Investigación Príncipe Felipe, 46012, Valencia, Spain
| | - Francisco García
- Bioinformatics and Biostatistics Unit, Centro Investigación Príncipe Felipe, 46012, Valencia, Spain
| | - Vicente Felipo
- Laboratory of Neurobiology, Centro Investigación Príncipe Felipe, 46012, Valencia, Spain
| | - Carmina Montoliu
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain. .,Department of Pathology, Faculty of Medicine, University of Valencia/INCLIVA-Health Research Institute, Avda. Blasco Ibañez, 17, 46010, Valencia, Spain.
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6
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Arenas YM, Martínez-García M, Llansola M, Felipo V. Enhanced BDNF and TrkB Activation Enhance GABA Neurotransmission in Cerebellum in Hyperammonemia. Int J Mol Sci 2022; 23:ijms231911770. [PMID: 36233065 PMCID: PMC9570361 DOI: 10.3390/ijms231911770] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 11/28/2022] Open
Abstract
Background: Hyperammonemia is a main contributor to minimal hepatic encephalopathy (MHE) in cirrhotic patients. Hyperammonemic rats reproduce the motor incoordination of MHE patients, which is due to enhanced GABAergic neurotransmission in the cerebellum as a consequence of neuroinflammation. In hyperammonemic rats, neuroinflammation increases BDNF by activating the TNFR1–S1PR2–CCR2 pathway. (1) Identify mechanisms enhancing GABAergic neurotransmission in hyperammonemia; (2) assess the role of enhanced activation of TrkB; and (3) assess the role of the TNFR1–S1PR2–CCR2–BDNF pathway. In the cerebellum of hyperammonemic rats, increased BDNF levels enhance TrkB activation in Purkinje neurons, leading to increased GAD65, GAD67 and GABA levels. Enhanced TrkB activation also increases the membrane expression of the γ2, α2 and β3 subunits of GABAA receptors and of KCC2. Moreover, enhanced TrkB activation in activated astrocytes increases the membrane expression of GAT3 and NKCC1. These changes are reversed by blocking TrkB or the TNFR1–SP1PR2–CCL2–CCR2–BDNF–TrkB pathway. Hyperammonemia-induced neuroinflammation increases BDNF and TrkB activation, leading to increased synthesis and extracellular GABA, and the amount of GABAA receptors in the membrane and chloride gradient. These factors enhance GABAergic neurotransmission in the cerebellum. Blocking TrkB or the TNFR1–SP1PR2–CCL2–CCR2–BDNF–TrkB pathway would improve motor function in patients with hepatic encephalopathy and likely with other pathologies associated with neuroinflammation.
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7
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Changing Epidemiology of Cirrhosis and Hepatic Encephalopathy. Clin Gastroenterol Hepatol 2022; 20:S1-S8. [PMID: 35940729 PMCID: PMC9531320 DOI: 10.1016/j.cgh.2022.04.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 02/07/2023]
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8
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Mincheva G, Gimenez-Garzo C, Izquierdo-Altarejos P, Martinez-Garcia M, Doverskog M, Blackburn TP, Hällgren A, Bäckström T, Llansola M, Felipo V. Golexanolone, a GABA A receptor modulating steroid antagonist, restores motor coordination and cognitive function in hyperammonemic rats by dual effects on peripheral inflammation and neuroinflammation. CNS Neurosci Ther 2022; 28:1861-1874. [PMID: 35880480 PMCID: PMC9532914 DOI: 10.1111/cns.13926] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/08/2022] [Accepted: 07/09/2022] [Indexed: 11/29/2022] Open
Abstract
Aims Hyperammonemic rats show peripheral inflammation, increased GABAergic neurotransmission and neuroinflammation in cerebellum and hippocampus which induce motor incoordination and cognitive impairment. Neuroinflammation enhances GABAergic neurotransmission in cerebellum by enhancing the TNFR1‐glutaminase‐GAT3 and TNFR1‐CCL2‐TrkB‐KCC2 pathways. Golexanolone reduces GABAA receptors potentiation by allopregnanolone. This work aimed to assess if treatment of hyperammonemic rats with golexanolone reduces peripheral inflammation and neuroinflammation and restores cognitive and motor function and to analyze underlying mechanisms. Methods Rats were treated with golexanolone and effects on peripheral inflammation, neuroinflammation, TNFR1‐glutaminase‐GAT3 and TNFR1‐CCL2‐TrkB‐KCC2 pathways, and cognitive and motor function were analyzed. Results Hyperammonemic rats show increased TNFα and reduced IL‐10 in plasma, microglia and astrocytes activation in cerebellum and hippocampus, and impaired motor coordination and spatial and short‐term memories. Treating hyperammonemic rats with golexanolone reversed changes in peripheral inflammation, microglia and astrocytes activation and restored motor coordination and spatial and short‐term memory. This was associated with reversal of the hyperammonemia‐enhanced activation in cerebellum of the TNFR1‐glutaminase‐GAT3 and TNFR1‐CCL2‐TrkB‐KCC2 pathways. Conclusion Reducing GABAA receptors activation with golexanolone reduces peripheral inflammation and neuroinflammation and improves cognitive and motor function in hyperammonemic rats. The effects identified would also occur in patients with hepatic encephalopathy and, likely, in other pathologies associated with neuroinflammation.
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Affiliation(s)
- Gergana Mincheva
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Carla Gimenez-Garzo
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | | | - Mar Martinez-Garcia
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | | | | | | | - Torbjörn Bäckström
- Umecrine Cognition AB, Solna, Sweden.,Umeå Neurosteroid Research Center, Clinical Sciences at Umeå University, Umeå, Sweden
| | - Marta Llansola
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Vicente Felipo
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
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9
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Braverman-Jaiven D, Vargas DS, Bojorges-Valdez E, Higuera-de la Tijera F, Pwrez-Hernandez JL. Exploration of the Severity of Hepatic Encephalopathy Deterioration Process Through Dynamics of the EEG Band Power time series. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:3603-3606. [PMID: 36086079 DOI: 10.1109/embc48229.2022.9871273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Cirrhosis is a liver disease that could impair the functionality of the neural system, limiting cognitive processes and reduce mobility, possibly because alterations on dynamics of neural communications. In this study the dynamics of band power fluctuations on ß and γ bands were studied on three groups: control, patients with cirrhosis and patients diagnosed with minimal hepatic encephalopathy. EEG signals were recorded on an oddball paradigm and analyzed to obtain the latency and amplitude of the P300 wave and Detrended Fluctuation Analysis (DFA) exponent values over ß and γ band power time series for each channel. As expected, the latency of the P300 wave was significantly different for control subjects ( ). Amplitudes were not as different, but they tend to decrease for cirrhosis and minimal hepatic encephalopathy groups. DFA exponent values also tends to describe a more regular process and seems to be related with presence of symptoms of hepatic encephalopathy. These subtle changes could be produced by the mechanisms of a mild neurological impairment and be used, if it is confirmed, as an index to evaluate such deterioration.
