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Gilbert MC, Setayesh T, Wan YJY. The contributions of bacteria metabolites to the development of hepatic encephalopathy. LIVER RESEARCH 2023; 7:296-303. [PMID: 38221945 PMCID: PMC10786625 DOI: 10.1016/j.livres.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Over 20% of mortality during acute liver failure is associated with the development of hepatic encephalopathy (HE). Thus, HE is a complication of acute liver failure with a broad spectrum of neuropsychiatric abnormalities ranging from subclinical alterations to coma. HE is caused by the diversion of portal blood into systemic circulation through portosystemic collateral vessels. Thus, the brain is exposed to intestinal-derived toxic substances. Moreover, the strategies to prevent advancement and improve the prognosis of such a liver-brain disease rely on intestinal microbial modulation. This is supported by the findings that antibiotics such as rifaximin and laxative lactulose can alleviate hepatic cirrhosis and/or prevent HE. Together, the significance of the gut-liver-brain axis in human health warrants attention. This review paper focuses on the roles of bacteria metabolites, mainly ammonia and bile acids (BAs) as well as BA receptors in HE. The literature search conducted for this review included searches for phrases such as BA receptors, BAs, ammonia, farnesoid X receptor (FXR), G protein-coupled bile acid receptor 1 (GPBAR1 or TGR5), sphingosine-1-phosphate receptor 2 (S1PR2), and cirrhosis in conjunction with the phrase hepatic encephalopathy and portosystemic encephalopathy. PubMed, as well as Google Scholar, was the search engines used to find relevant publications.
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Affiliation(s)
- Miranda Claire Gilbert
- Department of Pathology and Laboratory Medicine, University of California, Davis, Sacramento, CA, USA
| | - Tahereh Setayesh
- Department of Pathology and Laboratory Medicine, University of California, Davis, Sacramento, CA, USA
| | - Yu-Jui Yvonne Wan
- Department of Pathology and Laboratory Medicine, University of California, Davis, Sacramento, CA, USA
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Widjaja F, Rietjens IMCM. From-Toilet-to-Freezer: A Review on Requirements for an Automatic Protocol to Collect and Store Human Fecal Samples for Research Purposes. Biomedicines 2023; 11:2658. [PMID: 37893032 PMCID: PMC10603957 DOI: 10.3390/biomedicines11102658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 09/22/2023] [Accepted: 09/24/2023] [Indexed: 10/29/2023] Open
Abstract
The composition, viability and metabolic functionality of intestinal microbiota play an important role in human health and disease. Studies on intestinal microbiota are often based on fecal samples, because these can be sampled in a non-invasive way, although procedures for sampling, processing and storage vary. This review presents factors to consider when developing an automated protocol for sampling, processing and storing fecal samples: donor inclusion criteria, urine-feces separation in smart toilets, homogenization, aliquoting, usage or type of buffer to dissolve and store fecal material, temperature and time for processing and storage and quality control. The lack of standardization and low-throughput of state-of-the-art fecal collection procedures promote a more automated protocol. Based on this review, an automated protocol is proposed. Fecal samples should be collected and immediately processed under anaerobic conditions at either room temperature (RT) for a maximum of 4 h or at 4 °C for no more than 24 h. Upon homogenization, preferably in the absence of added solvent to allow addition of a buffer of choice at a later stage, aliquots obtained should be stored at either -20 °C for up to a few months or -80 °C for a longer period-up to 2 years. Protocols for quality control should characterize microbial composition and viability as well as metabolic functionality.
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Affiliation(s)
- Frances Widjaja
- Division of Toxicology, Wageningen University & Research, 6708 WE Wageningen, The Netherlands;
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Zhou Z, Li K, Guo J, Wang Y, Wei Y, Duan J, Chen M, Shi L, Hu W. Green Tea Catechin EGCG Ameliorates Thioacetamide-Induced Hepatic Encephalopathy in Rats via Modulation of the Microbiota-Gut-Liver Axis. Mol Nutr Food Res 2022; 67:e2200821. [PMID: 36573265 DOI: 10.1002/mnfr.202200821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 11/23/2022] [Indexed: 12/28/2022]
Abstract
SCOPE Existing research suggests that (-)-epigallocatechin-3-gallate (EGCG), which is a natural tea catechin active substance, can protect against liver injury. However, its mechanism for hepatic encephalopathy (HE) treatment is still unclear. In this study, the role of EGCG in the amelioration of HE rats and the effect on the microbiota-gut-liver axis are mainly analyzed. METHODS AND RESULTS Thioacetamide (TAA) is employed to induce the HE model in rats. The results of open field test show that EGCG restores locomotor activity and exploratory behavior. Histological and biochemical results demonstrate that EGCG ameliorates brain and liver damage, decreases the expression of pro-inflammatory cytokines, and increases the activity of antioxidant enzymes. Meanwhile, EGCG modulates the Nrf2 pathway and TLR4/NF-κB pathway to mitigate TAA-induced oxidative stress and inflammatory responses. Immunohistochemistry reveals protection of the intestinal barrier by EGCG upregulating the expression of occludin and zonula occludens-1. Furthermore, serum levels of ammonia and LPS are reduced. 16S rRNA analysis shows that EGCG treatment increases the abundance of beneficial bacteria (e.g., Bifidobacterium, Lactobacillus, and Limosilactobacillus). CONCLUSION The above results reveal that EGCG has anti-oxidative stress and anti-inflammatory effects, and ameliorates the condition through the microbiota-gut-liver axis, with potential for the treatment of HE.
