Hepatic Encephalopathy Is Associated With Mortality in Patients With Cirrhosis Independent of Other Extrahepatic Organ Failures

Real-time breath ammonia measurement using a novel cuprous bromide sensor device in patients with chronic liver disease: a feasibility and pilot study

We developed a small portable sensor device using a p-type semiconductor cuprous bromide (CuBr) thin film to measure breath ammonia in real time with highsensitivity and selectivity. Breath ammonia is reportedly associated with chronic liver disease (CLD). We aimed to assess the practical utility of the novel CuBr sensor device for exhaled breath ammonia and the correlation between breath and blood ammonia in CLD patients. This was a feasibility and pilot clinical study of 21 CLD patients and 18 healthy volunteers. Breath ammonia was directly and quickly measured using the novel CuBr sensor device and compared with blood ammonia measured at the same time. CLD patients had significantly higher breath ammonia levels than healthy subjects (p = 1.51 × 10^-3), with the level of significance being similar to that for blood ammonia levels (p= 0.024). Significant differences were found in breath and blood ammonia between the healthy and cirrhosis groups (p = 2.97 × 10^-3 and 3.76 × 10^-3, respectively). Significant, positive correlations between breath and blood ammonia were noted in the CLD group (R = 0.747, p = 1.00 × 10^-4), healthy/CLD group (R = 0.741, p = 6.75 × 10^-8), and cirrhosis group (R = 0.744, p = 9.52 × 10^-4). In conclusion, the newly developed, easy-to-use, and small portable CuBr sensor device was able to non-invasively measure breath ammonia in real time. Breath ammonia measured using the device was correlated with blood ammonia and the presence of liver cirrhosis, and might be an alternative surrogate biomarker to blood ammonia.

Role of ammonia in predicting the outcome of patients with acute-on-chronic liver failure

BACKGROUND

High venous ammonia (VA) values have been proven to be a part of the mechanism of hepatic encephalopathy in patients with liver cirrhosis (LC) as well as acute hepatitis. Moreover, VA has been associated with poor prognosis and high mortality in these clinical settings. However, the role of ammonia in acute-on-chronic liver failure (ACLF) has not yet been clearly established.

AIM

To assess the role of VA in predicting the outcome of cirrhotic patients with ACLF in a tertiary care center.

METHODS

We performed a retrospective observational study including consecutive patients with LC hospitalized for acute non-elective indications such as ascites, hepatic encephalopathy (HE), upper gastrointestinal bleeding, or bacterial infections that fulfilled the Asian Pacific Association for the Study of the Liver (APASL) criteria for ACLF. The study was conducted in “St. Spiridon” University Hospital, Iasi, Romania, a tertiary care center, between January 2017 and January 2019. The APASL ACLF Research Consortium (AARC) score was calculated and ACLF grade was established accordingly. West-haven classification was used for HE. Statistical analysis was performed using IBM SPSS version 22.0.

RESULTS

Four hundred and forty-six patients were included, aged 59 (50-65) years, 57.4% men. Child-Pugh, model for end-stage liver disease (MELD) and AARC scores were 11 (10-12), 19.13 ± 6.79, and 7 (6-8), respectively. 66.4% had ACLF grade I, 31.2% ACLF grade II, and 2.5% ACLF grade III. HE was diagnosed in 83.9%, 34% grade I, 37.2% grade II, 23.5% grade III, and 5.3% grade IV. Overall mortality was 7.8%. VA was 103 (78-148) μmol/L. Receiver operating characteristic analysis showed good accuracy for the prediction of in-hospital mortality for the AARC score [Area under the curve (AUC) = 0.886], MELD score (AUC = 0.816), VA (AUC = 0.812) and a fair accuracy for the Child-Pugh score (AUC = 0.799). Subsequently, a cut-off value for the prediction of mortality was identified for VA (152.5 μmol/L, sensitivity = 0.706, 1-specificity = 0.190). Univariate analysis found acute kidney injury, severe HE (grade III or IV), VA ≥ 152.5 μmol/L, MELD score ≥ 22.5, Child-Pugh score ≥ 12.5, and AARC score ≥ 8.5 to be associated with in-hospital mortality. Multivariate analysis identified AARC score ≥ 8.5 and venous ammonia ≥ 152 μmol/L to be independent predictors of in-hospital mortality.

CONCLUSION

VA could be used as an inexpensive predictor of in-hospital mortality in patients with ACLF. Patients with both ACLF and VA > 152.5 μmol/L have a high risk for a poor outcome.

Fecal microbiota transplantation in hepatic encephalopathy : a review of the current evidence and future perspectives

Hepatic encephalopathy (HE) is a leading cause of hospitalization and morbimortality in advanced cirrhosis with limited therapeutic options available. Given the paramount role of gut microbiota in HE, and the efficacy of fecal microbiota transplantation (FMT) in other diseases, this review intends to summarize the evidence supporting the safety, efficacy and future perspectives of FMT in HE. Current evidence, despite being scarce, points towards FMT being a safe, effective and tolerable procedure in HE. Some unanswered questions remain about the optimal dose, the administration route, the long term effects and the selection of the optimal donor. Future trials, some of which are already underway, will provide us additional evidence and hopefully the necessary answers.

The Prevalence, Predictors, and In-Hospital Mortality of Hepatic Encephalopathy in Patients with Liver Cirrhosis Admitted at St. Dominic Hospital in Akwatia, Ghana

BACKGROUND

Hepatic encephalopathy (HE) is one of the most debilitating complications of cirrhosis leading to death. Decrease in HE mortality and recurrence has been linked with timely identification and early treatment. There is a need to document the burden, predictors, and treatment outcomes of HE in an adult population with liver cirrhosis in our setting as only reports from resource-endowed countries abound in the literature. This study aimed therefore to determine the prevalence, predictors, and treatment outcomes of patients with liver cirrhosis admitted at St. Dominic Hospital (SDH) in Akwatia, Ghana.

MATERIALS AND METHODS

A prospective study was conducted involving one hundred and sixty-seven (167) patients admitted at the medical wards in SDH with liver cirrhosis from January 1st, 2018, to March 24th, 2020. The demographic and clinical features of the patients were collected using a standardized questionnaire. Biochemical, haematological, and abdominal ultrasound scans were done for all patients. Patients were then followed up until discharge or death.

RESULTS

There were 109 (65.3%) males out of the 167 patients with a mean age of 45.8 and 47.5 years for those with and without HE, respectively. The prevalence of HE was 31.7% (53/167). Out of 53 participants with HE, 75.5% (40/53) died. There was a strong association between HE and death (p < 0.001). The major precipitating factor of HE was infection (64.2%). Severe ascites (OR = 0.009) were clinical feature independently associated with HE, whereas high creatinine (OR = 0.987), blood urea nitrogen (BUN) (OR = 1.199), Child-Pugh score (CPS) (OR = 5.899), and low platelets (OR = 0.992) were the laboratory parameters and scores independently predictive of HE.

CONCLUSION

HE was common among patients with liver cirrhosis admitted at SDH with high in-patient mortality. The commonest precipitating factor for HE was infection(s). Severe ascites, low platelet count, high creatinine, BUN, and CPS were independent predictors of HE.

Cognitive Tests and Stool Frequency at Hospital Discharge Do Not Predict Outcomes in Hepatic Encephalopathy

OBJECTIVES

Hepatic encephalopathy (HE) is associated with hospital readmissions and mortality. We sought to determine whether cognitive testing and stool frequency at discharge predicted 30-day readmission or death in cirrhotic patients admitted with overt HE.

