Cognitive impairment in alcoholic and nonalcoholic cirrhotic patients

Disentangling the contributions of alcohol use disorder and alcohol-related liver disease towards dementia: A population-based cohort study

AIMS

The aim of the study was to disentangle the contributions of alcohol and alcohol-related liver disease (ALD) towards dementia by independently measuring the association between alcohol use disorder (AUD) alone and ALD with dementia.

DESIGN

This was a nation-wide cohort study.

SETTING

The study was conducted in Sweden from 1987 to 2020.

PARTICIPANTS

DELIVER (DEcoding the epidemiology of LIVER disease in Sweden) cohort, containing administrative codes on patients with chronic liver disease from the National Patient Register and other registers between 1987 and 2020.

MEASUREMENTS

International Classification of Disease 9th (ICD-9) and 10th (ICD-10) version codes were used to define the presence of AUD, ALD and dementia. The associations of AUD alone and ALD with incident dementia were estimated using Cox regression models adjusting for potential confounders. Cumulative incidences were also calculated accounting for competing risks of death.

FINDINGS

A total of 128 884 individuals with AUD alone, 17 754 with ALD and 2 479 049 controls were identified. During a median follow-up of 8.9 years, 13 395 (10.4%), 2187 (12.3%) and 138 925 (5.6%) dementia cases were identified in these groups, respectively. Dementia rates were increased in AUD alone [adjusted hazard ratio (aHR) = 4.6, 95% confidence interval (CI) = 4.5-4.6] and in ALD (aHR = 8.6, 95% CI = 8.3-9.0) compared with controls. AUD alone was also associated with increased rates of vascular dementia (aHR = 2.3, 95% CI = 2.2-2.5) and Alzheimer's disease (aHR = 1.4, 95% CI = 1.3-1.4), while ALD was only associated with vascular dementia (aHR = 2.7, 95% CI = 2.3-3.2). The median age at dementia diagnosis was 67 years [interquartile range (IQR) = 56-76] in AUD alone and 63 years (IQR = 56-71) in ALD compared with 85 years (IQR = 79-89) in controls.

CONCLUSION

In Sweden, patients with alcohol use disorder (AUD) appear to have increased rates of dementia and diagnosis at a younger age, compared with patients without AUD. Concurrent alcohol-related liver disease appears to increase the diagnosis rate and lower the median age further.

Subclinical Cognitive Impairment in Chronic Pancreatitis Is Associated With Reduced Mobility and Quality of Life

INTRODUCTION

This study explores how chronic pancreatitis (CP) relates to subclinical cognitive impairment (SCI) and its prevalence, characteristics, risk factors, and effects on patients' quality of life (QoL) and physical performance.

METHODS

Patients with fulfilled CP criteria in imaging were prospectively enrolled. Overt encephalopathy, neurodegenerative disorders, decompensated cirrhosis, and sepsis were exclusion criteria. All patients underwent psychometric testing and assessment of health-related QoL, such as mobility and strength. SCI was diagnosed when at least 1 test of the psychometric test battery was pathological.

RESULTS

Seventy-one patients were enrolled. The etiology was toxic (alcohol/smoking) in most (49%) of the cases. SCI was prevalent in 41% of the patients while 25% had only 1 and 16% had 2 or more pathological tests. Patients with SCI exhibited diminished overall QoL scores ( P = 0.048), primarily affecting physical functionality ( P < 0.001). This was reaffirmed in mobility tests, where patients with SCI were slower in the timed up-and-go test ( P = 0.008) and showed increased prevalence of abnormal chair rising tests ( P = 0.004). Among all variables analyzed, only alcohol abuse was an independent risk factor of SCI (odds ratio 3.46; P = 0.02) in a multivariable regression model together with the variables age, sex, education, and compensated cirrhosis. Despite SCI affecting global QoL, sleep disturbance seemed to be the strongest variable independently associated with impaired QoL (odds ratio 9.9; P = 0.001).

DISCUSSION

The largest study to the subject to date shows that SCI is common in patients with CP and is linked to significant morbidity. These findings suggest the need for addressing modifiable risk factors in patients with CP to improve outcomes.

Alcohol-related cognitive impairments in patients with and without cirrhosis

AIMS

up to 80% of patients with alcohol use disorder display cognitive impairments. Some studies have suggested that alcohol-related cognitive impairments could be worsened by hepatic damage. The primary objective of this study was to compare mean scores on the Brief Evaluation of Alcohol-Related Neurocognitive Impairments measure between alcohol use disorder patients with (CIR+) or without cirrhosis (CIR-).

METHODS

we conducted a prospective case-control study in a hepatology department of a university hospital. All patients were assessed using the Evaluation of Alcohol-Related Neuropsychological Impairments test.