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10
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Berry K, Duarte-Rojo A, Grab JD, Dunn MA, Boyarsky BJ, Verna EC, Kappus MR, Volk ML, McAdams-DeMarco M, Segev DL, Ganger DR, Ladner DP, Shui A, Tincopa MA, Rahimi RS, Lai JC. Cognitive Impairment and Physical Frailty in Patients With Cirrhosis. Hepatol Commun 2021; 6:237-246. [PMID: 34558844 PMCID: PMC8710786 DOI: 10.1002/hep4.1796] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 06/04/2021] [Accepted: 06/25/2021] [Indexed: 01/10/2023] Open
Abstract
Physical frailty and impaired cognition are common in patients with cirrhosis. Physical frailty can be assessed using performance-based tests, but the extent to which impaired cognition may impact performance is not well characterized. We assessed the relationship between impaired cognition and physical frailty in patients with cirrhosis. We enrolled 1,623 ambulatory adult patients with cirrhosis waiting for liver transplantation at 10 sites. Frailty was assessed with the liver frailty index (LFI; "frail," LFI ≥ 4.4). Cognition was assessed at the same visit with the number connection test (NCT); continuous "impaired cognition" was examined in primary analysis, with longer NCT (more seconds) indicating worse impaired cognition. For descriptive statistics, "impaired cognition" was NCT ≥ 45 seconds. Linear regression associated frailty and impaired cognition; competing risk regression estimated subhazard ratios (sHRs) of wait-list mortality (i.e., death/delisting for sickness). Median NCT was 41 seconds, and 42% had impaired cognition. Median LFI (4.2 vs. 3.8) and rates of frailty (38% vs. 20%) differed between those with and without impaired cognition. In adjusted analysis, every 10-second NCT increase associated with a 0.08-LFI increase (95% confidence interval [CI], 0.07-0.10). In univariable analysis, both frailty (sHR, 1.63; 95% CI, 1.43-1.87) and impaired cognition (sHR, 1.07; 95% CI, 1.04-1.10) associated with wait-list mortality. After adjustment, frailty but not impaired cognition remained significantly associated with wait-list mortality (sHR, 1.55; 95% CI, 1.33-1.79). Impaired cognition mediated 7.4% (95% CI, 2.0%-16.4%) of the total effect of frailty on 1-year wait-list mortality. Conclusion: Patients with cirrhosis with higher impaired cognition displayed higher rates of physical frailty, yet frailty independently associated with wait-list mortality while impaired cognition did not. Our data provide evidence for using the LFI to understand mortality risk in patients with cirrhosis, even when concurrent impaired cognition varies.
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Affiliation(s)
- Kacey Berry
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Andres Duarte-Rojo
- Center for Liver Diseases, Thomas A. Starzl Transplantation Institute and Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joshua D Grab
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Michael A Dunn
- Center for Liver Diseases, Thomas A. Starzl Transplantation Institute and Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian J Boyarsky
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Elizabeth C Verna
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, NY, USA
| | - Matthew R Kappus
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Michael L Volk
- Division of Gastroenterology and Hepatology, and Transplantation Institute, Loma Linda University Health, Loma Linda, CA, USA
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Daniel R Ganger
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Daniela P Ladner
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University Transplant Outcomes Research Collaborative, Northwestern University, Chicago, IL, USA
| | - Amy Shui
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Monica A Tincopa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Robert S Rahimi
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Baylor Scott and White, Dallas, TX, USA
| | - Jennifer C Lai
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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11
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Giménez-Garzó C, Fiorillo A, Ballester-Ferré MP, Gallego JJ, Casanova-Ferrer F, Urios A, Benlloch S, Martí-Aguado D, San-Miguel T, Tosca J, Ríos MP, Montón C, Durbán L, Escudero-García D, Aparicio L, Felipo V, Montoliu C. A New Score Unveils a High Prevalence of Mild Cognitive Impairment in Patients with Nonalcoholic Fatty Liver Disease. J Clin Med 2021; 10:2806. [PMID: 34202269 PMCID: PMC8268962 DOI: 10.3390/jcm10132806] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/21/2021] [Accepted: 06/24/2021] [Indexed: 01/10/2023] Open
Abstract
Patients with nonalcoholic fatty liver disease (NAFLD) may show mild cognitive impairment (MCI). The neurological functions affected remain unclear. The aims were to: (1) Characterize the neuropsychological alterations in NAFLD patients; (2) assess the prevalence of impairment of neurological functions evaluated; (3) develop a new score for sensitive and rapid MCI detection in NAFLD; (4) assess differences in MCI features between patients with nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH); and (5) compare neuropsychological alterations in NAFLD patients with cirrhotic patients with MCI. Fifty-nine NAFLD patients and 53 controls performed psychometric tests assessing different neurological functions: PHES (Psychometric Hepatic Encephalopathy Score) battery, d2, Stroop, Oral SDMT (Symbol Digit Modalities Test), Digit Span, number-letter test, and bimanual and visual-motor coordination tests. NAFLD patients show impairment in attention, mental concentration, psychomotor speed, cognitive flexibility, inhibitory mental control, and working memory. We developed a new, rapid, and sensitive score based on the most affected parameters in NAFLD patients, unveiling that 32% of NAFLD show MCI. Prevalence was similar in NAFL (36%) or NASH (27%) patients, but lower in NAFLD than in cirrhosis (65%). MCI prevalence is significant in NAFLD patients. Psychometric testing is warranted in these patients to unveil MCI and take appropriate measures to reverse and prevent its progression.
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Affiliation(s)
- Carla Giménez-Garzó
- Laboratory of Neurobiology, Centro Investigación Príncipe Felipe, 46012 Valencia, Spain; (C.G.-G.); (A.U.)
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
| | - Alessandra Fiorillo
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
| | - María-Pilar Ballester-Ferré
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
- Servicio de Medicina Digestiva, Hospital Clínico Valencia, 46010 Valencia, Spain
| | - Juan-José Gallego
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
| | - Franc Casanova-Ferrer
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
| | - Amparo Urios
- Laboratory of Neurobiology, Centro Investigación Príncipe Felipe, 46012 Valencia, Spain; (C.G.-G.); (A.U.)
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
| | - Salvador Benlloch
- Servicio de Digestivo, Hospital Arnau de Vilanova, 46015 Valencia, Spain; (S.B.); (M.-P.R.); (L.D.)