METHODS

We approached consecutive inpatients with cirrhosis and overt HE when they were within 48 hours of discharge. Patients underwent cognitive tests, including Psychometric Hepatic Encephalopathy Score (PHES), and stool frequency was documented. Chart review identified Model for End-Stage Liver Disease-sodium (MELD-Na) and the presence of non-HE extrahepatic organ failures. Cox proportional hazards models were used to evaluate predictors of time to the primary composite outcome of hospital readmission for HE or death within 30 days, censoring for liver transplantation.

RESULTS

Of 51 patients consented and enrolled, 14 patients met the primary composite outcome. In unadjusted Cox models, 4 variables predicted HE readmission or death: MELD-Na (hazard ratio [HR] 1.10 [1.01-1.20], P = 0.03), respiratory failure (HR 4.26 [1.47-12.35], P = 0.008), total number of HE extrahepatic organ failures (HR 1.79 [1.12-2.88], P = 0.02), and score on a PHES subtest, Number Connection Test A (per 30 seconds; HR 1.25 [1.06-1.47], P = 0.01). PHES and 24-hour stool frequency did not predict the primary outcome. When controlling for MELD-Na, respiratory failure predicted the primary outcome (HR 3.67 [1.24-10.86], P = 0.02).

CONCLUSION

Cognitive testing and stool frequency at discharge did not predict poor outcomes in patients admitted with HE, while respiratory failure appeared to be a strong predictor.

An update from the Canadian Association for the Study of the Liver on the management of liver disease during the COVID-19 pandemic

Coronavirus disease 2019 (COVID-19) has challenged how care is delivered to patients with chronic liver disease (CLD). In an attempt to update Canadian health care practitioners taking care of individuals with CLD, the Canadian Association for the Study of the Liver (CASL) hosted a webinar on May 7, 2020, with more than 120 participants. The resultant article is a partnership between members of CASL’s executive and education committees to provide best practice management principles on liver disease during COVID-19 to the broader hepatology community.

Contemporary Epidemiology of Chronic Liver Disease and Cirrhosis

BACKGROUND & AIMS

Accurate estimates for the contemporary burden of chronic liver disease (CLD) are vital for setting clinical, research, and policy priorities. We aimed to review the incidence, prevalence, and mortality of CLD and its resulting complications, including cirrhosis and hepatocellular carcinoma (HCC).

METHODS

We reviewed the published literature on the incidence, prevalence, trends of various etiologies of CLD and its resulting complications. In addition, we provided updated data from the Centers for Disease Control and Global Burden of Disease Study on the morbidity and mortality of CLD, cirrhosis, and hepatocellular carcinoma (HCC). Lastly, we assessed the strengths and weaknesses of available sources of data in hopes of providing important context to these national estimates of cirrhosis burden.

RESULTS

An estimated 1.5 billion persons have CLD worldwide and the age-standardized incidence of CLD and cirrhosis is 20.7/100,000, a 13% increase since 2000. Similarly, cirrhosis prevalence and mortality has increased in recent years in the United States. The epidemiology of CLD is shifting, reflecting implementation of large-scale hepatitis B vaccination and hepatitis C treatment programs, the increasing prevalence of the metabolic syndrome, and increasing alcohol misuse.

CONCLUSIONS

The global burden of CLD and cirrhosis is substantial. Although vaccination, screening, and antiviral treatment campaigns for hepatitis B and C have reduced the CLD burden in some parts of the world, concomitant increases in injection drug use, alcohol misuse, and metabolic syndrome threaten these trends. Ongoing efforts to address CLD-related morbidity and mortality require accurate contemporary estimates of epidemiology and outcomes.

A Comprehensive Review of Outcome Predictors in Low MELD Patients

Risk scoring for patients with cirrhosis has evolved greatly over the past several decades. However, patients with low Model for End-Stage Liver Disease-Sodium scores still suffer from liver-related morbidity and mortality. Unfortunately, it is not clear which of these low Model for End-Stage Liver Disease-Sodium score patients would benefit from earlier consideration of liver transplantation. This article reviews the literature of risk prediction in patients with cirrhosis, identifies which patients may benefit from earlier interventions, such as transplantation, and proposes directions for future research.

Underutilization of Hospice in Inpatients with Cirrhosis: The NACSELD Experience

BACKGROUND

Little is known about patients discharged to hospice following hospitalization for complications of cirrhosis.

AIM

We sought to understand the current pattern of hospice utilization in patients with cirrhosis by evaluating the North American Consortium for the Study of End-stage Liver Disease (NACSELD) cohort.

METHODS

Patients with cirrhosis from 14 tertiary-care hepatology centers across North America non-electively hospitalized and prospectively enrolled were evaluated. Exclusion criteria included HIV infection, transplantation or non-hepatic malignancy. Random computer-based propensity score matching was undertaken in a 1:2 ratio based on admission MELD score ± 3 points.

RESULTS

Totally, 2718 patients were enrolled, 5% (N = 132) were discharged to hospice, 6% (N = 171) died, and the rest were discharged alive. Patients discharged to hospice were older (60 vs. 57 years, p = 0.04), less likely to have had SBP (13% vs. 28%, p = 0.002) and be listed for liver transplantation (11% vs. 26%, p = 0.0007). Features, on multivariable modeling, associated with increased probability of discharge to hospice as opposed to being discharged alive: grade-3-4 hepatic encephalopathy, a higher Child-Turcotte-Pugh (CTP) score, and a higher discharge serum creatinine; however, a higher serum sodium, being listed for transplant and being prescribed rifaximin or a statin were protective from hospice discharge.

CONCLUSION

Patients with more advanced liver disease, hepatic encephalopathy, renal dysfunction, and those not candidates for liver transplantation were more likely to be discharged to hospice. However, in this sick multinational cohort of cirrhotic inpatients, it seems that hospice is markedly underutilized (5%) since 25% of patients not discharged to hospice died within 6 months.

Complications and Mortality in Hospitalised Patients With Decompensated Cirrhosis of Liver in a Tertiary Care Centre in Nepal

Background

Patients with decompensated cirrhosis present with various complications and are associated with increased inpatients mortality. This study aimed to evaluate the complications and mortality in hospitalised patients with decompensated cirrhosis of liver.

Methods

This descriptive, cross-sectional, hospital-based study included 754 decompensated cirrhotic patients. The primary endpoints were mortality and hospital stay. The data analysis was done using Statistical Product and Service Solutions (SPSS) version 20 (IBM Corp., Armonk, NY). The chi-square test was used to compare the differences between different predictors of mortality with p<0.05 considered significant.

Results

A total of 754 patients (mean age 54±11.51 years; male/female ratio of 3.6:1) were studied. Ascites was the most common complication (99.2%) followed by upper gastrointestinal (UGI) bleed (42.3%), hepatic encephalopathy (32.5%), rebleeding (33.2%), spontaneous bacterial peritonitis (26%), and hepatorenal syndrome (19.1%). Inpatient mortality was 19.8%. The most common causes of mortality were rebleeding (21.5%) followed by hepatic encephalopathy (HE) (18.7%), hepatorenal syndrome (HRS) (14.7%), and spontaneous bacterial peritonitis (SBP) (12.1%). The presence of Grades IV HE, the presentation with shock, Child Turcotte Pugh (CTP) C, rebleeding, variceal bleed, HRS, hyponatremia (<130 mEq/L), the requirement of ≥3 units of blood and blood products, co-existence of hepatocellular carcinoma (HCC), and multiple comorbidities and complications in a single patient were strong predictors of mortality (p≤0.05).