RESULTS

a total of 82 patients (50 CIR+, 32 CIR-) were included in this study. CIR- patients were significantly younger than CIR+ patients (respectively, 45.5 ± 6.8 vs 60.1 ± 9.0; P < .0001). After adjusting for age and educational level, the mean Evaluation of Alcohol-Related Neuropsychological Impairments total scores in the CIR+ group were significantly lower than in the group of CIR- patients (14.1 ± 0.7 vs 7.8 ± 0.4, respectively, P < .0001). The mean subscores on delayed verbal memory, alphabetical ordination, alternating verbal fluency, visuospatial abilities, and ataxia subtests were also significantly lower in the CIR+ than in the CIR- group (respectively, 1.9 ± 0.2 vs 2.8 ± 0.2; 1.8 ± 0.2 vs 2.7 ± 0.2; 2.2 ± 0.2 vs 3.6 ± 0.2; 0.7 ± 0.2 vs 1.6 ± 0.2; 0.7 ± 0.2 vs 3.1 ± 0.2; P < .0001 for all comparisons).

CONCLUSIONS

in the present study, alcohol use disorder patients with cirrhosis presented more severe cognitive impairments than those without cirrhosis. Longitudinal studies are needed to investigate how cirrhosis can influence cognitive impairments.

Plasma Concentrations of Lysophosphatidic Acid and Autotaxin in Abstinent Patients with Alcohol Use Disorder and Comorbid Liver Disease

Lysophosphatidic acid (LPA) is an endogenous lysophospholipid and a bioactive lipid that is synthesized by the enzyme autotaxin (ATX). The ATX-LPA axis has been associated with cognitive dysfunction and inflammatory diseases, mainly in a range of nonalcoholic liver diseases. Recently, preclinical and clinical evidence has suggested a role of LPA signaling in alcohol use disorder (AUD) and AUD-related cognitive function. However, the ATX-LPA axis has not been sufficiently investigated in alcoholic liver diseases. An exploratory study was conducted in 136 participants, 66 abstinent patients with AUD seeking treatment for alcohol (alcohol group), and 70 healthy control subjects (control group). The alcohol group was divided according to the presence of comorbid liver diseases (i.e., fatty liver/steatosis, alcoholic steatohepatitis, or cirrhosis). All participants were clinically evaluated, and plasma concentrations of total LPA and ATX were measured using enzyme-linked immunosorbent assays. Data were primarily analyzed using analysis of covariance (ANCOVA) while controlling for age, body mass index, and sex. Logistic regression models were created to assess the association of the ATX-LPA axis and AUD or liver disease. LPA and ATX were log₁₀-transformed to fit the assumptions of parametric testing.The main results were as follows: total LPA and ATX concentrations were dysregulated in the alcohol group, and patients with AUD had significantly lower LPA (F_(1,131) = 10.677, p = 0.001) and higher ATX (F_(1,131) = 8.327, p = 0.005) concentrations than control subjects; patients with AUD and liver disease had significantly higher ATX concentrations (post hoc test, p < 0.05) than patients with AUD but not liver disease; significant correlations between AUD-related variables and concentrations of LPA and ATX were only found in the non-liver disease subgroup (the duration of alcohol abstinence with LPA and ATX (r = +0.33, p < 0.05); and the severity of AUD with ATX (rho = -0.33, p < 0.05)); and a logistic regression model with LPA, ATX, and AUD-related variables showed an excellent discriminative power (area under the curve (AUC) = 0.915, p < 0.001) for distinguishing patients with AUD and comorbid liver disease. In conclusion, our data show that the ATX-LPA axis is dysregulated in AUD and suggest this lipid signaling, in combination with relevant AUD-related variables, as a reliable biomarker of alcoholic liver diseases.

Increased risk of chronic liver disease in patients with bipolar disorder: A population-based study

OBJECTIVE

This study aimed to investigate the prevalence and incidence of chronic liver disease in patients with bipolar disorder.

METHODS

We used a random sample of 766,427 subjects aged ≥18 years from the National Health Research Institute database in the year 2005. Subjects with at least one primary diagnosis of bipolar disorder in 2005 were identified. Patients with a primary or secondary diagnosis of chronic liver disease were also defined. We compared the prevalence and associated factors of chronic liver disease between patients with bipolar disorder and the general population in 2005. We also compared the incidence of chronic liver disease in patients with bipolar disorder and the general population from 2006 to 2010.

RESULTS

The prevalence of chronic liver disease in patients with bipolar disorder (13.9%) was 2.68 times higher than that of the general population (5.8%) in 2005. The average annual incidence of chronic liver disease in patients with bipolar disorder from 2006 to 2010 was also higher than that of the general population (2.95% vs. 1.73%; risk ratio: 1.71; 95% confidence interval: 1.46-2.01).

CONCLUSIONS

Patients with bipolar disorder had a significantly higher prevalence and incidence of chronic liver disease than those in the general population, and younger patients with bipolar disorder have a much higher prevalence and incidence than those in the general population. Male sex, second-generation antipsychotic or antidepressant use, and hyperlipidemia were associated factors for chronic liver disease in patients with bipolar disorder.