- CIBERehd, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - David Martí-Aguado
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
- Servicio de Medicina Digestiva, Hospital Clínico Valencia, 46010 Valencia, Spain
| | - Teresa San-Miguel
- Departamento de Patología, Universidad Valencia, 46010 Valencia, Spain;
| | - Joan Tosca
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
- Servicio de Medicina Digestiva, Hospital Clínico Valencia, 46010 Valencia, Spain
| | - María-Pilar Ríos
- Servicio de Digestivo, Hospital Arnau de Vilanova, 46015 Valencia, Spain; (S.B.); (M.-P.R.); (L.D.)
| | - Cristina Montón
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
- Servicio de Medicina Digestiva, Hospital Clínico Valencia, 46010 Valencia, Spain
| | - Lucía Durbán
- Servicio de Digestivo, Hospital Arnau de Vilanova, 46015 Valencia, Spain; (S.B.); (M.-P.R.); (L.D.)
| | - Desamparados Escudero-García
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
- Servicio de Medicina Digestiva, Hospital Clínico Valencia, 46010 Valencia, Spain
- Departamento de Medicina, Universidad Valencia, 46010 Valencia, Spain
| | - Luis Aparicio
- Departamento de Anatomía y Embriología, Universidad Valencia, 46010 Valencia, Spain;
| | - Vicente Felipo
- Laboratory of Neurobiology, Centro Investigación Príncipe Felipe, 46012 Valencia, Spain; (C.G.-G.); (A.U.)
| | - Carmina Montoliu
- Fundación Investigación Hospital Clínico, Instituto de Investigación Sanitaria, INCLIVA, 46010 Valencia, Spain; (A.F.); (M.-P.B.-F.); (J.-J.G.); (F.C.-F.); (D.M.-A.); (J.T.); (C.M.); (D.E.-G.); (C.M.)
- Departamento de Patología, Universidad Valencia, 46010 Valencia, Spain;
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12
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Acharya C, White MB, Fagan A, Sterling RK, Stravitz RT, Puri P, Fuchs M, Luketic V, Sanyal AJ, Wade JB, Gilles H, Heuman DM, Tinsley F, Matherly S, Lee H, Siddiqui MS, Thacker LR, Bajaj JS. Liver Transplant Is Associated with Sustained Improvement in Tandem Gait and Risk of Falls. Dig Dis Sci 2021; 66:1360-1366. [PMID: 32323075 PMCID: PMC7578102 DOI: 10.1007/s10620-020-06261-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 04/08/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Cirrhosis is associated with poor health-related quality of life (HRQOL), cognitive dysfunction (CD), and lack of coordination leading to falls. Tandem gait (TG; heel-toe) can be used to assess coordination. The impact and relationship between CD, TG and falls pre-/post-liver transplant (LT) is unclear. We aimed to determine the impact of LT on CD, abnormal TG, and HRQOL in cirrhosis. METHODS We analyzed patients who underwent complete neurological examination, cognitive testing by psychometric hepatic encephalopathy score (PHES), and HRQOL assessment using sickness impact profile (SIP). All patients were followed for 1 post-LT visit at 6 or 12 months post-LT for clinical course and falls. Change in CD, TD, and falls pre-/post-LT were compared. RESULTS Off 131 recruited, 61 patients completed all visits. Majority were men (84%), with HCV etiology (34%). Pre-LT: Abnormal TG trended towards increased falls (OR 3.3, P = 0.08). Forty-nine % had abnormal TG, 61% had CD, 32.7% had CD + abnormal TG, 62% had prior OHE, and 14.7% had falls. Abnormal and normal TG patients had similar ages, BMI, sex, education level, and MELD scores. Abnormal TG group had higher prior overt HE (P = 0.03) and worse physical SIP score (P = 0.008). Post-LT: There was sustained improvement in CD, HRQOL, falls, and TG post-LT more at 12 than 6 months in all patients. Patients who had abnormal TG pre-LT continued to have a worse PHES (P = 0.0064) and physical SIP score (P = 0.008) compared to normal pre-LT TG patients. CONCLUSION After LT, there is a sustained improvement in coordination measured via tandem gait, accompanied by a lower rate of falls.
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Affiliation(s)
- Chathur Acharya
- Department of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA, 23249, USA
| | - Melanie B White
- Department of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA, 23249, USA
| | - Andrew Fagan
- Department of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA, 23249, USA
| | - Richard K Sterling
- Department of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA, 23249, USA
| | - R Todd Stravitz
- Department of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA, 23249, USA
| | - Puneet Puri
- Department of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA, 23249, USA
| | - Michael Fuchs
- Department of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA, 23249, USA
| | - Velimir Luketic
- Department of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA, 23249, USA
| | - Arun J Sanyal
- Department of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA, 23249, USA
| | - James B Wade
- Department of Psychiatry, VCU Medical Center and McGuire VA Medical Center, Richmond, VA, USA
| | - HoChong Gilles
- Department of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA, 23249, USA
| | - Douglas M Heuman
- Department of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA, 23249, USA
| | - Felicia Tinsley
- Department of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA, 23249, USA
| | - Scott Matherly
- Department of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA, 23249, USA
| | - Hannah Lee
- Department of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA, 23249, USA
| | - Mohammad S Siddiqui
- Department of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA, 23249, USA
| | - Leroy R Thacker
- Department of Biostatistics, VCU Medical Center and McGuire VA Medical Center, Richmond, VA, USA
| | - Jasmohan S Bajaj
- Department of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA, 23249, USA.
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13
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Gou LB, Zhang W, Guo DJ, Zhong WJ, Wu XJ, Zhou ZM. Aberrant brain structural network and altered topological organization in minimal hepatic encephalopathy. ACTA ACUST UNITED AC 2021; 26:255-261. [PMID: 32209507 DOI: 10.5152/dir.2019.19216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE We aimed to investigate the multilevel impairments of brain structural network in patients with minimal hepatic encephalopathy (MHE). METHODS Twenty-two patients with MHE and 22 well-matched healthy controls (HC) underwent structural magnetic resonance imaging (MRI) brain scans and neuropsychological evaluations. Individual brain structural networks were constructed using diffusion tensor imaging. Comparing with HC, we investigated the possible impairments of brain structural network in MHE, by applying graph-theory approaches to analyze the topological organization at global, modular, and local levels. The correlations between altered brain structural network and neuropsychological tests scores and venous ammonia levels were also examined in MHE patients. RESULTS In the MHE group, small-worldness showed significant decrease and normalized characteristic path length showed increase at the global level. In the modular section, six modules were identified. The inter-modular connective strengths showed significant increase between modules 2 and 4 and between modules 4 and 5. The results of node analysis showed similar hub distributions in the MHE and HC groups except for the right postcentral gyrus, which was only found in the MHE group. No significant differences were found in connective strength of edges between MHE and HC groups using network-based statistics. CONCLUSION The altered brain structural networks with reduced network integration and module segregation were demonstrated in patients with MHE. The dysconnectivity of brain structural network could provide an explanation for the brain dysfunctions of MHE.
