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Testino G, Bottaro LC, Andorno E, Bandini F, Balbinot P, Beltramini S, Bottino S, Caltabellotta M, Caputo F, Caviglia E, Curone P, DI Biagio A, Gagliano C, Gandolfo N, Pestarino L, Rollero A, Romairone E, Sampietro L, Torre E, Zuccarelli S, Pellicano R. Hepatic encephalophathy: management and diagnostic therapeutic assistance path of Ligurian Local Health Company 3 (ASL3). Minerva Med 2023; 114:698-718. [PMID: 36952221 DOI: 10.23736/s0026-4806.22.08408-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Hepatic encephalophathy (HE) is a neuropsychiatric syndrome with a prevalence in the cirrhotic population ranging from 20 to 80%. HE is a cause of inappropriate hospitalization, caregiver burdening and increased social costs. There is need to create dedicated care pathways to better manage patients and support family caregivers. The data used for the preparation of this diagnostic therapeutic assistance path (DTAP) are based on a detailed analysis of the scientific literature published before June 30, 2022 (PubMed, Web of Science, Scopus, Google Scholar). Furthermore, in the process of developing this work, we consulted in particular the guidelines/ position papers of International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN), Italian Association for the Study of the Liver (AISF), European Association for the Study of the Liver (EASL), American Association for the Study of Liver Diseases (AASLD), Italian Society on Alcohol (Società Italiana di Alcologia [SIA]) and other relevant papers. DTAP was created based on the most recent recommendations of the international scientific literature. The present DTAP highlight the need for a multidisciplinary activity integrated with territorial medicine in close connection with caregivers. This guarantees improved therapeutic adherence, hospital readmission reduction, improved quality of life for patients and caregivers and a significant reduction in costs.
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Affiliation(s)
- Gianni Testino
- Addiction and Hepatology Unit/Alcohological Regional Centre and Study Centre "Self Help, Community Program and Caregiver Training" ASL3, Genoa, Italy -
| | | | - Enzo Andorno
- Liver Transplantation Unit, San Martino Polyclinic Hospital, Genoa, Italy
| | | | - Patrizia Balbinot
- Addiction and Hepatology Unit/Alcohological Regional Centre and Study Centre "Self Help, Community Program and Caregiver Training" ASL3, Genoa, Italy
| | | | | | | | - Fabio Caputo
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Center for the Study and Treatment of Chronic Inflammatory Intestinal Diseases (IBD) and Gastroenterological Manifestations of Rare Diseases, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Center for the Study and Treatment of Alcohol-Related Diseases, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Internal Medicine, Santissima Annunziata Hospital, University of Ferrara, Ferrara, Italy
| | | | | | - Antonio DI Biagio
- Department of Health Sciences, Infectious Diseases Clinic, IRCCS San Martino Polyclinic Hospital, University of Genoa, Genoa, Italy
| | | | | | | | | | | | | | - Enrico Torre
- Unit of Endocrinology, Metabolic Diseases and Diabetology, ASL3 Liguria, Genoa, Italy
| | | | - Rinaldo Pellicano
- Unit of Gastroenterology, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
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Vutien P, Li R, Karkar R, Munson SA, Fogarty J, Walter K, Yacoub M, Ioannou GN. Evaluating a Novel, Portable, Self-Administrable Device ("Beacon") That Measures Critical Flicker Frequency as a Test for Hepatic Encephalopathy. Am J Gastroenterol 2023; 118:1096-1100. [PMID: 36746413 PMCID: PMC10238616 DOI: 10.14309/ajg.0000000000002211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/26/2023] [Indexed: 02/08/2023]
Abstract
INTRODUCTION We compared critical flicker frequency (CFF) thresholds obtained using a novel portable device "Beacon" with thresholds from the commercially available Lafayette Flicker Fusion System (Lafayette-FFS) in patients with cirrhosis. METHODS One hundred fifty-three participants with chronic liver disease underwent CFF testing using Beacon and Lafayette-FFS with a method-of-limits and/or forced-choice protocol. RESULTS Beacon demonstrated excellent test-retest reliability (intraclass correlation 0.91-0.97) and good correlation with the Lafayette-FFS values (intraclass correlation 0.77-0.84). Forced-choice CFF were on average 4.1 Hz higher than method-of-limits descending CFFs. DISCUSSION Beacon can be self-administered by patients with chronic liver disease and cirrhosis to measure CFF, a validated screening test for minimal hepatic encephalopathy.