Driving Performance Among Patients with Cirrhosis Who Drove to Their Outpatient Hepatology Clinic Appointments

BACKGROUND

Minimal hepatic encephalopathy (MHE) may adversely affect driving skills.

AIMS

To compare the driving performance of cirrhotic patients with and without prior HE as well as controls using a driving stimulator and to correlate psychometric testing with driving performance.

METHODS

Adult patients with cirrhosis, who drove to the outpatient clinic for their routine appointments underwent a battery of driving and psychometric tests including number connection tests A & B (NCT-A and NCT-B), digit symbol test (DST) and critical flicker and fusion frequency (CFF) testing.

RESULTS

Cirrhotics had significantly higher NCT-A (39.3 s vs. 31.2 s, P = 0.006) and DST scores (317 s vs. 245 s, P = 0.012), and lower CFF scores Fusion (33 vs. 36 Hz, P = 0.05), Flicker (35 vs. 42 Hz, P = 0.007) than controls. There was no difference in NCT-A, DST and CFF scores between patients with and without HE. Ten (22%) patients, 7 (27%) with prior HE and 3 (15%) without prior HE, had abnormal NCT-A scores (i.e. >control mean ± 2SD), and 12% of patients with prior HE had one or more driving test accidents, while controls and patients without prior HE had none. Patients with cirrhosis were more likely to hit pedestrians compared to controls (P = 0.05). There was no correlation between CFF, DST and NCTB scores with driving performance test results.

CONCLUSIONS

Unlike previous reports, no significant differences were noted between the patients with and without prior HE on psychometric testing, and on the driving simulator, but driving accidents were seen in only those with previous history of HE.

Confounders in the detection of minimal hepatic encephalopathy: a neuropsychological and quantified EEG study

BACKGROUND & AIMS

Chronic alcohol misuse, HCV infection and cirrhosis may cause cognitive alterations. The aim of the present study was to assess the influence of alcohol misuse, HCV infection and cirrhosis per se on the neuropsychological and electroencephalogram (EEG) profile and to evaluate the role of alcohol misuse and HCV infections as potential confounding factors in the detection of minimal hepatic encephalopathy.

METHODS

A comprehensive neuropsychological profile and EEG spectral parameters were obtained in six age-matched groups of 30 subjects each: (i) HCV-related hepatitis without cirrhosis, (ii) chronic alcohol abusers, (iii) patients with HCV-related cirrhosis, (iv) alcohol-related cirrhosis, (v) cirrhosis not related to alcohol or HCV and (vi) healthy subjects. Cirrhotic patients were matched for MELD score.

RESULTS

The factor 'cirrhosis' was associated with low Phonemic Verbal Fluency (PVF) and Difference between Trail Making Test B and A (TMT) (B-A) (P < 0.001). Chronic alcohol misuse was associated with low PVF, TMT (B-A), Memory with Interference Task at 10 (ITM 10) and 30 s (ITM 30) (all P < 0.05). An interaction was found between the factors 'cirrhosis', 'alcohol misuse' and tests (P < 0.01). HCV hepatitis reduced ITM 10 (P < 0.05), but no interaction was found between 'cirrhosis', 'HCV infection' and tests (P = 0.14). The EEG parameters were mainly influenced by 'cirrhosis' (P < 0.05), and EEG alterations were more pronounced in patients with alcoholic cirrhosis (P = 0.04).

CONCLUSIONS

Cirrhosis per se, chronic alcohol misuse and HCV infection were found to be associated with cognitive dysfunction. In patients with cirrhosis, the interaction with alcohol misuse further impinged on brain dysfunction.

Challenges in transplantation for alcoholic liver disease

Transplantation for the treatment of alcoholic cirrhosis is more controversially discussed than it is for any other indication. The crucial aspect in this setting is abstinence before and after liver transplantation. We established pre-transplant selection criteria for potential transplant candidates. Provided that the underlying disease can be treated, there is no reason to withhold liver transplantation in a patient suffering from alcoholic cirrhosis. Evaluation of the patient by a multidisciplinary team, including an addiction specialist, is considered to be the gold standard. However, several centers demand a specified period of abstinence - usually 6 mo- irrespective of the specialist’s assessment. The 6-mo rule is viewed critically because liver transplantation was found to clearly benefit selected patients with acute alcoholic hepatitis; the benefit was similar to that achieved for other acute indications. However, the discussion may well be an academic one because the waiting time for liver transplantation exceeds six months at the majority of centers. The actual challenge in liver transplantation for alcoholic cirrhosis may well be the need for lifelong post-transplant follow-up rather than the patient’s pre-transplant evaluation. A small number of recipients experience a relapse of alcoholism; these patients are at risk for organ damage and graft-related death. Post-transplant surveillance protocols should demonstrate alcohol relapse at an early stage, thus permitting the initiation of adequate treatment. Patients with alcoholic cirrhosis are at high risk of developing head and neck, esophageal, or lung cancer. The higher risk of malignancies should be considered in the routine assessment of patients suffering from alcoholic cirrhosis. Tumor surveillance protocols for liver transplant recipients, currently being developed, should become a part of standard care; these will improve survival by permitting diagnosis at an early stage. In conclusion, the key factor determining the outcome of transplantation for alcoholic cirrhosis is intensive lifelong medical and psychological care. Post-transplant surveillance might be much more important than pre-transplant selection.