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Affiliation(s)
- Lu-Bin Gou
- Department of Radiology, First Hospital of Lan Zhou University, Gansu, China
| | - Wei Zhang
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Da-Jing Guo
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei-Jia Zhong
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao-Jia Wu
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhi-Ming Zhou
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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14
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Rega D, Aiko M, Peñaranda N, Urios A, Gallego JJ, Giménez-Garzó C, Casanova F, Fiorillo A, Cabrera-Pastor A, San-Miguel T, Ipiens C, Escudero-García D, Tosca J, Montón C, Ballester MP, Ballester J, Aparicio L, Ríos MP, Durbán L, Mir A, Kosenko E, Cases P, Felipo V, Montoliu C. Patients with Minimal Hepatic Encephalopathy Show Altered Thermal Sensitivity and Autonomic Function. J Clin Med 2021; 10:jcm10020239. [PMID: 33440769 PMCID: PMC7826803 DOI: 10.3390/jcm10020239] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/30/2020] [Accepted: 01/05/2021] [Indexed: 12/21/2022] Open
Abstract
Cirrhotic patients may experience alterations in the peripheral nervous system and in somatosensory perception. Impairment of the somatosensory system could contribute to cognitive and motor alterations characteristic of minimal hepatic encephalopathy (MHE), which affects up to 40% of cirrhotic patients. We assessed the relationship between MHE and alterations in thermal, vibration, and/or heat pain sensitivity in 58 cirrhotic patients (38 without and 20 with MHE according to Psychometric Hepatic Encephalopathy Score) and 39 controls. All participants underwent attention and coordination tests, a nerve conduction study, autonomic function testing, and evaluation of sensory thresholds (vibration, cooling, and heat pain detection) by electromyography and quantitative sensory testing. The detection thresholds for cold and heat pain on the foot were higher in patients with, than those without MHE. This hyposensitivity was correlated with attention deficits. Reaction times in the foot were longer in patients with, than without MHE. Patients with normal sural nerve amplitude showed altered thermal sensitivity and autonomic function, with stronger alterations in patients with, than in those without MHE. MHE patients show a general decrease in cognitive and sensory abilities. Small fibers of the autonomic nervous system and thermal sensitivity are altered early on in MHE, before large sensory fibers. Quantitative sensory testing could be used as a marker of MHE.
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Affiliation(s)
- Dalia Rega
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
| | - Mika Aiko
- Servicio de Neurofisiología, Hospital Clínico de Valencia, 46010 Valencia, Spain; (M.A.); (N.P.); (C.I.); (P.C.)
| | - Nicolás Peñaranda
- Servicio de Neurofisiología, Hospital Clínico de Valencia, 46010 Valencia, Spain; (M.A.); (N.P.); (C.I.); (P.C.)
| | - Amparo Urios
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
| | - Juan-José Gallego
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
| | - Carla Giménez-Garzó
- Laboratorio de Neurobiología. Centro Investigación Príncipe Felipe, 46012 Valencia, Spain; (C.G.-G.); (V.F.)
| | - Franc Casanova
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
| | - Alessandra Fiorillo
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
| | - Andrea Cabrera-Pastor
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
| | - Teresa San-Miguel
- Departamento de Patología, Facultad de Medicina, Universidad de Valencia, 46010 Valencia, Spain;
| | - Cristina Ipiens
- Servicio de Neurofisiología, Hospital Clínico de Valencia, 46010 Valencia, Spain; (M.A.); (N.P.); (C.I.); (P.C.)
| | - Desamparados Escudero-García
- Servicio de Medicina Digestiva, Hospital Clinico de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.); (J.B.)
- Departamento de Medicina, Universidad de Valencia, 46010 Valencia, Spain;
| | - Joan Tosca
- Servicio de Medicina Digestiva, Hospital Clinico de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.); (J.B.)
| | - Cristina Montón
- Servicio de Medicina Digestiva, Hospital Clinico de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.); (J.B.)
| | - María-Pilar Ballester
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
- Servicio de Medicina Digestiva, Hospital Clinico de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.); (J.B.)
| | - José Ballester
- Servicio de Medicina Digestiva, Hospital Clinico de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.); (J.B.)
| | - Luis Aparicio
- Departamento de Anatomía y Embriología, Universidad Valencia, 46010 Valencia, Spain;
| | - María-Pilar Ríos
- Servicio de Digestivo, Hospital Arnau de Vilanova, 46015 Valencia, Spain; (M.-P.R.); (L.D.)
| | - Lucía Durbán
- Servicio de Digestivo, Hospital Arnau de Vilanova, 46015 Valencia, Spain; (M.-P.R.); (L.D.)
| | - Amparo Mir
- Departamento de Medicina, Universidad de Valencia, 46010 Valencia, Spain;
| | - Elena Kosenko
- Institute of Theoretical and Experimental Biophysics of Russian Academy of Sciences, 142290 Pushchino, Russia;
| | - Paula Cases
- Servicio de Neurofisiología, Hospital Clínico de Valencia, 46010 Valencia, Spain; (M.A.); (N.P.); (C.I.); (P.C.)
| | - Vicente Felipo
- Laboratorio de Neurobiología. Centro Investigación Príncipe Felipe, 46012 Valencia, Spain; (C.G.-G.); (V.F.)
| | - Carmina Montoliu
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
- Departamento de Patología, Facultad de Medicina, Universidad de Valencia, 46010 Valencia, Spain;
- Correspondence: ; Tel.: +34-963-864-381
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15
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Neurocognitive and Muscular Capacities Are Associated with Frailty in Adults with Cirrhosis. Dig Dis Sci 2020; 65:3734-3743. [PMID: 31982996 PMCID: PMC7814530 DOI: 10.1007/s10620-020-06099-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/20/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Frailty is common in cirrhosis and associated with mortality, hospitalization, and reduced quality of life. Interventions aimed at forestalling frailty are limited by a lack of understanding of underlying physiologic deficits. AIMS This study's aim was to examine contributions of discrete sensorimotor and neurocognitive capacities to conventional frailty measures of unipedal stance time, chair stands, and grip strength. METHODS This cross-sectional study enrolled 119 outpatients with cirrhosis (50% female, aged 62.9 ± 7.3 years). Capacities included sensory (lower limb sensation and visual contrast), neurocognitive (Number Connection Tests A and B, simple and recognition reaction time), and muscular (hip/core strength determined by lateral plank time (LPT)). Bivariate analyses and linear regression models were performed to identify significant contributors to each frailty measure. RESULTS The average performance was 9.8 ± 3.9 chair stands, 12.7 s ±9.9 unipedal stance time, and 60.3 ± 25.6 lb grip strength. In multivariate models, factors explained 40% of variance in unipedal stance and 43% of variance in chair stands. The LPT was most strongly associated with unipedal stance and chair stands. Grip strength was associated with LPT, but did not have physiologic predictors. CONCLUSIONS Clinically useful measures of frailty in adults with cirrhosis can be explained by disease severity but also deficits in strength and neurocognitive function. Recognition reaction time, a novel measure in cirrhosis, had a significant contribution to frailty. These findings have implications for frailty assessment and suggest that the optimal rehabilitation approach to frailty targets neurocognitive function in addition to strengthening.