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Affiliation(s)
- Philip Vutien
- University of Washington, Division of Gastroenterology and Hepatology, Seattle, WA, USA
- Department of Medicine Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| | - Richard Li
- Paul G. Allen School of Computer Science & Engineering, University of Washington, Seattle, WA, USA
| | - Ravi Karkar
- Paul G. Allen School of Computer Science & Engineering, University of Washington, Seattle, WA, USA
- Manning College of Information and Computer Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Sean A. Munson
- Human Centered Design & Engineering, University of Washington, Seattle, WA, USA
| | - James Fogarty
- Paul G. Allen School of Computer Science & Engineering, University of Washington, Seattle, WA, USA
| | - Kara Walter
- University of Washington, Division of Gastroenterology and Hepatology, Seattle, WA, USA
| | - Michael Yacoub
- University of Washington, Division of Gastroenterology and Hepatology, Seattle, WA, USA
| | - George N. Ioannou
- University of Washington, Division of Gastroenterology and Hepatology, Seattle, WA, USA
- Department of Medicine Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
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Siddiqui OM, Baskaran AB, Lin KA, Najam N, Shah T, Beestrum ML, Thuluvath A, Bonakdarpour B, Kim M, Dietch Z, Wolf M, Ladner DP. Cognitive Impairment in Liver Transplant Recipients With a History of Cirrhosis: A Systematic Review. Transplant Direct 2023; 9:e1479. [PMID: 37096151 PMCID: PMC10121435 DOI: 10.1097/txd.0000000000001479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/16/2023] [Indexed: 04/26/2023] Open
Abstract
Cognitive impairment is common among patients with cirrhosis and may persist post-transplantation. This systematic review seeks to (1) describe the prevalence of cognitive impairment in liver transplant (LT) recipients with a history of cirrhosis, (2) describe risk factors for this population, and (3) describe associations between post-transplant cognitive impairment and quality outcome measures. Methods Studies in PubMed, Embase, Scopus, PsychINFO, and the Cochrane Database of Controlled Trials were included through May 2022. Inclusion criteria included (1) population - LT recipient, age ≥18 y, (2) exposure - history of cirrhosis before transplant, and (3) outcome - cognitive impairment after transplant (per validated cognitive testing). Exclusion criteria included (1) wrong study type, (2) abstract-only publication, (3) full-text unavailable, (4) wrong population, (5) wrong exposure, and (6) wrong outcome. The risk of bias was assessed using the Newcastle-Ottawa Scale and the Appraisal tool for Cross-Sectional Studies. The Grading of Recommendations, Assessment, Development, and Evaluations system was used to assess evidence certainty. Data from individual tests were categorized into six cognitive domains: attention, executive function, working memory, long-term memory, visuospatial, and language. Results Twenty-four studies were included covering 847 patients. Follow-up ranged from 1 mo to 1.8 y after LT. Studies had a median of 30 (interquartile range 21.5-50.5) patients. The prevalence of cognitive impairment after LT ranged from 0% to 36%. Forty-three unique cognitive tests were used, the most common being the Psychometric Hepatic Encephalopathy Score. The most frequently assessed cognitive domains were attention (10 studies) and executive function (10 studies). Conclusions The prevalence of cognitive impairment after LT varied across studies depending on cognitive tests utilized and follow-up duration. Attention and executive function were most impacted. Generalizability is limited due to small sample size and heterogeneous methodology. Further studies are needed to examine differences in the prevalence of post-LT cognitive impairment by etiology, risk factors, and ideal cognitive measures.