Neuropsychological functioning in patients with alcohol-related liver disease before and after liver transplantation

BACKGROUND

Cognitive dysfunction is common in both end-stage liver disease and chronic alcohol misuse. The impact of orthotopic liver transplantation (OLT) on neuropsychological function is poorly documented. This prospective study examined changes in cognitive function pre- and post-OLT in patients with alcohol-related liver disease (ALD).

METHODS

Comprehensive neuropsychological assessment was conducted with 92 abstinent patients with ALD scheduled for OLT. Forty-two patients were available for reassessment 12 months post-OLT.

RESULTS

Posttransplantation, cognitive performance on all measures fell within normal limits. Greatest improvement occurred in visuomotor speed, complex visual attention processes, and the ability to solve visually presented problems. Performance on memory assessment tasks also improved posttransplantation. Applying a more robust assessment of change (Reliable Change Index), approximately half improved reliably on overall cognitive function. One quarter improved in memory performance. With the exception of the Full-Scale Intelligence Quotient scales, discriminant analysis was unable to successfully predict which patients reliably improved.

CONCLUSIONS

Overall improvement in cognitive function occurs after liver transplantation in ALD. It was not possible to identify which patient characteristics were associated with reliable change.

Clinical efficacy and safety of lactulose for minimal hepatic encephalopathy: a meta-analysis

OBJECTIVE

To evaluate the clinical efficacy of lactulose in patients with minimal hepatic encephalopathy (MHE).

METHODS

Randomized controlled trials (RCTs) comparing lactulose with placebo or with no intervention in the management of MHE that were conducted from January 1990 to July 2011 were searched from MEDLINE, EMBASE, SCI, Cochrane Controlled Trials Register, and China Biological Medicine Database. Studies with a Jadad score higher than 3 were included in the meta-analysis and evaluated using RevMan5.0 software for relative risk (RR) or weighted mean difference (WMD) with 95% confidence intervals (95% CI). Sensitivity analysis was performed on the ethnical differences and quality of the trials. Publication bias was observed using an inverted funnel plot.

RESULTS

Nine studies with 434 patients were included in the meta-analysis. Compared with placebo or no intervention, lactulose significantly reduced the risk of no improvement in neuropsychological tests (RR: 0.52, 95% CI: 0.44-0.62, P<0.00001), the time required for the completion of the number connection test-A (WMD: -26.95, 95% CI: -37.81 to -16.10, P<0.00001), and the mean number of abnormal neuropsychological tests (WMD: -1.76, 95% CI: -1.96 to -1.56, P<0.00001). Furthermore, the meta-analysis also showed that lactulose prevented the progression to overt hepatic encephalopathy (RR: 0.17, 95% CI: 0.06-0.52, P=0.002), reduced blood ammonia levels (WMD: -9.89 µmol/l, 95% CI: -11.01 to -8.77 µmol/l, P<0.00001), and improve health-related quality of life (WMD: -6.05, 95% CI: -6.30 to -5.20, P<0.00001). However, no significant difference was observed in the mortality of patients with MHE (RR: 0.75, 95% CI: 0.21-2.72, P=0.66), and lactulose significantly increased the incidence of diarrhea (RR: 4.38, 95% CI: 1.35-14.25, P=0.01).

CONCLUSION

Lactulose has significant beneficial effects for patients with MHE compared with placebo or no intervention.

Computerized psychometric testing in minimal encephalopathy and modulation by nitrogen challenge and liver transplant

BACKGROUND & AIMS

A lack of standardized tests was cited by hepatologists for not testing for minimal hepatic encephalopathy. We therefore compared paper and pencil neuropsychologic tests with a comprehensive computerized assessment (Cognitive Drug Research [CDR], Goring-on-Thames, United Kingdom) of cognitive function.

METHODS

Eighty-nine cirrhotic patients were studied. Composite scores were calculated from the CDR subtests to reflect 5 cognitive domains, and results were validated by comparison with those from 6 standard paper and pencil tests. Level of impairment was defined using the sum of the standard deviations by which each CDR domain (CDR factor score [CDRS]) and each paper and pencil test score (PHES) differed from age-matched norms. CDRS and PHES were repeated in 21 patients after liver transplantation and CDRS in 24 patients after a 108-g amino acid challenge.