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16
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Lauridsen MM, Jepsen P, Wernberg CW, Schaffalitzky de Muckadell OB, Bajaj JS, Vilstrup H. Validation of a Simple Quality-of-Life Score for Identification of Minimal and Prediction of Overt Hepatic Encephalopathy. Hepatol Commun 2020; 4:1353-1361. [PMID: 32923838 PMCID: PMC7471424 DOI: 10.1002/hep4.1555] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/07/2020] [Accepted: 05/17/2020] [Indexed: 12/28/2022] Open
Abstract
Minimal hepatic encephalopathy (MHE) is underdiagnosed because most clinics refrain from psychometric testing. Diagnostic activities need to go up so patients with MHE can get the treatment their condition requires. The sickness impact profile questionnaire for covert hepatic encephalopathy (SIPCHE) score is based on quality‐of‐life outcomes and has been proposed as a simple, patient‐administered diagnostic score for grade 1 and MHE. Validate the SIPCHE for MHE identification and overt hepatic encephalopathy (OHE) prediction. 110 patients with liver cirrhosis (age 60 years, Model for End‐Stage Liver Disease score of 11.4, 80% blue‐collar) provided information for SIPCHE scoring: gender, age, and four SIP statements: “I do not maintain balance (physically),” “I act irritable or impatient with myself,” “I am not doing any of the usual physical recreation or activities,” and “I am eating much less than usual.” MHE was diagnosed using an abnormal continuous reaction time test and/or portosystemic encephalopathy syndrome test score. Patients were followed for 2.7 years on average. SIPCHE score positivity had high sensitivity (82%) but low specificity (38%) for MHE detection. Patients with an abnormal SIPCHE had a higher incidence of OHE during follow‐up (35% vs. 14%, P = 0.05). OHE prediction sensitivity was 87% and exclusion sensitivity was 85%. The patients with an abnormal SIPCHE had twice as many subsequent episodes of OHE, and despite their high mortality, also a higher risk. An abnormal SIPCHE had a high sensitivity and low specificity for MHE identification. An abnormal SIPCHE was associated with a more than doubled risk of OHE, even with death as a competing event. SIPCHE could be used as a high‐sensitivity, low‐cost, surrogate marker of MHE in clinics without availability of psychometric tests and allow more patients to benefit from anti‐MHE treatment.
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Affiliation(s)
- Mette Munk Lauridsen
- Department of Gastroenterology and Hepatology University Hospital of South Denmark Esbjerg Denmark
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology Aarhus University Hospital Aarhus Denmark
| | | | | | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition Virginia Commonwealth University and McGuire VA Medical Center Richmond VA
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology Aarhus University Hospital Aarhus Denmark
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17
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San Martín-Valenzuela C, Borras-Barrachina A, Gallego JJ, Urios A, Mestre-Salvador V, Correa-Ghisays P, Ballester MP, Escudero-García D, Tosca J, Montón C, Ríos MP, Kosenko E, Felipo V, Tabares-Seisdedos R, Selva-Vera G, Montoliu C. Motor and Cognitive Performance in Patients with Liver Cirrhosis with Minimal Hepatic Encephalopathy. J Clin Med 2020; 9:E2154. [PMID: 32650464 PMCID: PMC7408738 DOI: 10.3390/jcm9072154] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/01/2020] [Accepted: 07/06/2020] [Indexed: 12/28/2022] Open
Abstract
Minimal hepatic encephalopathy (MHE) is associated with mild cognitive impairment and frailty. This study aims to identify cognitive and motor differences in cirrhotic patients with and without MHE, and the correlations between motor signs and cognitive performance. Gait, balance, hand strength and motor speed performance were evaluated in 66 cirrhotic patients (38 without and 28 with MHE, according to the Psychometric Hepatic Encephalopathy Score (PHES). Cognitive performance was measured with the Mini-Mental State Examination, Verbal Fluency Test, Aprendizaje Verbal España-Complutense Test (TAVEC), Wechsler Adult Intelligence Scale III, Hamilton Depression and Anxiety Rating Scale and Functioning Assessment Short Test (FAST). MHE patients performed worse than patients without MHE in cognitive and autonomous functioning, learning and long-term memory, and verbal fluency. The same pattern was found in gait, center of pressure movement, variability of hand strength performance and hand motor speed. In MHE patients, high correlations were found between balance and FAST test, gait velocity and verbal skills, hand strength variability and anxiety and depression, and motor speed and FAST and TAVEC. MHE patients showed worse motor and cognitive performance than patients without MHE. MHE patients could have impaired movement control expressed as bradykinesia, and this reduced motor performance could correlate with cognitive performance.
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Affiliation(s)
- Constanza San Martín-Valenzuela
- Unit of Personal Autonomy, Dependency and Mental Disorder Assessment, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain; (C.S.M.-V.); (A.B.-B.); (V.M.-S.); (R.T.-S.)
- Department of Physiotherapy, Faculty of Physiotherapy, University of Valencia, 46010 Valencia, Spain
- Centro Investigación Biomédica en Red de Salud Mental, CIBERSAM, 28029 Madrid, Spain;
| | - Aroa Borras-Barrachina
- Unit of Personal Autonomy, Dependency and Mental Disorder Assessment, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain; (C.S.M.-V.); (A.B.-B.); (V.M.-S.); (R.T.-S.)
| | - Juan-José Gallego
- INCLIVA, Health Research Institute, 46010 Valencia, Spain; (J.-J.G.); (A.U.); (M.-P.B.)
| | - Amparo Urios
- INCLIVA, Health Research Institute, 46010 Valencia, Spain; (J.-J.G.); (A.U.); (M.-P.B.)
| | - Víctor Mestre-Salvador
- Unit of Personal Autonomy, Dependency and Mental Disorder Assessment, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain; (C.S.M.-V.); (A.B.-B.); (V.M.-S.); (R.T.-S.)
| | - Patricia Correa-Ghisays
- Centro Investigación Biomédica en Red de Salud Mental, CIBERSAM, 28029 Madrid, Spain;
- Faculty of Psychology, University of Valencia, 46010 Valencia, Spain
| | - María-Pilar Ballester
- INCLIVA, Health Research Institute, 46010 Valencia, Spain; (J.-J.G.); (A.U.); (M.-P.B.)
- Digestive Medicine Unit, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.)
| | - Desamparados Escudero-García
- Digestive Medicine Unit, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.)