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Affiliation(s)
- Osama M. Siddiqui
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Archit B. Baskaran
- Department of Neurology, University of Chicago Medical Center, University of Chicago, Chicago, IL
| | - Katherine A. Lin
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Naela Najam
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Tahir Shah
- Department of Neuroscience, University of Cincinnati, Cincinnati, OH
| | - Molly L. Beestrum
- Galter Health Sciences Library, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Avesh Thuluvath
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern Medicine, Chicago, IL
| | - Borna Bonakdarpour
- Division of Behavioral Neurology, Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Minjee Kim
- Division of Neurocritical Care, Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Zachary Dietch
- Division of Transplant, Department of Surgery, Northwestern Medicine, Chicago, IL
| | - Michael Wolf
- Division of General Internal Medicine & Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Daniela P. Ladner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Transplant, Department of Surgery, Northwestern Medicine, Chicago, IL
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Thabut D, Bouzbib C, Meunier L, Haas M, Weiss N, Louvet A, Imbert-Bismut F, Mochel F, Nadjar Y, Santiago A, Thevenot T, Duhalde V, Oberti F, Francoz C, Coilly A, Hilleret MN, Lebray P, Liou-Schischmanoff A, Barbier L, Duvoux C, Pageaux GP, Bismuth M, Galanaud D, Broucker TD, Cadranel JF, Leroy V, Di Martino V, Larrey D, Camus C, Scatton O, De Ledinghen V, Mallat A, Rudler M, Bureau C. Diagnosis and management of hepatic encephalopathy: The French recommendations. Liver Int 2023; 43:750-762. [PMID: 36625084 DOI: 10.1111/liv.15510] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/27/2022] [Accepted: 12/31/2022] [Indexed: 01/11/2023]
Abstract
Hepatic encephalopathy (HE) is a frequent and severe complication of liver disease with poor patient outcomes. However, it is a poorly understood complication, with no consensus for diagnosis. Therefore, HE is often underdiagnosed. Differential diagnosis may be cumbersome because of non-specific symptoms, such as confusion, cognitive disorders, the aetiological factors of cirrhosis and comorbidities, which are often observed in cirrhotic patients. Therefore, an overt or covert form of HE should be systematically investigated. Advice is provided to drive patient work-up. Effective treatments are available to prevent or treat HE bouts, but the issue of single or combination therapy has not been resolved. Transjugular intrahepatic portosystemic shunt (TIPS) placement largely improved the prognosis of cirrhotic patients, but HE occurrence of HE is often a fear, even when post-TIPS HE can be avoided by a careful selection of patients and preventive treatment. HE is an indication of liver transplantation. However, its reversibility post-transplantation and the consequences of transplantation in patients with other causes of neurological disorders remain controversial, which supports the performance of an extensive work-up in expert centres for this subset of patients. The present guidelines assist clinicians in the diagnosis of the overt or covert form of HE to implement curative and preventive treatments and clarify which patients require referral to expert centres for consideration for liver transplantation. These guidelines are very clinically oriented and address different frequent clinical issues to help physicians make bedside decisions.
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Affiliation(s)
- Dominique Thabut
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Charlotte Bouzbib
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Lucy Meunier
- Service d'hépato-gastroentérologie A et Transplantation, Hôpital Saint-Eloi, CHU de Montpellier, Montpellier, France
| | - Manon Haas
- APHP-Paris Saclay, Centre Hépato-Biliaire, Hôpital Paul Brousse, Université Paris-saclay, Villejuif, France
| | - Nicolas Weiss
- APHP-Sorbonne Université, Service de réanimation neurologique, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Alexandre Louvet
- Services des maladies de l'appareil digestif, CHRU de Lille, Lille, France
| | - Francois Imbert-Bismut
- APHP-Sorbonne Université, Service de biochimie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Fanny Mochel
- APHP-Sorbonne Université, Service de génétique, Hôpital Pitié-Salpêtrière, Paris, France
| | - Yann Nadjar
- APHP-Sorbonne Université, Service de neurologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Antoine Santiago