RESULTS

There was a high correlation between the 2 assessment methods (r = 0.748; P = .001). Using multiple regression, Model of End-Stage Liver Disease score (P = .011) correlated with PHES. In contrast, the CDR domains Continuity of Attention and Quality of Episodic Memory were significantly related to venous blood ammonia levels (adjusted R(2) = 0.200; F(6,76) = 4.41; P = .001). There were marked deteriorations in the CDR composite scores representing Accuracy of Working (P = .005) and Episodic Memory (P = .001) after amino acid challenge when blood ammonia increased from 63 +/- 36 to 126 +/- 62 micromol/L (P = .001). Both PHES and CDRS returned to the control range after liver transplantation (PHES: pretransplantation, -6; posttransplantation, 0; P < .001; CDRS: pretransplantation, -6; posttransplantation, -2; P = .003).

CONCLUSIONS

CDRS is valuable for the recognition of minimal hepatic encephalopathy.

Type and etiology of liver cirrhosis are not related to the presence of hepatic encephalopathy or health-related quality of life: a cross-sectional study

BACKGROUND

Hepatic encephalopathy has a negative impact on health-related quality of life (QoL) in liver cirrhosis. There are scarce and conflicting data on whether type or etiology of liver cirrhosis could be related to hepatic encephalopathy in patients with cirrhosis. We aimed to determine the impact of cirrhosis etiology on hepatic encephalopathy and whether hepatic encephalopathy affects health-related QoL among patients with cirrhosis of different etiologies.

METHODS

A total of 156 cirrhotic patients were prospectively evaluated for the presence of hepatic encephalopathy according to the West-Haven criteria as well as by means of two psychometric tests. Patients with cryptogenic cirrhosis or cirrhosis due to mixed hepatocellular/cholestatic etiologies were excluded. Fasting plasma glucose levels were also measured. QoL was evaluated by means of a validated questionnaire (SF-36).

RESULTS

Diabetes mellitus was more common in patients with hepatocellular cirrhosis compared to those with cholestatic cirrhosis but the two groups did not differ in cirrhosis severity or the prevalence of hepatic encephalopathy (p > 0.05). The groups of patients with cirrhosis due to alcohol, hepatitis C, or cholestatic liver disease did not differ in severity of liver cirrhosis or the prevalence of hepatic encephalopathy (p > 0.05). Patients with cirrhosis of different etiologies did not differ in any SF-36 domain (p > 0.05). In multivariate analysis, performance at neuropsychological testing was independently related only to age, diabetes mellitus, and the Child-Pugh score whereas the SF-36 physical component summary only to the Child-Pugh score and hepatic encephalopathy.

CONCLUSION

Cirrhosis etiology does not seem to be related to hepatic encephalopathy or health-related QoL. Cognitive impairment is associated mainly with age, liver disease severity and diabetes mellitus.

Clinicopathologic correlates of hepatitis C virus in brain: a pilot study

Hepatitis C virus (HCV) has been detected in the brain tissues of 10 individuals reported to date; it is unclear what clinical factors are associated with this, and with what frequency it occurs. Accordingly, a pilot analysis utilizing reverse transcriptase-polymerase chain reaction (RT- PCR) to detect and sequence HCV in premortem plasma and postmortem brain and liver from 20 human immunodeficiency virus (HIV)-infected and 10 HIV-naive individuals was undertaken. RNA encoding the first 126 amino acids of the HCV E1 envelope protein and the majority of the E1 signal sequence was analyzed in parallel with an 80-base-long segment of the 5' untranslated region (UTR). Liver HCV was detected only in subjects with premortem HCV viremia (10 HIV-infected and 3 HIV-naive). Brain HCV was detected in 6/10 HCV/HIV-coinfected and 1/3 HCV-monoinfected subjects. In the setting of HIV, the magnitude of plasma HCV load did not correlate with the presence of brain HCV. However, coinfected patients with brain HCV were more often off antiretroviral therapy and tended to have higher plasma HIV loads than those with HCV restricted to liver. Furthermore, premortem cerebrospinal fluid (CSF) analysis revealed that HCV/HIV-coinfected patients with brain HCV had detectable CSF HIV, whereas those without brain HCV had undetectable CSF HIV loads (P = .0205). Neuropsychologic tests showed a trend for hierarchical impairment of abstraction/executive functioning in HIV/HCV coinfection, with mean T scores for HIV monoinfected patients 43.2 (7.3), for liver-only HCV 39.5 (9.0), and for those with HCV in brain and liver 33.2 (5.1) (P = .0927). Predominant brain HCV sequences did not match those of the plasma or liver in 4 of the 6 coinfected patients analyzed. We conclude that in the setting of HIV/HCV coinfection, brain HCV is a common phenomenon unrelated to the magnitude of HCV viremia, but related to active HIV disease and detectable CSF HIV. Furthermore, there is sequence evidence of brain compartmentalization. Differences in abstraction/executive function of HCV/HIV coinfected patients compared to HIV monoinfected warrant further studies to determine if neuropsychiatric effects are predicated upon brain infection.