- Department of Medicine, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain
| | - Joan Tosca
- Digestive Medicine Unit, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.)
| | - Cristina Montón
- Digestive Medicine Unit, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.)
| | - María-Pilar Ríos
- Digestive Service, Arnau de Vilanova Hospital, 46015 Valencia, Spain;
| | - Elena Kosenko
- Institute of Theoretical and Experimental Biophysics of Russian Academy of Sciences, 142290 Pushchino, Russia;
| | - Vicente Felipo
- Laboratory of Neurobiology, Príncipe Felipe Research Center, 46012 Valencia, Spain;
| | - Rafael Tabares-Seisdedos
- Unit of Personal Autonomy, Dependency and Mental Disorder Assessment, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain; (C.S.M.-V.); (A.B.-B.); (V.M.-S.); (R.T.-S.)
- Centro Investigación Biomédica en Red de Salud Mental, CIBERSAM, 28029 Madrid, Spain;
- Department of Medicine, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain
| | - Gabriel Selva-Vera
- Unit of Personal Autonomy, Dependency and Mental Disorder Assessment, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain; (C.S.M.-V.); (A.B.-B.); (V.M.-S.); (R.T.-S.)
- Centro Investigación Biomédica en Red de Salud Mental, CIBERSAM, 28029 Madrid, Spain;
- Unit of Psychiatry and Psychological Medicine, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain
| | - Carmina Montoliu
- INCLIVA, Health Research Institute, 46010 Valencia, Spain; (J.-J.G.); (A.U.); (M.-P.B.)
- Department of Pathology, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain
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18
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Xu XY, Ding HG, Li WG, Jia JD, Wei L, Duan ZP, Liu YL, Ling-Hu EQ, Zhuang H, Hepatology CSO, Association CM. Chinese guidelines on management of hepatic encephalopathy in cirrhosis. World J Gastroenterol 2019; 25:5403-5422. [PMID: 31576089 PMCID: PMC6767982 DOI: 10.3748/wjg.v25.i36.5403] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/07/2019] [Accepted: 08/24/2019] [Indexed: 02/06/2023] Open
Abstract
The Chinese Society of Hepatology developed the current guidelines on the management of hepatic encephalopathy in cirrhosis based on the published evidence and the panelists' consensus. The guidelines provided recommendations for the diagnosis and management of hepatic encephalopathy (HE) including minimal hepatic encephalopathy (MHE) and overt hepatic encephalopathy, emphasizing the importance on screening MHE in patients with end-stage liver diseases. The guidelines emphasized that early identification and timely treatment are the key to improve the prognosis of HE. The principles of treatment include prompt removal of the cause, recovery of acute neuropsychiatric abnormalities to baseline status, primary prevention, and secondary prevention as soon as possible.
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Affiliation(s)
- Xiao-Yuan Xu
- Department of Infectious Diseases, Peking University First Hospital, Beijing 100034, China
| | - Hui-Guo Ding
- Hepatology and Digestion Center, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Wen-Gang Li
- Department of Liver Oncology, Cancer Radiation Therapy Center, Fifth Medical Center, PLA General Hospital, Beijing 100039, China
| | - Ji-Dong Jia
- Hepatology Center, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Lai Wei
- Hepatobiliary and Pancreatic Department, Beijing Tsinghua Changgeng Hospital, Beijing 102218, China
| | - Zhong-Ping Duan
- Artificial Liver Center, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Yu-Lan Liu
- Department of Gastroenterology, Peking University People's Hospital, Beijing 100044, China
| | - En-Qiang Ling-Hu
- Department of Gastroenterology, First Medical Center, PLA General Hospital, Beijing 100853, China
| | - Hui Zhuang
- Department of Pathogenic Biology, Peking University Health Science Center, Beijing 100191, China
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19
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Román E, Nieto JC, Gely C, Vidal S, Pozuelo M, Poca M, Juárez C, Guarner C, Manichanh C, Soriano G. Effect of a Multistrain Probiotic on Cognitive Function and Risk of Falls in Patients With Cirrhosis: A Randomized Trial. Hepatol Commun 2019; 3:632-645. [PMID: 31061952 PMCID: PMC6492476 DOI: 10.1002/hep4.1325] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/30/2019] [Indexed: 12/11/2022] Open
Abstract
Probiotics can modulate gut microbiota, intestinal permeability, and immune response and could therefore improve cognitive dysfunction and help avoid potential consequences, such as falls, in patients with cirrhosis. The aim of this study was to evaluate the effect of a multistrain probiotic on cognitive function, risk of falls, and inflammatory response in patients with cirrhosis. Consecutive outpatients with cirrhosis and cognitive dysfunction (defined by a Psychometric Hepatic Encephalopathy Score [PHES] < -4) and/or falls in the previous year were randomized to receive either a sachet of a high-concentration multistrain probiotic containing 450 billion bacteria twice daily for 12 weeks or placebo. We evaluated the changes in cognitive function (PHES); risk of falls (Timed Up and Go [TUG] test, gait speed, and incidence of falls); systemic inflammatory response; neutrophil oxidative burst; intestinal barrier integrity (serum fatty acid-binding protein 6 [FABP-6] and 2 [FABP-2] and zonulin and urinary claudin-3); bacterial translocation (lipopolysaccharide-binding protein [LBP]); and fecal microbiota. Thirty-six patients were included. Patients treated with the probiotic (n = 18) showed an improvement in the PHES (P = 0.006), TUG time (P = 0.015) and gait speed (P = 0.02), and a trend toward a lower incidence of falls during follow-up (0% compared with 22.2% in the placebo group [n = 18]; P = 0.10). In the probiotic group, we observed a decrease in C-reactive protein (P = 0.01), tumor necrosis factor alpha (P = 0.01), FABP-6 (P = 0.009), and claudin-3 (P = 0.002), and an increase in poststimulation neutrophil oxidative burst (P = 0.002). Conclusion: The multistrain probiotic improved cognitive function, risk of falls, and inflammatory response in patients with cirrhosis and cognitive dysfunction and/or previous falls.