Conclusions

Ascites followed by UGI bleed, hepatic encephalopathy, rebleeding, spontaneous bacterial peritonitis, and hepatorenal syndrome were common complications among the admitted decompensated cirrhotic patients. Inpatient mortality was high. The most common cause of mortality was rebleeding followed by hepatic encephalopathy, HRS, and SBP.

Preoperative Evaluation and Anesthetic Management of Patients With Liver Cirrhosis Undergoing Cardiac Surgery

Preoperative evaluation and anesthetic management of patients with liver cirrhosis undergoing cardiac surgery remain a clinical challenge because of its high risk for perioperative complications. This narrative review article summarizes the pathophysiology and anesthetic implication of liver cirrhosis on each organ system. It will help physicians to evaluate surgical candidates, to optimize intraoperative management, and to anticipate complications in liver cirrhosis patients undergoing cardiac surgery. Morbidity typically results from bleeding, sepsis, multisystem organ failure, or hepatic insufficiency. These complications occur as a result of the presence of coagulopathy, poor nutritional status, immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction that occur with liver cirrhosis. Therefore, liver cirrhosis should not be seen as a single disease, but one that manifests with multiorgan dysfunction. Cardiac surgery in patients with liver cirrhosis increases the risk of perioperative complications, and it presents a particular challenge to the anesthesiologist in that nearly every aspect of normally functioning physiology may be jeopardized in a unique way. Accurately classifying the extent of liver disease, preoperative optimization, and surgical risk communication with the patient are crucial. In addition, all teams involved in the surgery should communicate openly and coordinate in order to ensure optimal care. To reduce perioperative complications, consider using off-pump cardiopulmonary bypass techniques and optimal perfusion modalities to mimic current physiologic conditions.

Outcomes after hepatic encephalopathy in population-based cohorts of patients with cirrhosis

BACKGROUND

Hepatic encephalopathy is a devastating complication of cirrhosis.

AIM

To describe the outcomes after developing hepatic encephalopathy among contemporary, aging patients.

METHODS

We examined data for a 20% random sample of United States Medicare enrolees with cirrhosis and Part D prescription coverage from 2008 to 2014. Among 49 164 persons with hepatic encephalopathy, we evaluated the associations with transplant-free survival using Cox proportional hazard models with time-varying covariates (hazard ratios, HR) and incidence rate ratios (IRR) for healthcare utilisation measured in hospital-days and 30-day readmissions per person-year. We validated our findings in an external cohort of 2184 privately insured patients with complete laboratory values.

RESULTS

Hepatic encephalopathy was associated with median survivals of 0.95 and 2.5 years for those ≥65 or <65 years old and 1.1 versus 3.9 years for those with and without ascites. Non-alcoholic fatty-liver disease posed the highest adjusted risk of death among aetiologies, HR 1.07 95% CI (1.02, 1.12). Both gastroenterology consultation and rifaximin utilisation were associated with lower mortality, respective adjusted-HR 0.73 95% CI (0.67, 0.80) and 0.40 95% CI (0.39, 0.42). Thirty-day readmissions were fewer for patients seen by gastroenterologists (0.71 95% CI [0.57-0.88]) and taking rifaximin (0.18 95% CI [0.08-0.40]). Lactulose alone was associated with fewer hospital-days, IRR 0.31 95% CI (0.30-0.32), than rifaximin alone, 0.49 95% CI (0.45-0.53), but the optimal therapy combination was lactulose/rifaximin, IRR 0.28 95% CI (0.27-0.30). These findings were validated in the privately insured cohort adjusting for model for endstage liver disease-sodium score and serum albumin.

CONCLUSIONS

Hepatic encephalopathy remains morbid and associated with poor outcomes among contemporary patients. Gastroenterology consultation and combination lactulose-rifaximin are both associated with improved outcomes. These data inform the development of care coordination efforts for subjects with cirrhosis.

Ammonia Levels Do Not Guide Clinical Management of Patients With Hepatic Encephalopathy Caused by Cirrhosis

INTRODUCTION

Ammonia appears to play a major role in the pathophysiology of hepatic encephalopathy (HE), but its role in guiding management is unclear. We aimed to understand the impact of ammonia levels on inpatient HE management, hypothesizing that patients with elevated ammonia levels would receive more aggressive lactulose therapy than patients with normal ammonia or no ammonia level drawn.

METHODS

We examined patients with cirrhosis older than 18 years admitted for management of HE from 2005 to 2015. We additionally used propensity matching to control for confounding by the severity of underlying disease. Patients with an ammonia level taken at time of HE diagnosis were further separated into those with normal or elevated ammonia levels. The primary endpoint was the total lactulose (mL) amount (or dose) given in the first 48 hours of HE management.

RESULTS

One thousand two hundred two admissions with HE were identified. Ammonia levels were drawn in 551 (46%) patients; 328 patients (60%) had an abnormal ammonia level (>72 μmol/L). There were no significant differences in the Child-Pugh score, MELD, or Charlson Comorbidity Index in those with and without ammonia levels drawn. The average total lactulose dose over 48 hours was 167 and 171 mL in the no ammonia vs ammonia groups, respectively (P = 0.42). The average lactulose dose in patients with an elevated ammonia level was 161 mL, identical to the lactulose dose in patients with a normal ammonia level. There was no correlation between lactulose dose and ammonia level (R = 0.0026).

DISCUSSION

Inpatient management of HE with lactulose was not influenced by either the presence or level of ammonia level, suggesting that ammonia levels do not guide therapy in clinical practice.

Serial assessment of hepatic encephalopathy in patients hospitalised for acute decompensation of cirrhosis

INTRODUCTION AND AIM

Hepatic encephalopathy (HE) is a frequent complication of cirrhosis, but the clinical and prognostic significance of the progression of mental status in hospitalised cirrhotics is unknown. We aimed to investigate the prognostic significance of serial evaluation of HE in patients hospitalised for acute decompensation (AD) of cirrhosis.

MATERIALS AND METHODS

Patients (n=293) were evaluated for HE (West-Haven criteria) at admission and at day-3 and classified in two groups: (1) Absent or improved HE: HE absent at admission and at day-3, or any improvement at day-3; (2) Unfavourable progression: Development of HE or HE present at admission and stable/worse at day-3.

RESULTS

Unfavourable progression of HE was observed in 31% of patients and it was independently associated with previous HE, Child-Pugh C and acute-on-chronic liver failure (ACLF). MELD score and unfavourable progression of HE were independently associated with 90-day mortality. The 90-day Kaplan-Meier survival probability was 91% in patients with MELD<18 and absent or improved HE and only 31% in subjects with both MELD≥18 and unfavourable progression of HE. Unfavourable progression of HE was also related to lower survival in patients with or without ACLF. Worsening of GCS at day-3 was observed in 11% of the sample and was related with significantly high mortality (69% vs. 27%, P<0.001).

CONCLUSION

Among cirrhotics hospitalised for AD, unfavourable progression of HE was associated with high short-term mortality and therefore can be used for prognostication and to individualise clinical care.

Hospitalisation for cirrhosis in Australia: disparities in presentation and outcomes for Indigenous Australians

Background

Indigenous Australians experience greater health disadvantage and have a higher prevalence of many chronic health conditions. Liver diseases leading to cirrhosis are among the most common contributor to the mortality gap between Indigenous and other Australian adults. However, no comparative data exist assessing differences in presentation and patient outcomes between Indigenous and non-Indigenous Australians hospitalised with cirrhosis.