Renal function and cognitive impairment in patients with liver cirrhosis

OBJECTIVE

Cognitive impairment is a common problem in patients with liver cirrhosis. Its pathogenesis is multifactorial and ammonia is considered to play a central role. Renal function has been shown to be important for ammonia metabolism in cirrhosis. Although renal dysfunction is common in cirrhotic patients, its effect on cognitive function is largely unexplored.

MATERIAL AND METHODS

A total of 128 consecutive cirrhotic patients were prospectively evaluated for the presence of cognitive dysfunction according to the West-Haven criteria and by means of two psychometric tests. Serum creatinine, sodium and potassium as well as plasma ammonia concentrations were assessed. Glomerular filtration rate was also measured by (51)Cr- EDTA clearance in a subgroup of patients.

RESULTS

Forty-one patients (32%) were found to have cognitive dysfunction (clinical evaluation and/or psychometric tests). Sixteen patients (13%) found with serum creatinine levels above reference values had cognitive dysfunction more frequently than patients with creatinine within the normal range (69% versus 31%; p = 0.001), but did not differ in aetiology or severity of cirrhosis (p >0.1). Patients with loop diuretics versus without did not differ in creatinine values (p >0.1). Multivariate analysis showed that cognitive dysfunction was related to hospital admission at inclusion in the study, international normalized ratio and serum creatinine (p <0.05 for all), but not to potassium or sodium levels. Plasma ammonia concentration was related to serum creatinine (r = 0.26, p = 0.004) and the glomerular filtration rate (r = -0.44, p = 0.023).

CONCLUSIONS

Renal dysfunction seems to be related to cognitive impairment in patients with liver cirrhosis and might be implicated in the pathogenesis of hepatic encephalopathy.

Cognitive impairment in people diagnosed with end-stage liver disease evaluated for liver transplantation

Cognitive impairments are common in patients with end-stage liver disease (ESLD). The aim of the present study was to identify and characterize the neuropsychological deficits between groups of patients with a variety of causes of ESLD and to assess the impact of heavy alcohol use on cognitive functioning. Cognitive functioning in 300 consecutive outpatients presenting for liver transplantation evaluation was assessed using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). All patients underwent a psychiatric interview and a physical and laboratory assessment. The prevalence of neuropsychological impairment was highest among patients with liver disease secondary to alcohol. Poor performance on neuropsychological testing was correlated strongly with the severity of liver disease as measured by the model for end-stage liver disease (MELD). After controlling for the linear effects of MELD in subsequent analysis, a group difference emerged in patients with cholestatic liver disease showing less cognitive impairment when compared to all other groups. After controlling for the severity of liver disease, those patients with a history of alcohol abuse or dependence were found to perform more poorly on neuropsychological testing than those patients without such a history. Furthermore, the presence of these cognitive impairments predicted disability independent of the severity of the underlying liver disease.

Effects of hepatic function and hepatitis C virus on the nervous system assessment of advanced-stage HIV-infected individuals

OBJECTIVES

To examine the effects of liver function and hepatitis C virus (HCV) serostatus on neurological, neuropsychological, and psychiatric abnormalities in an advanced-stage HIV-infected cohort.

DESIGN

A correlational analysis of baseline data accumulated on 137 participants in the Manhattan HIV Brain Bank, a longitudinal study of HIV-infected individuals.

METHODS

Patients underwent a battery of neuropsychological tests, a semi-structured psychiatric interview, and a neurological examination. The resulting diagnostic data were correlated with biochemical indices of hepatic function and HCV serostatus.

RESULTS

Biochemical indices of liver function correlated with motor dysfunction determined by neurological evaluation, but not with neuropsychological or psychiatric disorders. Discrete neurological diagnostic entities showed no relationship with biochemical indices, with one exception: patients with cryptococcal leptomeningitis had worse liver function than those without. HCV had no relationship with any neurological disorder or symptom complex. In contrast, HCV serostatus was related to neuropsychological and psychiatric abnormalities, and indices of liver function were not. HCV-seropositive patients were more likely to have histories of opiate, cocaine or stimulant dependency, to have greater impairment in executive functioning, and to meet diagnostic criteria for AIDS dementia, compared with HCV-negative individuals of similar immunological and virological status.

CONCLUSIONS

HCV and biochemical indices of liver function associate differentially with nervous system abnormalities in this HIV-infected population. Neurological abnormalities correlate with biochemical indices of liver function, whereas neuropsychological and psychiatric dysfunction are linked to HCV infection. We postulate that multifactorial impacts of HCV and liver disease on HIV-related nervous system disorders may originate in different anatomical and cellular compartments.