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Affiliation(s)
- Eva Román
- Department of Gastroenterology Hospital de la Santa Creu i Sant Pau Barcelona Spain.,Escola Universitària d'Infermeria EUI-Sant Pau Barcelona Spain.,Institut de Recerca IIB-Sant Pau Barcelona Spain.,CIBERehd Instituto de Salud Carlos III Madrid Spain
| | | | | | - Sílvia Vidal
- Institut de Recerca IIB-Sant Pau Barcelona Spain.,Department of Immunology Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona Barcelona Spain
| | - Marta Pozuelo
- Fundació Hospital Universitari Vall d'Hebron-Institut de Recerca Barcelona Spain
| | - Maria Poca
- Department of Gastroenterology Hospital de la Santa Creu i Sant Pau Barcelona Spain.,CIBERehd Instituto de Salud Carlos III Madrid Spain
| | - Cándido Juárez
- Institut de Recerca IIB-Sant Pau Barcelona Spain.,Department of Immunology Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona Barcelona Spain
| | - Carlos Guarner
- Department of Gastroenterology Hospital de la Santa Creu i Sant Pau Barcelona Spain.,CIBERehd Instituto de Salud Carlos III Madrid Spain
| | - Chaysavanh Manichanh
- Fundació Hospital Universitari Vall d'Hebron-Institut de Recerca Barcelona Spain.,CIBERehd Instituto de Salud Carlos III Madrid Spain
| | - Germán Soriano
- Department of Gastroenterology Hospital de la Santa Creu i Sant Pau Barcelona Spain.,CIBERehd Instituto de Salud Carlos III Madrid Spain
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20
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Murphy SL, Tapper EB, Blackwood J, Richardson JK. Why Do Individuals with Cirrhosis Fall? A Mechanistic Model for Fall Assessment, Treatment, and Research. Dig Dis Sci 2019; 64:316-323. [PMID: 30327964 DOI: 10.1007/s10620-018-5333-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/09/2018] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Susan L Murphy
- Department of Physical Medicine and Rehabilitation, University of Michigan, 24 Frank Lloyd Wright Drive, PO Box 344, Ann Arbor, MI, 48106, USA. .,Geriatric Research, Education and Clinical Center, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, USA.
| | - Elliot B Tapper
- Department of Internal Medicine, Division of Gasteroenterology, University of Michigan, Ann Arbor, MI, USA. .,Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, USA.
| | - Jennifer Blackwood
- Department of Physical Therapy, University of Michigan - Flint Campus, Flint, MI, USA
| | - James K Richardson
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
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21
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Ridola L, Nardelli S, Gioia S, Riggio O. Quality of life in patients with minimal hepatic encephalopathy. World J Gastroenterol 2018; 24:5446-5453. [PMID: 30622374 PMCID: PMC6319138 DOI: 10.3748/wjg.v24.i48.5446] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 11/08/2018] [Accepted: 11/09/2018] [Indexed: 02/06/2023] Open
Abstract
Minimal hepatic encephalopathy (MHE) represents the mildest type of hepatic encephalopathy (HE). This condition alters the performance of psychometric tests by impairing attention, working memory, psychomotor speed, and visuospatial ability, as well as electrophysiological and other functional brain measures. MHE is a frequent complication of liver disease, affecting up to 80% of tested patients, depending of the diagnostic tools used for the diagnosis. MHE is related to falls, to an impairment in fitness to drive and the development of overt HE, MHE severely affects the lives of patients and caregivers by altering their quality of life (QoL) and their socioeconomic status. MHE is detected in clinically asymptomatic patients through appropriate psychometric tests and neurophysiological methods which highlight neuropsychological alterations such as video-spatial orientation deficits, attention disorders, memory, reaction times, electroencephalogram slowing, prolongation of latency evoked cognitive potentials and reduction in the critical flicker frequency. Several treatments have been proposed for MHE treatment such as non-absorbable disaccharides, poorly absorbable antibiotics such rifaximin, probiotics and branched chain amino acids. However, because of the multiple diagnosis methods, the various endpoints of treatment trials and the variety of agents used in trials, to date the treatment of MHE is not routinely recommended apart from on a case-by-case basis. Aim of this review is analyze the burden of MHE on QoL of patients and provide a brief summary of therapeutic approaches.
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Affiliation(s)
- Lorenzo Ridola
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina 04100, Italy
| | - Silvia Nardelli
- Department of Clinical Medicine, Sapienza University of Rome, Rome 00185, Italy
| | - Stefania Gioia
- Department of Clinical Medicine, Sapienza University of Rome, Rome 00185, Italy
| | - Oliviero Riggio
- Department of Clinical Medicine, Sapienza University of Rome, Rome 00185, Italy
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22
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Exercise in cirrhosis: Translating evidence and experience to practice. J Hepatol 2018; 69:1164-1177. [PMID: 29964066 DOI: 10.1016/j.jhep.2018.06.017] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 06/21/2018] [Accepted: 06/22/2018] [Indexed: 02/06/2023]
Abstract
Physical inactivity, sarcopenia, and frailty are highly prevalent, independent predictors of morbidity and mortality in patients with cirrhosis. Across a range of chronic diseases, exercise training is a key recommendation supported by guidelines and, for some conditions, even by governmental funding of exercise programmes. Consistent with the broader chronic disease literature, the evidence for a benefit of exercise in cirrhosis is promising. Several small trials have reported significant improvements in muscle health (mass, strength, functional capacity), quality of life, fatigue, and reductions in the hepatic venous pressure gradient, without adverse events. With strong emerging evidence surrounding the substantial risks of sarcopenia/frailty and our first-hand experiences with liver pre-transplant exercise programmes, we contend that routine patient care in cirrhosis should include an exercise prescription. Some clinicians may lack the resources and necessary background to translate the existing evidence into a practicable intervention. Our team, comprised of physiotherapists, exercise physiologists, hepatologists, transplant specialists, and knowledge translation experts from six North American centres, has distilled the essential background information, tools, and practices into a set of information ready for immediate implementation into clinics ranging from a family practice setting to specialty cirrhosis clinics. Augmenting the rationale and evidence are supplementary materials including video and downloadable materials for both patients and the physician. Supporting the exercising patient is a section regarding information about nutrition, providing practical tips suitable for all patients with cirrhosis.
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23
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Sun Q, Fan W, Ye J, Han P. Abnormal Regional Homogeneity and Functional Connectivity of Baseline Brain Activity in Hepatitis B Virus-Related Cirrhosis With and Without Minimal Hepatic Encephalopathy. Front Hum Neurosci 2018; 12:245. [PMID: 29988437 PMCID: PMC6024159 DOI: 10.3389/fnhum.2018.00245] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 05/29/2018] [Indexed: 12/16/2022] Open
Abstract
Background and Aims: Abnormalities in neural activity have been reported in cirrhosis with minimal hepatic encephalopathy (MHE). However, little is known about the neurophysiological mechanisms in this disorder. We aimed to investigate the altered patterns of regional synchronization and functional connections in hepatitis B virus-related cirrhosis (HBV-RC) patients with and without MHE using both regional homogeneity (ReHo) and region of interest (ROI)-based functional connectivity (FC) computational methods. Methods: Data of magnetic resonance imaging scans were collected from 30 HBV-RC patients with MHE, 32 HBV-RC patients without MHE (NMHE) and 64 well-matched controls. Several regions showing differences in ReHo after one-way analysis of variance (ANOVA) were defined as ROIs for FC analysis. Next, post hoc t-tests were applied to calculate the group differences in ReHo and FC (false discovery rate (FDR) correction, p < 0.05). Correlations between clinical variables and the altered ReHo and FC were then assessed in patient groups. Results: Across three groups, significant ReHo differences were found in nine ROI regions mainly within the visual network (VN), dorsal attention network (DAN), somatomotor network (SMN), fronto parietal control (FPC) network and thalamus. Compared with healthy controls (HC), the MHE group exhibited abnormal FC mainly between the right calcarine (CAL.R) and middle frontal gyrus (MFG.L)/right thalamus. The MHE patients showed increased FC between the MFG.L and CAL.R compared to NMHE patients. Disease duration of MHE patients was positively correlated with increased mean ReHo values in the right fusiform gyrus (FFG); psychometric hepatic encephalopathy score (PHES) test scores were negatively correlated with increased FC between MFG.L and CAL.R and positively correlated with reduced FC between the CAL.R and THA.R. For NMHE patients, the mean ReHo values in the right frontal pole were positively correlated with disease duration and positively correlated with the PHES scores. Conclusion: Our results exhibited that the functional brain modifications in patients with and without MHE are characterized by compound alterations in local coherence and functional connections in the VN, SMN, DAN, FPC networks and thalamus by using a combination of ReHo and ROI-based FC analysis. These functional imaging changes are correlated with disease duration/PHES. This study helped us gain a better understanding of the features of brain network modifications in cirrhosis.