Methods

Using data from the Hospital Admitted Patient Data Collection and the Death Registry, this retrospective, population-based, cohort study including all people hospitalised for cirrhosis in the state of Queensland during 2008–2017 examined rate of readmission (Poisson regression), cumulative survival (Kaplan–Meier), and assessed the differences in survival (Multivariable Cox regression) by Indigenous status. Predictor variables included demographic, health service characteristics and clinical data.

Results

We studied 779 Indigenous and 10,642 non-Indigenous patients with cirrhosis. A higher proportion of Indigenous patients were younger than 50 years (346 [44%] vs. 2063 [19%] non-Indigenous patients), lived in most disadvantaged areas (395 [51%) vs. 2728 [26%]), had alcohol-related cirrhosis (547 [70%] vs. 5041 [47%]), had ascites (314 [40%] vs. 3555 [33%), and presented to hospital via the Emergency Department (510 [68%] vs. 4790 [47%]). Indigenous patients had 3.04 times the rate of non-cirrhosis readmissions (95%CI 2.98–3.10), 1.35 times the rate of cirrhosis-related readmissions (95%CI 1.29–1.41), and lower overall survival (17% vs. 27%; unadjusted hazard ratio (HR) = 1.16 95%CI 1.06–1.27), compared to non-Indigenous patients. Most of the survival deficit was explained by Emergency Department presentation (adj-HR = 1.03 95%CI 0.93–1.13), and alcohol-related aetiology (adj-HR = 1.08 95%CI 0.99–1.19). The remaining survival deficit was influenced by the other clinico-demographic and health service factors (final adj-HR = 1.08 95%CI 0.96–1.20).

Conclusions

There was evidence of differential presentation, higher rates of readmissions, and poorer survival for Indigenous Australians with cirrhosis, compared to other Australians. The increased prevalence of Emergency Department presentation among Indigenous patients suggests missed opportunities for early intervention to prevent progressive cirrhosis complications and hospital readmissions.

Efficacy of rifaximin in the different clinical scenarios of hepatic encephalopathy

Hepatic encephalopathy is a frequent complication in patients with cirrhosis of the liver and is associated with a high mortality rate. Costs attributed to the management of patients with cirrhosis are especially high due to complications, such as hepatic encephalopathy, given that they increase the number of days of hospital stay. Different drugs are currently used to treat hepatic encephalopathy, and the main ones are lactulose, L-ornithine L-aspartate (LOLA), and certain antibiotics, especially rifaximin-α (RFX). Even though many of them have been shown to be effective to greater or lesser degrees, it is important to understand the differences between them, so that every patient receives individualized treatment and the best option is chosen, in accordance with the different clinical scenarios. Thus, the aim of the present study was to analyze the evidence on the advantages and disadvantages of the individual or combined use of the 3 main treatments for hepatic encephalopathy, specifically taking into consideration their different degrees of efficacy, their impact on quality of life, prophylaxis, and cost reduction.

Hepatic Encephalopathy and Nutrition Influences: A Narrative Review

Hepatic encephalopathy (HE) is a potentially reversible neurocognitive condition seen in patients with advanced liver disease. The overt form of HE has been reported in up to 45% of patients with cirrhosis. This debilitating condition is associated with increased morbidity and mortality and imposes a significant burden on the caregivers and healthcare system. After providing an overview of HE epidemiology and pathophysiology, this review focuses on the interaction of HE and frailty, nutrition requirements and recommendations in cirrhotic patients with HE, and current dietary and pharmacologic options for HE treatment.

Acute-on-chronic liver failure: definition, prognosis and management

Acute-on-chronic liver failure (ACLF) is a recently described entity in chronic liver disease defined by acute hepatic decompensation, organ failure and a high risk of short-term mortality (usually less than 4 weeks). This condition is distinct from acute liver failure and stable progression of cirrhosis in numerous ways, including triggering precipitant factors, systemic inflammation, rapid progression and a potential for recovery. While a clear definition of ACLF has been forwarded from a large European Consortium study, some heterogeneity remains in how patients present and the types of organ failure, depending on whether they are described in Asian or European studies. Active alcoholism, acute alcoholic hepatitis and infections are the most frequent precipitants for ACLF. Underpinning the pathophysiology of ACLF is a state of persistent inflammation and immune dysfunction, collectively driving a systematic inflammatory response syndrome and an increased propensity to sepsis. Prevention and early treatment of organ failure are key in influencing survival. Given increasing organ shortage and more marginal grafts, liver transplantation is a limited resource and emphasises the need for new therapies to improve ACLF outcomes. Recent data indicate that liver transplantation has encouraging outcomes even in patients with advanced ACLF if patients are carefully selected during the permissive window of clinical presentation. ACLF remains a significant challenge in the field of hepatology, with considerable research and resource being channelled to improve upon the definition, prognostication, treatment and unravelling of mechanistic drivers. This Review discusses updates in ACLF definition, prognosis and management.

Impaired cognition predicts the risk of hospitalization and death in cirrhosis

Objective

Cognitive impairment, detected in up to 80% of patients with liver cirrhosis, is associated with negative health outcomes but is underdiagnosed in the clinical setting due to the lack of practical testing method. This single‐center prospective observational study aimed to test the feasibility and prognostic utility of in‐clinic cognitive assessment of patients with liver cirrhosis using the NIH Toolbox cognition battery (NIHTB).

Methods

Patients recruited from a hepatology/transplant clinic underwent cognitive assessments using West‐Haven Grade (WHG) and NIHTB between November 2016 and August 2018 and were prospectively followed until December 2018. The primary outcome was a composite end point of hospitalization related to overt hepatic encephalopathy (OHE) and all‐cause mortality during follow‐up, evaluated by a Cox proportional hazards regression model that adjusted for a priori covariates (age and MELD‐Na).

Results

Among 127 patients (median age 60 years, 48 [38%] women) assessed, cognitive performance was significantly impaired in 82 [78%] patients with WHG 0 and 22 [100%] patients with WHG 1 and 2. Over a median of 347 days follow‐up, 18 OHE and 8 deaths were observed. Lower cognitive performance was associated with an increased risk of OHE/death adjusting for age and MELD‐Na. Subclinical cognitive impairment detected by NIH Toolbox in WHG 0 patients was significantly associated with greater mortality. Median time to complete the two prognostically informative NIH Toolbox tests was 9.4 min.

Interpretation

NIH Toolbox may enable a rapid cognitive screening in the outpatient setting and identify patients at high risk for death and hospitalization for severe encephalopathy.

Advance Care Planning Preferences and Readiness in Cirrhosis: A Prospective Assessment of Patient Perceptions and Knowledge

Background: In 2014, the province of Alberta launched a campaign to promote public awareness of advance care planning (ACP) and its associated two-part documentation-a Goals of care designation (GCD, a medical order written by a health care practitioner detailing wishes for care) and a personal directive (PD, a document naming a surrogate decision maker). Notably, unlike the GCD, the PD can be self-initiated independent of a health practitioner. Objective: Two years after the campaign, we aimed to assess knowledge and recall of participation in ACP among cirrhosis patients. Design/Setting: Consecutive adult cirrhosis patients attending one of two specialty cirrhosis clinics in Edmonton, Alberta, were surveyed. Results: Ninety-seven patients were included. Mean model for end-stage liver disease was 12. Although 97% of patients indicated it was extremely important to know the reality of their illness, only 53% understood that cirrhosis would affect their future quality of life. Thirty-three percent of patients had completed a PD and 14% had completed a GCD. Seventy-eight percent of patients believed a GCD was important to them and 85% preferred to complete it in an outpatient clinic setting. Only a minority of patients who had taken the initiative to complete a PD in the community also had a GCD. Conclusions: Despite efforts to raise awareness of and educate Albertans about ACP, <20% of cirrhosis patients have a completed GCD. Additional strategic prioritization is required in both patients and providers to ensure that health practitioner-facilitated ACP is carried out as standard-of-care in all patients with cirrhosis.