Cognition in liver disease

BACKGROUND

Cognitive dysfunction has been observed in a range of liver diseases including chronic hepatitis C virus, alcoholic liver disease, primary biliary cirrhosis and Wilson's disease. Such dysfunction may range from mild cognitive changes to overt hepatic encephalopathy, and represents a significant complication of liver disease that may negatively impact the patient's quality of life, and normal activities of daily living (e.g., driving).

METHOD

This article reviews the published evidence relating to cognitive dysfunction in liver disease.

OUTCOME

Issues of definition, diagnosis, epidemiology, aetiology, treatment and outcome are discussed. Particular attention is devoted to identifying the mild cognitive changes that occur in liver diseases of different aetiology.

Executive Functioning Early in Abstinence From Alcohol

BACKGROUND

Executive dysfunction is among the cognitive impairments that may persist after abstinence in alcohol-dependent persons. The type(s) and extent of executive dysfunction early in abstinence have not been well characterized, but they may have important implications for the evolution of behavioral treatment strategies.

METHODS

To determine which aspects of executive functioning were impaired in early abstinence, we administered memory and executive function tests to veterans who successively presented for treatment at an outpatient substance abuse clinic. We then compared the neuropsychological performance of these recovering alcoholics (n = 27) with that of age-matched primary care outpatients (n = 18). We also examined group differences in self-evaluation of cognitive decline and evaluated associations between drinking history and cognitive impairment in the index group.

RESULTS

We found that the normal and alcohol-dependent groups differed on abstract reasoning, memory discrimination, and effectiveness on timed tasks. Patients in the alcohol-dependent sample were also more likely to perceive themselves as cognitively impaired. It is interesting to note that the duration of alcohol use did not relate to neuropsychological test performance, but recent quantity consumed and days of sobriety were associated with nonverbal abstract reasoning ability.

CONCLUSIONS

Executive functions are impaired early in abstinence and should, therefore, be taken into account when early behavioral treatments are being developed.

Performance of recently detoxified patients with alcoholism on a neuropsychological screening test

OBJECTIVE

Early in recovery from alcoholism, cognitive deficits may compromise patients' utilization of rehabilitative information. Cognitive impairment in a sample of newly detoxified inpatients with alcoholism was examined using the Neurobehavioral Cognitive Status Examination (NCSE).

METHODS

Consecutively admitted psychiatric inpatients (N=233) with an alcohol-related primary diagnosis (63% male, mean age 46.3) were administered the NCSE following medical stabilization. Within-samples differences between age and diagnostic groups were examined and scores were compared to normative samples.

RESULTS

Inpatients older than 50 demonstrated significant cognitive deficits for all scales except Attention. In comparison with normative samples, patients with alcoholism produced lower scores, with the most pronounced deficits among middle-aged patients. In alcohol-abusing patients with medical comorbidities, language deficits and more severe memory deficits were observed. Abuse severity or comorbid psychiatric disorder produced no differences in NCSE scores.

CONCLUSIONS

Neuropsychological screening following detoxification in patients diagnosed with an alcohol disorder reflected the effects of increased age and medical comorbidity. Our finding of frequent deficits in abstraction, comprehension, and memory suggests that cognitive-behavioral treatments for inpatients may be less effective if cognitive impairment is not considered.

Predictors of psychiatric disorders in liver transplantation candidates: logistic regression models

This study has two goals. The first goal is to assess the prevalence of psychiatric disorders in orthotopic liver transplantation (OLT) candidates by means of standardized procedures because there has been little research concerning psychiatric problems of potential OLT candidates using standardized instruments. The second goal focuses on identifying predictors of these psychiatric disorders. One hundred sixty-five elective OLT candidates were assessed by our unit. Psychiatric diagnoses were based on the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Patients also were assessed using the Hamilton Depression Rating Scale (HDRS) and the Spielberger Anxiety Index, State and Trait forms (STAI-X1 and STAI-X2). Severity of cirrhosis was assessed by applying Child-Pugh score criteria. Chi-squared and general linear model analysis of variance were used to test the univariate association between patient characteristics and both clinical psychiatric diagnoses and severity of psychiatric diseases. Variables with P less than.10 in univariate analyses were included in multiple regression models. Forty-three percent of patients presented at least one psychiatric diagnosis. Child-Pugh score and previous psychiatric diagnoses were independent significant predictors of depressive disorders. Severity of psychiatric symptoms measured by psychometric scales (HDRS, STAI-X1, and STAI-X2) was associated with Child-Pugh score in the multiple regression model. Our data suggest a high rate of psychiatric disorders, particularly adjustment disorders, in our sample of OLT candidates. Severity of liver disease emerges as the most important variable in predicting severity of psychiatric disorders in these patients.

Relationship of the model for end-stage liver disease (MELD) scale to hepatic encephalopathy, as defined by electroencephalography and neuropsychometric testing, and ascites

OBJECTIVE

It has recently been suggested that the Model for End-Stage Liver Disease (MELD) is a better and a more objective predictor of mortality in patients with end-stage liver disease. The aim of our study was to determine the relationship of the MELD score to hepatic encephalopathy (HE), as determined by electroencephalography (EEG) and clinical and neuropsychometric examination, and ascites.