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Affiliation(s)
- Qing Sun
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenliang Fan
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jin Ye
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ping Han
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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24
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Ridola L, Cardinale V, Riggio O. The burden of minimal hepatic encephalopathy: from diagnosis to therapeutic strategies. Ann Gastroenterol 2018; 31:151-164. [PMID: 29507462 PMCID: PMC5825945 DOI: 10.20524/aog.2018.0232] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 11/29/2017] [Indexed: 12/12/2022] Open
Abstract
Minimal hepatic encephalopathy (MHE) is the mildest form of hepatic encephalopathy (HE). It affects the performance of psychometric tests focused on attention, working memory, psychomotor speed, and visuospatial ability, as well as electrophysiological and other functional brain measures. MHE is a frequent complication of liver disease, affecting up to 80% of tested patients. By being related to falls, an impairment in fitness to drive and the development of overt HE, MHE severely affects the lives of patients and caregivers by altering their quality of life and their socioeconomic status. MHE is detected in clinically asymptomatic patients using appropriate psychometric tests and neurophysiological methods that highlight neuropsychological alterations, such as video-spatial orientation deficits, attention disorders, memory, reaction times, electroencephalogram slowing, prolongation of latency-evoked cognitive potentials, and reduction in the critical flicker frequency. Several treatments have been proposed for MHE treatment, including non-absorbable disaccharides, poorly absorbable antibiotics such as rifaximin, probiotics and branched-chain amino acids. However, because of the multiple diagnosis methods, the various endpoints of treatment trials and the variety of agents used in trials, the treatment of MHE is not currently recommended as routine, but only on a case-by-case basis.
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Affiliation(s)
- Lorenzo Ridola
- Department of Medico-Surgical Sciences and Biotechnologies (Lorenzo Ridola, Vincenzo Cardinale), Sapienza University of Rome, Italy
| | - Vincenzo Cardinale
- Department of Medico-Surgical Sciences and Biotechnologies (Lorenzo Ridola, Vincenzo Cardinale), Sapienza University of Rome, Italy
| | - Oliviero Riggio
- Department of Clinical Medicine (Oliviero Riggio), Sapienza University of Rome, Italy
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25
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García-García R, Cruz-Gómez ÁJ, Mangas-Losada A, Urios A, Forn C, Escudero-García D, Kosenko E, Ordoño JF, Tosca J, Giner-Durán R, Serra MA, Avila C, Belloch V, Felipo V, Montoliu C. Reduced resting state connectivity and gray matter volume correlate with cognitive impairment in minimal hepatic encephalopathy. PLoS One 2017; 12:e0186463. [PMID: 29023586 PMCID: PMC5638549 DOI: 10.1371/journal.pone.0186463] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 10/02/2017] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND AND AIMS Minimal hepatic encephalopathy (MHE) is associated with cognitive alterations and changes in connectivity. We assessed the relationship of the abnormalities of resting-state functional connectivity (rs-FC) and gray matter (GM) volume with different cognitive alterations and biochemical parameters associated to MHE. METHODS Thirty-nine cirrhotic patients (26 without and 13 with MHE) and 24 controls were widely cognitive assessed with a battery of psychometric tests. Atrophy was determined using Voxel-Based Morphometry and rs-FC was assessed by independent component analysis. Receiver operating characteristic (ROC) curves was performed to assess the diagnostic utility of rs-FC and GM reduction for the discrimination of patients with and without MHE. Blood ammonia, cGMP, and levels of pro-inflammatory interleukins were measured. RESULTS MHE patients showed significant decrease of GM volume and lesser degree of rs-FC in different networks related to attention and executive functions as compared to controls and patients without MHE. There is a progressive reduction in rs-FC in the default mode network with the progression of cognitive impairment. MHE patients showed GM reduction in the right frontal lobe, right insula and right cerebellum compared to patients without MHE. Alterations in GM volume and rs-FC correlated with the scores of different cognitive tests. CONCLUSIONS Decreased cognitive performance is associated by reduced rs-FC and GM atrophy in MHE patients. These changes could have predictive value for detecting MHE.
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Affiliation(s)
| | - Álvaro Javier Cruz-Gómez
- Departamento Psicologia Basica, Clinica y Psicobiologia. Universitat Jaume I. Castellon, Castellón de la Plana, Spain
| | - Alba Mangas-Losada
- Fundacion Investigacion Hospital Clinico Valencia. INCLIVA. Valencia, Spain
| | - Amparo Urios
- Centro Investigación Príncipe Felipe. Valencia, Spain
- Fundacion Investigacion Hospital Clinico Valencia. INCLIVA. Valencia, Spain
| | - Cristina Forn
- Departamento Psicologia Basica, Clinica y Psicobiologia. Universitat Jaume I. Castellon, Castellón de la Plana, Spain
| | | | - Elena Kosenko
- Institute of Theoretical and Experimental Biophysics, Pushchino, Russia
| | - Juan Fermín Ordoño
- Servicio Neurofisiología, Hospital Arnau de Vilanova, Valencia, Spain
- Psychopatology and Neurophysiology Unit, Paterna Mental Health Center, CIBERSAM, Valencia, Spain
| | - Joan Tosca
- Unidad de Digestivo-Hospital Clínico. Departamento Medicina, Universidad Valencia, Valencia, Spain
| | | | - Miguel Angel Serra
- Unidad de Digestivo-Hospital Clínico. Departamento Medicina, Universidad Valencia, Valencia, Spain
| | - César Avila
- Departamento Psicologia Basica, Clinica y Psicobiologia. Universitat Jaume I. Castellon, Castellón de la Plana, Spain
| | | | | | - Carmina Montoliu
- Fundacion Investigacion Hospital Clinico Valencia. INCLIVA. Valencia, Spain
- Departamento Patología, Facultad Medicina, Universidad Valencia, Valencia, Spain
- * E-mail:
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