Chinese guidelines on management of hepatic encephalopathy in cirrhosis

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.

Lactulose drives a reversible reduction and qualitative modulation of the faecal microbiota diversity in healthy dogs

Hepatic encephalopathy is a frequent and debilitating complication of liver disorders. Lactulose is an established and reasonably effective treatment, yet with incompletely understood mechanisms of action. The aims of this study were to examine how the faecal microbiota composition changed before, during and after lactulose treatment in a large animal model. Healthy, privately owned dogs (n = 18) completed a prospective cohort study. Faecal samples were collected weekly, while the subjects were either on their usual diet (week 1), or a standardised diet (weeks 2–9), with added oral lactulose in weeks 6–7. DNA extraction and 16S rRNA gene sequencing were undertaken. Faecal samples from week 7 had a significantly lower microbiota richness/diversity, based on observed operational taxonomic units, Shannon/Chao1 indexes and Pielou’s Evenness. Beta diversity based on UniFrac distances was significantly different in week 7 compared to weeks 1, 5 and 9. At the phylum level, week 7 was associated with a significant increase of Firmicutes and Actinobacteria, and a decrease of Bacteroidetes and Fusobacteria, when compared to weeks 5 and 9. In summary, we have shown that lactulose induces a reversible qualitative and quantitative change of the faecal microbiota, which may explain its clinical efficacy in the management of hepatic encephalopathy.

Short-term clinical outcomes of patients admitted with chronic liver disease to selected teaching hospitals in Ethiopia

BACKGROUND

Chronic liver disease (CLD) is a progressive destruction of liver tissue with subsequent necrosis that persists for at least 6 months. In Ethiopia, despite the high burden report, data on CLD is limited. The objective of this study was to assess short-term clinical outcomes in patients admitted with chronic liver disease to three tertiary teaching hospitals in Ethiopia and to identify predictors of mortality.

METHODS

A cohort of 109 patients admitted with CLD to three tertiary teaching hospitals in Ethiopia, were prospectively followed from the time of admission to 30-days of hospital discharge. The study was conducted from April 1, 2018, to October 5, 2018. Kaplan-Maier curve was used to estimate survival and cox-regression analysis to identify predictors of mortality.

RESULT

A total of 109 patients (80% male) diagnosed with CLD were included. Median age of the participants was 38(IQR, 30-48). The overall median length of hospital stay was 7(IQR, 4-11) days. Of the total, 39(35.8%) patients were HBsAg positive, and 12(11%) patients were anti-HCV positive. The 30-day mortality was 38(34.9%), and most of the deaths, 31(81.6%) occurred before hospital discharge. Hepatic encephalopathy at admission; being with unidentified risk factor/etiologies of CLD and total bilirubin level were independent predictors of in-hospital mortality. Patients with hepatic encephalopathy at admission had approximately 11 times increased risk of death as compared to patients without hepatic encephalopathy at admission. Similarly, the hazard of mortality was 5.8 times higher in those patients with unidentified risk factor/etiology as compared to others. The risk of dying had also increased with an increase in bilirubin (1.188[95% CI, 1.0719-1.316]) level.

CONCLUSION

Approximately one-quarter of patients with CLD died during their hospital stay, and the risk of death continued after hospital discharge. Hepatic encephalopathy at admission, unidentified risk factor/etiology and increased level of total bilirubin are poor prognostic factors. Given that more than one third the patients had HBV-infection, access to antiviral drugs could help improve the prognosis of patients with end-stage liver disease in Ethiopia, as well as prevent the progression of the disease if initiated earlier.

Copeptin – a biomarker of short-term mortality risk (7 days) in patients with end-stage liver disease

Background

For many patients with end-stage liver disease, liver transplantation represents the only curative therapy. Transplant recipients are scored and ranked using the model for end-stage liver disease (MELD/MELD-Na). Circulatory impairment is known to deteriorate outcomes; however, it is not incorporated into the current allocation system’s score. The aim of our study is to analyze the predictive value of copeptin as a biomarker of circulatory impairment and increased short-term mortality risk in patients with end-stage liver disease.

Methods

We conducted a retrospective observational study of 615 patients with end-stage liver disease. Patients were recruited using assessments performed during the evaluation process for liver transplantation. Copeptin values were analyzed in comparison to MELD-Na, interleukin 6 (IL-6), and C-reactive protein (CRP).

Results

Elevated levels of copeptin, IL-6 and CRP, as well as high MELD-Na scores, were significantly correlated with mortality. In a comparison of copeptin-tertiles, patients in group T3 (16.3 pmol/L or more) showed a significantly higher mortality risk (hazard ratio 11.2, p < 0.001). After adjusting for MELD-Na, copeptin remains an independent predictor of mortality. It shows its greatest prognostic strength in short-term mortality, where it performs comparable to MELD-Na (AUROC for 7 day-mortality, 0.941/0.939; p = 0.981) and shows an additional predictive value to MELD-Na for short-term mortality (7 days, p: 0.046; 30 days, p: 0.006).

Conclusions

Copeptin presents a valuable individual biomarker in detecting patients at risk for short-term mortality. Further studies should be performed to confirm our findings.

Targets to improve quality of care for patients with hepatic encephalopathy: data from a multi-centre cohort

BACKGROUND

Hepatic encephalopathy (HE) can adversely affect outcomes in both in-patients and out-patients with cirrhosis.

AIM

To define targets for improving quality of care in HE management in the multi-centre North American Consortium for End-Stage Liver Disease (NACSELD) cohort.

METHOD

NACSELD in-patient cohort was analysed for (a) medication-associated precipitants, (b) aspiration pneumonia development, (c) HE medication changes, and (d) 90-day HE recurrence/readmissions. Comparisons were made between patients on no-therapy, lactulose only, rifaximin only or both. Ninety-day HE-readmission analysis was adjusted for MELD score.

RESULTS

Two thousand eight hundred and ten patients (1102 no-therapy, 659 lactulose, 154 rifaximin, 859 both) were included. HE on admission, and HE rates during hospitalisation were highest in those on lactulose only or dual therapy compared to no-therapy or rifaximin only (P < 0.001). Medications were the most prevalent precipitants (32%; 21% lactulose over/underuse, 5% benzodiazepines, 4% opioids, 1% rifaximin underuse, 1% hypnotics). Patients with medication-associated precipitants had a better prognosis compared to other precipitants. A total of 23% (n = 217) reached grade 3/4 HE, of which 16% developed HE-related aspiration pneumonia. Two thousand four hundred and twenty patients were discharged alive without liver transplant (790 no-therapy, 639 lactulose, 136 rifaximin, 855 both); 12.5% (n = 99) of no-therapy patients did not receive a discharge HE therapy renewal. Ninety-day HE-related readmissions were seen in 16% of patients (9% no-therapy, 9% rifaximin only, lactulose only 18%, dual 21%, <0.001), which persisted despite MELD adjustment (P = 0.009).

CONCLUSION

Several targets to improve HE management were identified in a large cohort of hospitalised cirrhotic patients. Interventions to decrease medication-precipitated HE, prevention of aspiration pneumonia, and optimisation of HE medications are warranted.