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Thierry Thevenot
- Service d'hépatologie, Hôpital Jean Minjoz, CHU de Besançon, Besançon, France
| | - Véronique Duhalde
- Service de pharmacie, Hôpital Rangueil, CHU de Toulouse, Toulouse, France
| | - Frédéric Oberti
- Laboratoire HIFIH, UPRES-EA2170, Faculté de Médecine, Service d'hépato-gastroentérologie, CHU ANGERS, Angers, France
| | - Claire Francoz
- APHP-Hôpital Beaujon, Service d'hépatologie, Clichy, France
| | - Audrey Coilly
- APHP-Paris Saclay, Centre Hépato-Biliaire, Hôpital Paul Brousse, Université Paris-saclay, Villejuif, France
| | | | - Pascal Lebray
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | | | - Louise Barbier
- Service de chirurgie hépatique et transplantation, CHU de Tours, Tours, France
| | | | - Georges-Philippe Pageaux
- Service d'hépato-gastroentérologie A et Transplantation, Hôpital Saint-Eloi, CHU de Montpellier, Montpellier, France
| | - Michael Bismuth
- Service d'hépato-gastroentérologie B, Hôpital Saint Eloi, CHU de Montpellier, Montpellier, France
| | - Damien Galanaud
- APHP-Sorbonne Université, Service de neuro-radiologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Thomas De Broucker
- Service de Neurologie Hôpital Pierre Delafontaine, Centre Hospitalier de Saint-Denis, Saint-Denis, France
| | - Jean-François Cadranel
- Service d'hépato-gastroentérologie de nutrition et d'Alcoologie-GHPSO site de Creil, Creil, France
| | - Vincent Leroy
- APHP Hôpital Henri-Mondor, Service d'hépatologie, Créteil, France
| | - Vincent Di Martino
- Service d'hépatologie, Hôpital Jean Minjoz, CHU de Besançon, Besançon, France
| | - Dominique Larrey
- Service d'hépato-gastroentérologie A et Transplantation, Hôpital Saint-Eloi, CHU de Montpellier, Montpellier, France
| | - Christophe Camus
- Service de réanimation Médicale, Hôpital Pontchaillou, CHU de Rennes, Rennes, France
| | - Olivier Scatton
- APHP-Sorbonne Université, Service de chirurgie et transplantation hépatique, Hôpital Pitié-Salpêtrière, Paris, France
| | - Victor De Ledinghen
- Service d'hépato-gastroentérologie, Hôpital du Haut-Lévêque, CHU de Bordeaux, Bordeaux, France
| | - Ariane Mallat
- APHP Hôpital Henri-Mondor, Service d'hépatologie, Créteil, France
| | - Marika Rudler
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Christophe Bureau
- Service d'hépatologie, Hôpital Rangueil, CHU de Toulouse, Toulouse, France
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Cunha-Silva M, Neto FLP, de Araújo PS, Pazinato LV, Greca RD, Secundo TML, Imbrizi MR, Monici LT, Sevá-Pereira T, Mazo DF. EncephalApp Stroop Test validation for the screening of minimal hepatic encephalopathy in Brazil. Ann Hepatol 2022; 27:100543. [PMID: 34571266 DOI: 10.1016/j.aohep.2021.100543] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/24/2021] [Accepted: 05/04/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND OBJECTIVES The EncephalApp Stroop Test was developed to more easily diagnose minimal hepatic encephalopathy (MHE). A cut-off of >274.9sec (ONtime+OFFtime) reached a 78% sensitivity and 90% specificity in the validation study, but it has been poorly studied in Brazil. We aim to analyze the usefulness of this diagnostic method and to describe a cut-off value to screen MHE in Brazil. METHODS In this cross-sectional and single-center study, three positive psychometric tests defined the diagnosis of MHE as the gold standard. We evaluated gender, age, education, familiarity with smartphones, etiology of cirrhosis, Child-Pugh/MELD scores, and previous hepatic encephalopathy (HE). Healthy controls and patients without HE were compared for the task validation. The Chi-square and Mann-Whitney tests, logistic regression analysis, and ROC curves were used for statistical evaluation. RESULTS We included 132 patients with cirrhosis (61% male) and 42 controls (62% male) around 51y. Sixty-three were diagnosed with MHE on psychometric tests and 23 had clinical HE. Viral hepatitis (38%) was the major etiology of cirrhosis. The median MELD was 10 and Child-Pugh A was more frequent (70%). There was no significant difference in test results between controls and patients without HE. There was also no influence of gender, age, education, and familiarity with smartphones in the test results. Child-Pugh A was associated with MHE (p=0.0106). A cut-off of >269.8sec (ONtime+OFFtime) had an 87% sensitivity and 77% specificity to detect MHE (p=0.002). CONCLUSION This is a valid and reliable tool for screening MHE. However, optimal cut-off values need to be validated locally.
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Affiliation(s)
- Marlone Cunha-Silva
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil.