METHODS

A total of 66 patients underwent EEG, a neuropsychometric screening by Mini-Mental State Examination, Trails Making Tests, Rey-Osterreith Complex Figure, and Hopkins Verbal Learning Tests, and a clinical assessment for HE. The MELD score was calculated as previously described by using serum creatinine, bilirubin, and international normalized ratio. Subclinical HE was diagnosed if clinical examination did not detect HE but neuropsychometric tests and EEG were abnormal.

RESULTS

Sixteen patients had no HE, 28 had subclinical HE, and 22 had clinical HE. Age, sex, race, and cause of liver disease were similar in all three groups. Child-Turcotte-Pugh score was significantly higher in patients with clinical HE compared with the other two groups. There was only a modest correlation (r = 0.5) between Child-Turcotte-Pugh and the MELD scores. The distribution and mean MELD scores were similar in patients with or without HE as determined by clinical or neuropsychometric examination and EEG. Approximately 90% of patients with clinical HE or abnormal EEG and neuropsychometric tests had a MELD score less than 25. Similarly, the MELD score was not affected by the severity of ascites.

CONCLUSION

The MELD score does not correlate well with severity of HE or ascites. Patients with HE and ascites might not receive liver transplantation in a timely manner if MELD scores were to be used exclusively for organ allocation.

Neurophysiological evidence of cognitive impairment in patients without hepatic encephalopathy after transjugular intrahepatic portosystemic shunts

OBJECTIVES

We aimed to test the hypothesis that subclinical cognitive brain dysfunction in cirrhotic patients would deteriorate after a transjugular intrahepatic portosystemic shunt (TIPS) in the absence of clinically detectable hepatic encephalopathy.

METHODS

Out of 49 consecutive cirrhotic patients receiving elective TIPS for recurrent variceal hemorrhage, we identified 22 patients who were not encephalopathic and had not undergone liver transplantation at 6-month follow-up and confirmed TIPS patency by Doppler ultrasound. Patients were tested before and 6 months after TIPS implantation using event-related (P300) cognitive evoked potentials, late somatosensory median nerve (N70) potentials, and standard psychometric tests (Mini-Mental State and trailmaking test A). Twenty-two age-matched healthy subjects served as controls.

RESULTS

Relative to controls, patients showed significantly impaired P300 and N70 latencies and abnormal psychometric test results at baseline. Six months after the TIPS, a further impairment of P300 latency was observed (p = 0.005), whereas no relevant changes in N70 latency and psychometric test results occurred.

CONCLUSIONS

In cirrhotic patients with portal hypertension, neurophysiological signs of cognitive brain dysfunction are detectable in the absence of hepatic encephalopathy. A further subclinical deterioration of cognitive processing was observed 6 months after the TIPS. These findings demonstrate an aggravation of subclinical hepatic encephalopathy after a TIPS.

Alcoholic liver disease (ALD): a new domain for prevention efforts

Alcoholic liver disease (ALD) is a leading cause of death; yet relatively little has been written about it in the health behavior research literature. This paper will describe ALD, what factors predict ALD including findings from analyses of the 1998 state of California and Los Angeles County hospital discharge data, and possible means of preventing this disease. It is hoped that new interest among health behavior researchers and practitioners will be stimulated.

Subclinical hepatic encephalopathy predicts the development of overt hepatic encephalopathy

OBJECTIVES

In patients with compensated liver cirrhosis the clinical repercussions of detecting subclinical hepatic encephalopathy (SHE) are unclear. We present a long-term follow-up study in cirrhotic patients to examine the relationship between SHE and subsequent episodes of overt hepatic encephalopathy.

METHODS

A total of 63 cirrhotic patients were studied by Number Connection Test and auditory evoked potentials. We determined glutamine, ammonia, zinc, glutamate, urea, and ratio of branched chain amino acids to aromatic amino acids, and Child-Pugh classification.

RESULTS

Of 63 patients, 34 (53%) exhibited SHE. Nineteen out of 63 (30%) developed overt hepatic encephalopathy during follow-up. Hepatic encephalopathy in follow-up was related to alcoholic etiology, ammonia, glutamine, zinc, ratio of branched chain amino acids to aromatic amino acids, liver function, presence of esophageal varices, and detection of SHE (84% of patients who exhibited hepatic encephalopathy in follow-up showed SHE). In Cox-regression, glutamine levels, SHE, esophageal varices, and Child-Pugh class were the independent variables related to hepatic encephalopathy in follow-up.

CONCLUSIONS

SHE (defined on the basis of number connection test or auditory evoked potentials alteration) could predict a subsequent episode of overt hepatic encephalopathy. Lower glutamine levels, presence of esophageal varices, and liver dysfunction were also related to the development of overt hepatic encephalopathy.