Contemporary Epidemiology of Cirrhosis

PURPOSE OF REVIEW

We sought to review the contemporary epidemiology of cirrhosis, focusing on the relative burden of the most common chronic liver diseases.

RECENT FINDINGS

The key findings in the review highlight the increasing prevalence and impact of alcohol-related liver disease, particularly among young people, and the epidemic of nonalcoholic fatty liver commensurate with rising rates of obesity. We also contrast recent advances in the care of persons with hepatitis C with the lamentable rise in new infections associated with intravenous drug use. Finally, we highlight the impact of both conventional complications of cirrhosis (namely hepatic encephalopathy) but also the host of patient-reported outcomes adversely impacted by the symptoms of cirrhosis. Cirrhosis is associated with an expanding footprint in contemporary public health. In order to improve global outcomes, we must not only focus on the identifying and treating persons with viral hepatitis but also preventing the rise of alcohol-related liver disease and nonalcoholic fatty liver disease while attending to the urgent patient-centered needs posed by the symptoms of cirrhosis.

Diagnosis of covert hepatic encephalopathy: a multi-center study testing the utility of single versus combined testing

Covert hepatic encephalopathy (CHE) affects cognition in a multidimensional fashion. Current guidelines recommend performing Psychometric Hepatic Encephalopathy Score (PHES) and a second test to diagnose CHE for multi-center trials. We aimed to determine if a two-test combination strategy improved CHE diagnosis agreement, and accuracy to predict overt hepatic encephalopathy (OHE), compared to single testing. Cirrhotic outpatients without baseline OHE performed PHES, Inhibitory Control Test (ICT), and Stroop EncephAlapp (StE) at three centers. Patients were followed for OHE development. Areas under the receiver operation characteristic curve (AUROC) were calculated. We included 437 patients (399 with follow-up data). CHE prevalence varied with testing strategy: PHES+ICT 18%, ICT + StE 25%, PHES+StE 29%, ICT 35%, PHES 37%, and StE 54%. Combination with best test agreement was PHES+StE (k = 0.34). Sixty patients (15%) developed OHE. Although CHE by StE showed the highest sensitivity to predict OHE, PHES and PHES+StE were more accurate at the expense of a lower sensitivity (55%, AUROC: 0.587; 36%, AUROC: 0.629; and 29%, AUROC: 0.623; respectively). PHES+ICT was the most specific (85%) but all strategies including ICT showed sensitivities in the 33-45% range. CHE diagnosis by PHES (HR = 1.79, p = 0.04), StE (HR = 1.69, p = 0.04), and PHES+StE (HR = 1.72, p = 0.04), were significant OHE predictors even when adjusted for prior OHE and MELD. Our results demonstrate that combined testing decreases CHE prevalence without improving the accuracy of OHE prediction. Testing with PHES or StE alone, or a PHES+StE combination, is equivalent to diagnose CHE and predict OHE development in a multi-center setting.

Hepatic encephalopathy 2018: A clinical practice guideline by the Italian Association for the Study of the Liver (AISF)

Hepatic encephalopathy (HE) is a common, worrisome and sometimes difficult to manage complication of end-stage liver disease. HE is often recurrent, requiring multiple hospital admissions. It can have serious implications in terms of a patient's ability to perform complex tasks (for example driving), their earning capacity, their social and family roles. This guideline reviews current knowledge on HE definition, pathophysiology, diagnosis and treatment, both by general principles and by way of a summary of available drugs and treatment strategies. The quality of the published, pertinent evidence is graded, and practical recommendations are made. Where possible, these are placed within the Italian health service context, with reference to local diagnosis and management experience.

Early-Recurrent Overt Hepatic Encephalopathy Is Associated with Reduced Survival in Cirrhotic Patients after Transjugular Intrahepatic Portosystemic Shunt Creation

PURPOSE

To investigate the role of early overt hepatic encephalopathy (OHE) as a clinical marker of prognosis in cirrhosis with a transjugular intrahepatic portosystemic shunt (TIPS) and to assess the relationship between recurrence of OHE and survival after TIPS.

METHODS

From January 2012 to December 2013, a retrospective study of consecutive patients with cirrhosis and a TIPS was performed at a single institution. A total of 304 patients (196 males; mean age, 52 years) were enrolled during the study period. The mean Model for End-Stage Liver Disease (MELD) score was 11.6. Time-dependent Cox regression was applied to estimate the predictive ability of early OHE (within 3 months after TIPS) and the effect of its frequency on survival.

RESULTS

During a median follow-up of 28.3 months, 115 patients experienced OHE after the TIPS procedure; of these, 54 had at least 2 OHE episodes. Long-term survival worsened in patients with early OHE (hazard ratio [HR] = 2.75; 95% confidence interval [CI]: 1.75-4.32; P < .001). When early OHE was further divided into early-recurrent and single OHE, death was more common in patients with early-recurrent OHE (P < .001) than in patients with early-single OHE (P = .24). After adjustment by MELD score, ascites, serum albumin, indication for TIPS, and age, patients with early-recurrent OHE had a lower probability of survival (HR = 2.91; 95% CI: 1.04-4.89; P < .001). Furthermore, landmark and propensity score analyses confirmed the predictive value of early-recurrent OHE.

CONCLUSIONS

Early recurrence of OHE was associated with an increased risk of mortality for patients with cirrhosis who underwent TIPS.

Acetyl-L-carnitine for patients with hepatic encephalopathy

BACKGROUND

Hepatic encephalopathy is a common and devastating neuropsychiatric complication of acute liver failure or chronic liver disease. Ammonia content in the blood seems to play a role in the development of hepatic encephalopathy. Treatment for hepatic encephalopathy is complex. Acetyl-L-carnitine is a substance that may reduce ammonia toxicity. This review assessed the benefits and harms of acetyl-L-carnitine for patients with hepatic encephalopathy.

OBJECTIVES

To assess the benefits and harms of acetyl-L-carnitine for patients with hepatic encephalopathy.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, LILACS, and Science Citation Index Expanded for randomised clinical trials. We sought additional randomised clinical trials from the World Health Organization Clinical Trials Search Portal and ClinicalTrials.gov. We performed all electronic searches until 10 September 2018. We looked through the reference lists of retrieved publications and review articles, and we searched the FDA and EMA websites.

SELECTION CRITERIA

We searched for randomised clinical trials in any setting, recruiting people with hepatic encephalopathy. Trials were eligible for inclusion if they compared acetyl-L-carnitine plus standard care (e.g. antibiotics, lactulose) versus placebo or no acetyl-L-carnitine plus standard care. We are well aware that by selecting randomised clinical trials, we placed greater focus on potential benefits than on potential harms.

DATA COLLECTION AND ANALYSIS

We selected randomised clinical trials, assessed risk of bias in eight domains, and extracted data in a duplicate and independent fashion. We estimated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes. We measured statistical heterogeneity using I² and D² statistics. We subjected our analyses to fixed-effect and random-effects model meta-analyses. We assessed bias risk domains to control systematic errors. We assessed overall quality of the data for each individual outcome by using the GRADE approach.