| | - Fernando L Ponte Neto
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | - Priscila S de Araújo
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | - Lucas V Pazinato
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | - Raquel D Greca
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | - Tirzah M L Secundo
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | - Marcello R Imbrizi
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | - Leonardo T Monici
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | - Tiago Sevá-Pereira
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | - Daniel F Mazo
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil; Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo School of Medicine (FMUSP), Sao Paulo, Brazil
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Hansen MKG, Kjærgaard K, Eriksen LL, Grønkjær LL, Mikkelsen ACD, Sandahl TD, Vilstrup H, Thomsen KL, Lauridsen MME. Psychometric methods for diagnosing and monitoring minimal hepatic encephalopathy -current validation level and practical use. Metab Brain Dis 2022; 37:589-605. [PMID: 35102491 DOI: 10.1007/s11011-022-00913-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/14/2022] [Indexed: 02/07/2023]
Abstract
Hepatic encephalopathy (HE) is cerebral dysfunction caused by liver failure and inflicts 30-40% of patients with liver cirrhosis during their disease course. Clinically manifest HE is often preceded by minimal HE (MHE) - a clinically undetectable cognitive disturbance closely associated with loss of quality of life. Accordingly, detecting and treating MHE improve the patients' daily functioning and prevent HE-related hospital admissions. The scope of this review article is to create an overview of the validation level and usage of psychometric tests used to detect MHE: Portosystemic hepatic encephalopathy test, continuous reaction time test, Stroop EncephalApp, animal naming test, critical flicker frequency test, and inhibitory control test. Our work is aimed at the clinician or scientist who is about to decide on which psychometric test would fit best in their clinic, cohort, or study. First, we outline psychometric test validation obstacles and requirements. Then, we systematically approach the literature on each test and select well-conducted studies to answer the following questions:• Which percentage of patients with cirrhosis does the test deem as having MHE?• Is the test able to predict clinically manifest HE?• Is there a well-known test-retest variation and inter-observer variation?• Is the test able to detect a treatment response?• Is the test result affected by age, educational level, gender, or comorbidities?
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Affiliation(s)
- Mads Kingo Guldberg Hansen
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark.
| | - Kristoffer Kjærgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Lotte Lindgreen Eriksen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Lea Ladegaard Grønkjær
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark
| | - Anne Catrine Daugaard Mikkelsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Thomas Damgaard Sandahl
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Karen Louise Thomsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Mette Munk Enok Lauridsen
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark
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Acharya C, Bajaj JS. Hepatic Encephalopathy and Liver Transplantation: The Past, Present, and Future Toward Equitable Access. Liver Transpl 2021; 27:1830-1843. [PMID: 34018659 DOI: 10.1002/lt.26099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 04/22/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023]
Abstract
Cirrhosis is a debilitating chronic disease with high morbidity and mortality, with the only real cure being liver transplantation (LT). Currently, we allocate organs for transplantation based on the Model for End-Stage Liver Disease-Sodium (MELD-Na) score that does not account for hepatic encephalopathy (HE). HE affects patients, families, and the health care system because of high rates of recurrence and major readmission burden. Moreover, HE casts a long shadow even after LT. Accounting for HE and incorporating it into the current allocation system has many proponents, but the framework to do this is currently lacking because of differences in consensus or in operationalization parameters. We review the latest evidence of the burden of HE, management of HE before and after LT, and evaluate pros and cons of several methods of diagnosing HE objectively to ensure early and equitable access to LT in this underserved population.
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Affiliation(s)
- Chathur Acharya
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA
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López-Franco Ó, Morin JP, Cortés-Sol A, Molina-Jiménez T, Del Moral DI, Flores-Muñoz M, Roldán-Roldán G, Juárez-Portilla C, Zepeda RC. Cognitive Impairment After Resolution of Hepatic Encephalopathy: A Systematic Review and Meta-Analysis. Front Neurosci 2021; 15:579263. [PMID: 33790729 PMCID: PMC8006450 DOI: 10.3389/fnins.2021.579263] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 01/14/2021] [Indexed: 12/26/2022] Open
Abstract
Hepatic encephalopathy (HE) is one of the most disabling metabolic diseases. It consists of a complication of liver disease through the action of neurotoxins, such as excessive production of ammonia from liver, resulting in impaired brain function. Its prevalence and incidence are not well known, although it has been established that up to 40% of cirrhotic patients may develop HE. Patients with HE episodes display a wide range of neurological disturbances, from subclinical alterations to coma. Recent evidence suggests that the resolution of hepatic encephalopathy does not fully restore cognitive functioning in cirrhotic patients. Therefore, the aim of this review was to evaluate the evidence supporting the presence of lingering cognitive deficits in patients with a history of HE compared to patients without HE history and how liver transplant affects such outcome in these patients. We performed two distinct meta-analysis of continuous outcomes. In both cases the results were pooled using random-effects models. Our results indicate that cirrhotic patients with a history of HE show clear cognitive deficits compared to control cirrhotic patients (Std. Mean Difference (in SDs) = −0.72 [CI 95%: −0.94, −0.50]) and that these differences are not fully restored after liver transplant (Std. Mean Difference (in SDs) = −0.48 [CI 95%: −0.77, −0.19]).