MAIN RESULTS

We identified five randomised clinical trials involving 398 participants. All trials included only participants with cirrhosis as the underlying cause of hepatic encephalopathy. Trials included participants with covert or overt hepatic encephalopathy. All trials were conducted in Italy by a single team and assessed acetyl-L-carnitine compared with placebo. Oral intervention was the most frequent route of administration. All trials were at high risk of bias and were underpowered. None of the trials were sponsored by the pharmaceutical industry.None of the identified trials reported information on all-cause mortality, serious adverse events, or days of hospitalisation. Only one trial assessed quality of life using the Short Form (SF)-36 scale (67 participants; very low-quality evidence). The effects of acetyl-L-carnitine compared with placebo on general health at 90 days are uncertain (MD -6.20 points, 95% confidence interval (CI) -9.51 to -2.89). Results for additional domains of the SF-36 are also uncertain. One trial assessed fatigue using the Wessely and Powell test (121 participants; very low-quality evidence). The effects are uncertain in people with moderate-grade hepatic encephalopathy (mental fatigue: MD 0.40 points, 95% CI -0.21 to 1.01; physical fatigue: MD -0.20 points, 95% CI -0.92 to 0.52) and mild-grade hepatic encephalopathy (mental fatigue: -0.80 points, 95% CI -1.48 to -0.12; physical fatigue: 0.20 points, 95% CI -0.72 to 1.12). Meta-analysis showed a reduction in blood ammonium levels favouring acetyl-L-carnitine versus placebo (MD -13.06 mg/dL, 95% CI -17.24 to -8.99; 387 participants; 5 trials; very low-quality evidence). It is unclear whether acetyl-L-carnitine versus placebo increases the risk of non-serious adverse events (8/126 (6.34%) vs 3/120 (2.50%); RR 2.51, 95% CI 0.68 to 9.22; 2 trials; very low-quality evidence). Overall, adverse events data were poorly reported and harms may have been underestimated.

AUTHORS' CONCLUSIONS

This Cochrane systematic review analysed a heterogeneous group of five trials at high risk of bias and with high risk of random errors conducted by only one research team. We assessed acetyl-L-carnitine versus placebo in participants with cirrhosis with covert or overt hepatic encephalopathy. Hence, we have no data on the drug for hepatic encephalopathy in acute liver failure. We found no information about all-cause mortality, serious adverse events, or days of hospitalisation. We found no clear differences in effect between acetyl-L-carnitine and placebo regarding quality of life, fatigue, and non-serious adverse events. Acetyl-L-carnitine reduces blood ammonium levels compared with placebo. We rated all evidence as of very low quality due to pitfalls in design and execution, inconsistency, small sample sizes, and very few events. The harms profile for acetyl-L-carnitine is presently unclear. Accordingly, we need further randomised clinical trials to assess acetyl-L-carnitine versus placebo conducted according to the SPIRIT statements and reported according to the CONSORT statements.

Altered Microbiome in Patients With Cirrhosis and Complications

In patients with cirrhosis, the gut microbiome are affected by multiple gut and systemic alterations. These changes lead to dysbiosis in the microbiota of different parts of the body, resulting in inflammation. The constant immune stimulation resulting in part from dysbiosis is associated with morbidity in patients with cirrhosis. Dysbiosis as a dynamic event worsens with decompensation such as with hepatic encephalopathy, infections or acute-on-chronic liver failure (ACLF). These microbial patterns could be applied as diagnostic and prognostic measures in cirrhosis in the outpatient and inpatient setting. Current therapies for cirrhosis have differing impacts on gut microbial composition and functionality. Dietary modifications and the oral cavity have emerged as newer targetable factors to modulate the microbiome, which could affect inflammation and, potentially improve outcomes. Additionally, fecal microbial transplant is being increasingly studied to provide compositional and functional modulation of the microbiome. Ultimately, a combination of targeted therapies may be needed to provide an optimal gut milieu to improve outcomes in cirrhosis.

Acute-on-Chronic Liver Failure: Getting Ready for Prime Time?

Acute on chronic liver failure (ACLF) is the culmination of chronic liver disease and extrahepatic organ failures, which is associated with a high short-term mortality and immense health care expenditure. There are varying definitions for organ failures and ACLF in Europe, North America, and Asia. These differing definitions need to be reconciled to enhance progress in the field. The pathogenesis of ACLF is multifactorial and related to interactions between the immunoinflammatory system, microbiota, and the various precipitating factors. Individual organ failures related to the kidney, brain, lungs, and circulation have cumulative adverse effects on mortality and are often complicated or precipitated by infections. Strategies to prevent and rapidly treat these organ failures are paramount in improving survival. With the aging population and paucity of organs for liver transplant, the prognosis of ACLF patients is poor, highlighting the need for novel therapeutic strategies. The role of liver transplant in ACLF is evolving and needs further investigation across large consortia. A role for early palliative care and management of frailty as approaches to alleviate disease burden and improve patient-reported outcomes is being increasingly recognized.

CONCLUSION

ACLF is a clinically relevant syndrome that is epidemic worldwide and requires a dedicated multinational approach focused on prognostication and management; investigations are underway worldwide to prepare ACLF for prime time. (Hepatology 2018; 00:000-000).

Rifaximin has the potential to prevent complications of cirrhosis

BACKGROUND

Cirrhosis-related complications are associated with poor prognosis. With our analyses, we examined the potential benefit of rifaximin in reducing the risk of developing cirrhosis-related complications.

METHODS

Adults with cirrhosis and hepatic encephalopathy (HE) in remission were randomly assigned to receive rifaximin 550 mg twice daily or placebo for 6 months with concomitant lactulose permitted. Post hoc analyses examined time to cirrhosis-related complications (HE, spontaneous bacterial peritonitis (SBP), variceal bleeding, acute kidney injury/hepatorenal syndrome). Subgroup analyses evaluated efficacy for select baseline disease characteristics.

RESULTS

Of patients receiving rifaximin (n = 140) and placebo (n = 159), 53.6% and 49.1%, respectively, had baseline Model for End-Stage Liver Disease (MELD) score ⩾ 12 and international normalized ratio (INR) ⩾ 1.2. Baseline ascites was observed in 36.4% (rifaximin) and 34.6% (placebo) of patients. In patients with MELD score ⩾ 12 and INR ⩾ 1.2, rifaximin reduced the relative risk (RR) of any first complication experienced during trial by 59% [hazard ratio (HR) = 0.41, 95% confidence interval (CI): 0.25-0.67; p < 0.001] versus placebo. For patients with baseline ascites, rifaximin reduced the RR of any first complication experienced during trial by 42% versus placebo (HR = 0.58, 95% CI: 0.34-1.0; p = 0.045). For some subgroups, there was a decrease in RR of complications of SBP, variceal bleeding, and acute kidney injury/hepatorenal syndrome with rifaximin versus placebo, although there were few events reported in the study.

CONCLUSION

Rifaximin may reduce the incidence of cirrhosis-related complications and the recurrence of overt HE.[ClinicalTrials.gov identifier: NCT00298038.].

Serum Electrolyte Levels and Outcomes in Patients Hospitalized with Hepatic Encephalopathy

INTRODUCTION AND AIMS

Serum electrolyte derangements are common in patients with decompensated cirrhosis hospitalized for hepatic encephalopathy. There are limited data describing the association between electrolyte levels and outcomes in hepatic encephalopathy. We assessed the association between initial serum electrolyte values and outcomes in patients with hepatic encephalopathy.

MATERIAL AND METHODS

A total of 385 consecutive patients hospitalized with encephalopathy were included in the study. Baseline electrolyte levels (sodium, potassium, chloride, bicarbonate, calcium and phosphorus) were measured at the time of admission and assessed for association with outcomes, which included survival, admission to the intensive care unit, requirement for mechanical ventilation, and length of hospital stay. P-values ≤ 0.0083 were considered significant after adjustment for multiple testing.

RESULTS

In unadjusted analysis, significant associations were identified regarding both bicarbonate and phosphorus (admission to intensive care unit), and calcium (mechanical ventilation); however these findings weakened and no longer approached statistical significance when adjusting for confounding variables. No other significant associations between serum electrolyte measurements and outcomes were observed.

CONCLUSIONS

Our findings suggest that in patients hospitalized with encephalopathy, serum electrolyte measurements are not strong predictors of patient outcome.

Mortality due to cirrhosis and liver cancer in the United States, 1999-2016: observational study

OBJECTIVE

To describe liver disease related mortality in the United States during 1999-2016 by age group, sex, race, cause of liver disease, and geographic region.

DESIGN

Observational cohort study.

SETTING

Death certificate data from the Vital Statistics Cooperative, and population data from the US Census Bureau compiled by the Center for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (1999-2016).

PARTICIPANTS

US residents.

MAIN OUTCOME MEASURE

Deaths from cirrhosis and hepatocellular carcinoma, with trends evaluated using joinpoint regression.

RESULTS

From 1999 to 2016 in the US annual deaths from cirrhosis increased by 65%, to 34 174, while annual deaths from hepatocellular carcinoma doubled to 11 073. Only one subgroup-Asians and Pacific Islanders-experienced an improvement in mortality from hepatocellular carcinoma: the death rate decreased by 2.7% (95% confidence interval 2.2% to 3.3%, P<0.001) per year. Annual increases in cirrhosis related mortality were most pronounced for Native Americans (designated as "American Indians" in the census database) (4.0%, 2.2% to 5.7%, P=0.002). The age adjusted death rate due to hepatocellular carcinoma increased annually by 2.1% (1.9% to 2.3%, P<0.001); deaths due to cirrhosis began increasing in 2009 through 2016 by 3.4% (3.1% to 3.8%, P<0.001). During 2009-16 people aged 25-34 years experienced the highest average annual increase in cirrhosis related mortality (10.5%, 8.9% to 12.2%, P<0.001), driven entirely by alcohol related liver disease. During this period, mortality due to peritonitis and sepsis in the setting of cirrhosis increased substantially, with respective annual increases of 6.1% (3.9% to 8.2%) and 7.1% (6.1% to 8.4%). Only one state, Maryland, showed improvements in mortality (-1.2%, -1.7% to -0.7% per year), while many, concentrated in the south and west, observed disproportionate annual increases: Kentucky 6.8% (5.1% to 8.5%), New Mexico 6.0% (4.1% to 7.9%), Arkansas 5.7% (3.9% to 7.6%), Indiana 5.0% (3.8% to 6.1%), and Alabama 5.0% (3.2% to 6.8%). No state showed improvements in hepatocellular carcinoma related mortality, while Arizona (5.1%, 3.7% to 6.5%) and Kansas (4.3%, 2.8% to 5.8%) experienced the most severe annual increases.

CONCLUSIONS

Mortality due to cirrhosis has been increasing in the US since 2009. Driven by deaths due to alcoholic cirrhosis, people aged 25-34 have experienced the greatest relative increase in mortality. White Americans, Native Americans, and Hispanic Americans experienced the greatest increase in deaths from cirrhosis. Mortality due to cirrhosis is improving in Maryland but worst in Kentucky, New Mexico, and Arkansas. The rapid increase in death rates among young people due to alcohol highlight new challenges for optimal care of patients with preventable liver disease.

Myosteatosis and sarcopenia are associated with hepatic encephalopathy in patients with cirrhosis

BACKGROUND

Skeletal muscle is known to play a role in hepatic encephalopathy. Fatty infiltration of the muscle (myosteatosis) and muscle mass depletion (sarcopenia) are frequent complications of cirrhosis.

PURPOSE

The purposes of the study were to investigate if myosteatosis and sarcopenia are associated with overt hepatic encephalopathy in patients with cirrhosis and to evaluate their impact on mortality.

METHODS

A total of 675 cirrhotic patients were studied. Computed tomography scans were used to analyze the skeletal muscle. Hepatic encephalopathy was defined by either a hepatic encephalopathy-related hospitalization and/or taking ammonia-lowering treatment (i.e., lactulose, rifaximin).

RESULTS

Myosteatosis was observed in 348 patients (52%), sarcopenia in 242 (36%), and hepatic encephalopathy in 128 (19%) patients. Both myosteatosis (70 vs. 45%, p < 0.001) and sarcopenia (53 vs. 32%, p < 0.001) were more frequent in patients with hepatic encephalopathy. By multivariable regression analysis, both myosteatosis and sarcopenia were associated with a higher risk of hepatic encephalopathy, independent of the MELD score (OR 2.25; 95% CI, 1.32-3.85, p = 0.003 and OR 2.42; 95% CI, 1.43-4.10, p = 0.001, respectively). In univariate Cox proportional hazards analysis, sarcopenia (csHR 2.02; 95% CI, 1.57-2.58, p < 0.001), myosteatosis (csHR 1.45; 95% CI, 1.16-2.91, p = 0.004), and hepatic encephalopathy (csHR 1.61; 95% CI, 1.20-2.18, p = 0.002) were associated with mortality, but only sarcopenia was significant in the multivariable analysis (csHR 2.15; 95% CI, 1.52-3.05, p < 0.001).

CONCLUSIONS

Myosteatosis and sarcopenia are independently associated with overt hepatic encephalopathy in patients with cirrhosis. The association between hepatic encephalopathy and mortality may be explained at least partially by the presence of sarcopenia. These results identify the importance of muscle mass and suggest therapeutic strategies to attenuate muscle mass loss and improve muscle quality.

NACSELD acute-on-chronic liver failure (NACSELD-ACLF) score predicts 30-day survival in hospitalized patients with cirrhosis

The North American Consortium for the Study of End-Stage Liver Disease's definition of acute-on-chronic liver failure (NACSELD-ACLF) as two or more extrahepatic organ failures has been proposed as a simple bedside tool to assess the risk of mortality in hospitalized patients with cirrhosis. We validated the NACSELD-ACLF's ability to predict 30-day survival (defined as in-hospital death or hospice discharge) in a separate multicenter prospectively enrolled cohort of both infected and uninfected hospitalized patients with cirrhosis. We used the NACSELD database of 14 tertiary care hepatology centers that prospectively enrolled nonelective hospitalized patients with cirrhosis (n = 2,675). The cohort was randomly split 60%/40% into training (n = 1,605) and testing (n = 1,070) groups. Organ failures assessed were (1) shock, (2) hepatic encephalopathy (grade III/IV), (3) renal (need for dialysis), and (4) respiratory (mechanical ventilation). Patients were most commonly Caucasian (79%) men (62%) with a mean age of 57 years and a diagnosis of alcohol-induced cirrhosis (45%), and 1,079 patients had an infection during hospitalization. The mean Model for End-Stage Liver Disease score was 19, and the median Child score was 10. No demographic differences were present between the two split groups. Multivariable modeling revealed that the NACSELD-ACLF score, as determined by number of organ failures, was the strongest predictor of decreased survival after controlling for admission age, white blood cell count, serum albumin, Model for End-Stage Liver Disease score, and presence of infection. The c-statistics were 0.8073 for the training set and 0.8532 for the validation set.

CONCLUSION

Although infection status remains an important predictor of death, NACSELD-ACLF was independently validated in a separate large multinational prospective cohort as a simple, reliable bedside tool to predict 30-day survival in both infected and uninfected patients hospitalized with a diagnosis of cirrhosis. (Hepatology 2018;67:2367-2374).