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Affiliation(s)
- Óscar López-Franco
- Laboratorio de Medicina Traslacional, Instituto de Ciencias de la Salud, Universidad Veracruzana, Xalapa, Mexico
| | - Jean-Pascal Morin
- Laboratorio de Neurobiología de la Conducta, Departamento de Fisiología, Facultad de Medicina, Universidad Nacional Autónoma de Mexico, Ciudad de Mexico, Mexico
| | | | - Tania Molina-Jiménez
- Instituto Interdisciplinario de Investigaciones de la Universidad de Xalapa, Xalapa, Mexico
| | - Diana I Del Moral
- Programa de Doctorado en Ciencias Biomédicas, Universidad Veracruzana, Xalapa, Mexico
| | - Mónica Flores-Muñoz
- Laboratorio de Medicina Traslacional, Instituto de Ciencias de la Salud, Universidad Veracruzana, Xalapa, Mexico
| | - Gabriel Roldán-Roldán
- Laboratorio de Neurobiología de la Conducta, Departamento de Fisiología, Facultad de Medicina, Universidad Nacional Autónoma de Mexico, Ciudad de Mexico, Mexico
| | - Claudia Juárez-Portilla
- Laboratorio de Biomedicina Integral y Salud, Centro de Investigaciones Biomédicas, Universidad Veracruzana, Xalapa, Mexico
| | - Rossana C Zepeda
- Laboratorio de Biomedicina Integral y Salud, Centro de Investigaciones Biomédicas, Universidad Veracruzana, Xalapa, Mexico
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9
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Bosoi CR, Vandal M, Tournissac M, Leclerc M, Fanet H, Mitchell PL, Verreault M, Trottier J, Virgili J, Tremblay C, Lippman HR, Bajaj JS, Barbier O, Marette A, Calon F. High-Fat Diet Modulates Hepatic Amyloid β and Cerebrosterol Metabolism in the Triple Transgenic Mouse Model of Alzheimer's Disease. Hepatol Commun 2021; 5:446-460. [PMID: 33681678 PMCID: PMC7917280 DOI: 10.1002/hep4.1609] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/09/2020] [Accepted: 08/20/2020] [Indexed: 12/19/2022] Open
Abstract
Obesity and diabetes are strongly associated not only with fatty liver but also cognitive dysfunction. Moreover, their presence, particularly in midlife, is recognized as a risk factor for Alzheimer's disease (AD). AD, the most common cause of dementia, is increasingly considered as a metabolic disease, although underlying pathogenic mechanisms remain unclear. The liver plays a major role in maintaining glucose and lipid homeostasis, as well as in clearing the AD neuropathogenic factor amyloid-β (Aβ) and in metabolizing cerebrosterol, a cerebral-derived oxysterol proposed as an AD biomarker. We hypothesized that liver impairment induced by obesity contributes to AD pathogenesis. We show that the AD triple transgenic mouse model (3xTg-AD) fed a chow diet presents a hepatic phenotype similar to nontransgenic controls (NTg) at 15 months of age. A high-fat diet (HFD), started at the age of 6 months and continued for 9 months, until sacrifice, induced hepatic steatosis in NTg, but not in 3xTg-AD mice, whereas HFD did not induce changes in hepatic fatty acid oxidation, de novo lipogenesis, and gluconeogenesis. HFD-induced obesity was associated with a reduction of insulin-degrading enzyme, one of the main hepatic enzymes responsible for Aβ clearance. The hepatic rate of cerebrosterol glucuronidation was lower in obese 3xTg-AD than in nonobese controls (P < 0.05) and higher compared with obese NTg (P < 0.05), although circulating levels remained unchanged. Conclusion: Modulation of hepatic lipids, Aβ, and cerebrosterol metabolism in obese 3xTg-AD mice differs from control mice. This study sheds light on the liver-brain axis, showing that the chronic presence of NAFLD and changes in liver function affect peripheral AD features and should be considered during development of biomarkers or AD therapeutic targets.
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Affiliation(s)
- Cristina R Bosoi
- Centre De Recherche De L'institut De Cardiologie Et Pneumologie De QuébecQuébecCanada.,Faculté De MédecineUniversité LavalQuébecCanada.,Axe NeurosciencesCentre De Recherche du CHU de Québec-Université LavalQuébecCanada
| | - Milène Vandal
- Axe NeurosciencesCentre De Recherche du CHU de Québec-Université LavalQuébecCanada.,Faculté De PharmacieUniversité LavalQuébecCanada
| | - Marine Tournissac
- Axe NeurosciencesCentre De Recherche du CHU de Québec-Université LavalQuébecCanada.,Faculté De PharmacieUniversité LavalQuébecCanada.,OptiNutriBrain International Associated LaboratoryQuébecCanada
| | - Manon Leclerc
- Axe NeurosciencesCentre De Recherche du CHU de Québec-Université LavalQuébecCanada.,Faculté De PharmacieUniversité LavalQuébecCanada
| | - Hortense Fanet
- Axe NeurosciencesCentre De Recherche du CHU de Québec-Université LavalQuébecCanada.,Faculté De PharmacieUniversité LavalQuébecCanada.,OptiNutriBrain International Associated LaboratoryQuébecCanada
| | - Patricia L Mitchell
- Centre De Recherche De L'institut De Cardiologie Et Pneumologie De QuébecQuébecCanada
| | - Mélanie Verreault
- Laboratoire de Pharmacologie MoléculaireAxe Endocrinologie et NéphrologieCentre de Recherche du CHU de Québec (Pavillon CHUL)QuébecCanada
| | - Jocelyn Trottier
- Laboratoire de Pharmacologie MoléculaireAxe Endocrinologie et NéphrologieCentre de Recherche du CHU de Québec (Pavillon CHUL)QuébecCanada
| | - Jessica Virgili
- Axe NeurosciencesCentre De Recherche du CHU de Québec-Université LavalQuébecCanada.,Faculté De PharmacieUniversité LavalQuébecCanada
| | - Cynthia Tremblay
- Axe NeurosciencesCentre De Recherche du CHU de Québec-Université LavalQuébecCanada
| | - H Robert Lippman
- Central Virginia VA Health Care SystemRichmondVA.,Virginia Commonwealth UniversityRichmondVA
| | - Jasmohan S Bajaj
- Central Virginia VA Health Care SystemRichmondVA.,Virginia Commonwealth UniversityRichmondVA
| | - Olivier Barbier
- Faculté De PharmacieUniversité LavalQuébecCanada.,Laboratoire de Pharmacologie MoléculaireAxe Endocrinologie et NéphrologieCentre de Recherche du CHU de Québec (Pavillon CHUL)QuébecCanada
| | - André Marette
- Centre De Recherche De L'institut De Cardiologie Et Pneumologie De QuébecQuébecCanada.,Faculté De MédecineUniversité LavalQuébecCanada
| | - Frédéric Calon
- Axe NeurosciencesCentre De Recherche du CHU de Québec-Université LavalQuébecCanada.,Faculté De PharmacieUniversité LavalQuébecCanada.,OptiNutriBrain International Associated LaboratoryQuébecCanada
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10
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Machado JÚnior PAB, Ziliotto RD, Ferreira APVN, Buson TM, Couto CMD, Pissaia Junior A. USE OF THE STROOP ENCEPHALAPP FOR COVERT HEPATIC ENCEPHALOPATHY SCREENING IN CIRRHOTIC PATIENTS IN SOUTHERN BRAZIL. ARQUIVOS DE GASTROENTEROLOGIA 2020; 57:399-403. [PMID: 33237215 DOI: 10.1590/s0004-2803.202000000-73] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 07/29/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Covert hepatic encephalopathy (CHE) is difficult to detect due to the lack of easily applicable screening tools. The Stroop EncephalApp is a smartphone application already validated for CHE screening. However, its applicability to the Brazilian population is not known. OBJECTIVE To estimate the prevalence of CHE and evaluate the use of Stroop EncephalApp in a cirrhotic population in Brazil. METHODS In this cross-sectional study, we evaluated 99 patients previously diagnosed with liver cirrhosis in a Private Hospital in Curitiba/PR. Patients were initially submitted to the mini mental state examination (MMSE) to exclude individuals with dementia. After, the Psychometric Hepatic Encephalopathy Score (PHES) test was performed and lastly, the Stroop EncephalApp test. Results were adjusted for age, sex and education levels to evaluate the accuracy of the app on detecting the disease, comparing its results with the gold standard method (PHES). Patients with one or more of the following were excluded: dementia, inadequate MMSE score, illiteracy, color blindness, history of drugs/alcohol abuse within the past 3 months and previous or actual episodes of encephalopathy. The statistical analysis was performed by SPSS 2.0 and the significance adopted by 5%. RESULTS We included 82 individuals in the final analysis. Among these patients, 29 were diagnosed with CHE by the PHES test (35.36% prevalence) and 28 of those obtained equal diagnosis by the Stroop EncephalApp (96.6% sensitivity). A total of 53 patients obtained negative results for CHE by PHES, while the Stroop test classified 27 of them as having the disease. In the multivariate analysis, high levels of education were associated with better performance during the tests. No significant relationship was observed between age and sex with the probability of diagnosing CHE through the PHES test.
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Affiliation(s)
| | - Rafaela Deneka Ziliotto
- Pontifícia Universidade Católica do Paraná (PUCPR), Escola de Medicina, Curitiba, PR, Brasil
| | | | - Thiago Mesquita Buson
- Pontifícia Universidade Católica do Paraná (PUCPR), Escola de Medicina, Curitiba, PR, Brasil
| | | | - Alcindo Pissaia Junior
- Pontifícia Universidade Católica do Paraná (PUCPR), Escola de Medicina, Curitiba, PR, Brasil.,Hospital Nossa Senhora das Graças (HNSG), Serviço de Hepatologia, Curitiba, PR, Brasil
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11
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Bloom PP, Miller SJ, Nayak RK, Hussain MS, Arvind A, Bay C, Chung RT. Cognitive Tests and Stool Frequency at Hospital Discharge Do Not Predict Outcomes in Hepatic Encephalopathy. South Med J 2020; 113:578-584. [PMID: 33140112 DOI: 10.14423/smj.0000000000001172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Patricia P Bloom
- From the Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, and the Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts
| | - Samuel J Miller
- From the Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, and the Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rahul K Nayak
- From the Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, and the Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts
| | - Muhammad Sarib Hussain
- From the Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, and the Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ashwini Arvind
- From the Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, and the Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts
| | - Camden Bay
- From the Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, and the Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts
| | - Raymond T Chung
- From the Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, and the Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts
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12
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Ko D, Bratzke LC. Cognitive Function in Liver Transplant Recipients Who Survived More Than 6 Months. Prog Transplant 2020; 30:335-341. [DOI: 10.1177/1526924820958144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Introduction: Current research in the areas of liver transplant and cognitive function has primarily examined cognitive changes from pre- to 1-year posttransplant, resulting in an insufficient understanding of cognitive trajectory beyond early periods of transplant and its impact on self-management. This study aimed (1) to describe global and domain-specific cognitive function in liver transplant recipients who survived more than 6 months after transplant and (2) to describe patient and clinical characteristics of recipients with impaired global and/or domain-specific cognitive function. Further, this study explored the potential relationships between cognitive function and self-management by examining differences in cognitive function by levels of self-management. Design: This secondary data analysis included 107 adult liver transplant recipients, who had a functioning transplant for at least 6 months. Data of cognitive function, demographic and clinical characteristics, and self-management were extracted for this study. T tests, Mann-Whitney tests, and Kruskal-Wallis tests were used to examine differences in cognitive function by variables. Results: More than half of the recipients had global cognitive impairment. Significant differences were found in global and domain-specific cognitive function. Older, male, married, or deceased donor recipients had lower cognitive test scores than younger, female, single, or living donor recipients. There were no significant differences in global and domain-specific cognitive function by time since transplant and levels of self-management. Discussion: Future longitudinal studies should examine the long-term trajectory of cognitive function posttransplant. Other factors such as caregivers’ participation in self-management should be accounted for in future studies when examining the relationship between cognitive function and self-management.
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Affiliation(s)
- Dami Ko
- School of Nursing, Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA
| | - Lisa C. Bratzke
- School of Nursing, University of Wisconsin-Madison, Madison, WI, USA
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13
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Affiliation(s)
- Chathur Acharya
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
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14
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YILDIZ DENİZ G. SIÇANLARDA KARBON TERAKLORÜR İLE UYARILMIŞ BEYİN HASARINDA Morus nigra’ NIN KORUYUCU MEKANİZMASI. MEHMET AKIF ERSOY ÜNIVERSITESI VETERINER FAKÜLTESI DERGISI 2017. [DOI: 10.24880/maeuvfd.341661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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