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Affiliation(s)
- Zhengming Zhou
- Department of Nutrition and Food Hygiene, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Ke Li
- Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Jiankui Guo
- Department of Nutrition and Food Hygiene, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Yunfeng Wang
- Department of Nutrition and Food Hygiene, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Yaoyao Wei
- Department of Nutrition and Food Hygiene, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Juan Duan
- Department of Nutrition and Food Hygiene, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Muxi Chen
- Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Lei Shi
- Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Wen Hu
- Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
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Vidal-Cevallos P, Chávez-Tapia NC, Uribe M. Current approaches to hepatic encephalopathy. Ann Hepatol 2022; 27:100757. [PMID: 36115576 DOI: 10.1016/j.aohep.2022.100757] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/07/2022] [Indexed: 02/04/2023]
Abstract
Hepatic encephalopathy (HE) is a brain dysfunction caused by liver insufficiency and/or portosystemic shunts. Between 30%-40% of patients with cirrhosis will present overt HE during their lifetime. While the pathophysiology of HE is not entirely understood, three critical factors have been identified: hyperammonaemia, systemic inflammation and oxidative stress by glutaminase gene alterations. Minimal HE is defined by the presence of signs of cognitive abnormalities in a patient without asterixis or disorientation; it can only be diagnosed with neuropsychological or psychometric tests. The diagnosis of overt HE is based on clinical examination with clinical scales. Currently, only overt HE should be routinely treated. The aims of treatment in an acute episode should be to improve the mental status, identify and treat the precipitating factor, reduce duration and limit consequences. Treatment strategies are targeted at reducing ammonia production and/or increasing its elimination. Even though minimal HE has negative effects on the patient's quality of life and effects on prognosis, indications for treatment are still controversial. There are still many unanswered questions regarding the pathophysiology and management of HE. We should also endeavor to develop more accurate and objective diagnostic methods for overt HE that would permit early detection and help improve outcomes on quality of life and economic burden.
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Affiliation(s)
- Paulina Vidal-Cevallos
- Obesity and Digestive Disease Unit, Medica Sur Clinic and Foundation, Puente de Piedra 150, col. Toriello Guerra, C.P. 14050, Mexico City, Mexico
| | - Norberto C Chávez-Tapia
- Obesity and Digestive Disease Unit, Medica Sur Clinic and Foundation, Puente de Piedra 150, col. Toriello Guerra, C.P. 14050, Mexico City, Mexico
| | - Misael Uribe
- Obesity and Digestive Disease Unit, Medica Sur Clinic and Foundation, Puente de Piedra 150, col. Toriello Guerra, C.P. 14050, Mexico City, Mexico.
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Qi W, Ge Y, Wang X, Li Z, Li X, Wang N, He H, Luo X, Ma W, Chen L, Liu Y, Zhang T. Ameliorative Effect of Chitosan Oligosaccharides on Hepatic Encephalopathy by Reshaping Gut Microbiota and Gut-Liver Axis. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2022; 70:13186-13199. [PMID: 36194761 DOI: 10.1021/acs.jafc.2c01330] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
This study investigated the influence of chitosan oligosaccharides (COSs) on a thioacetamide-induced hepatic encephalopathy (HE) Wistar rat model. COS treatment statistically reduced the false neurotransmitters and blood ammonia in HE rats, along with the suppression of oxidative stress and inflammation. The disbalanced gut microbiota was detected in HE rats by 16S rDNA sequencing, but the abundance alterations of some intestinal bacteria at either the phylum or genus level were at least partly restored by COS treatment. According to metabolomics analysis of rat feces, six metabolism pathways with the greatest response to HE were screened, several of which were remarkably reversed by COS. The altered metabolites might serve as a bridge for the alleviated HE rats treated with COS and the enhanced intestinal bacterial structure. This study provides novel guidance to develop novel food or dietary supplements to improve HE diseases due to the potential beneficial effect of COS on gut-liver axis.
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Affiliation(s)
- Wei Qi
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Yanyan Ge
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Xinyue Wang
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Zihan Li
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Xiaoxue Li
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Nan Wang
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Hongpeng He
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Xuegang Luo
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Wenjian Ma
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Liehuan Chen
- New Youlan Healthy Technology Co., Ltd., Guangzhou 510530, Guangdong, P. R. China
| | - Yihan Liu
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Tongcun Zhang
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
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Timmer C, Davids M, Nieuwdorp M, Levels JHM, Langendonk JG, Breederveld M, Ahmadi Mozafari N, Langeveld M. Differences in faecal microbiome composition between adult patients with UCD and PKU and healthy control subjects. Mol Genet Metab Rep 2021; 29:100794. [PMID: 34527515 PMCID: PMC8433284 DOI: 10.1016/j.ymgmr.2021.100794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 08/19/2021] [Indexed: 01/07/2023] Open
Abstract
Urea cycle disorders (UCDs) are a group of rare inherited metabolic diseases causing hyperammonemic encephalopathy. Despite intensive dietary and pharmacological therapy, outcome is poor in a subset of UCD patients. Reducing ammonia production by changing faecal microbiome in UCD is an attractive treatment approach. We compared faecal microbiome composition of 10 UCD patients, 10 healthy control subjects and 10 phenylketonuria (PKU) patients. PKU patients on a low protein diet were included to differentiate between the effect of a low protein diet and the UCD itself on microbial composition. Participants were asked to collect a faecal sample and to fill out a 24 h dietary journal. DNA was extracted from faecal material, taxonomy was assigned and microbiome data was analyzed, with a focus on microbiota involved in ammonia metabolism.In this study we show an altered faecal microbiome in UCD patients, different from both PKU and healthy controls. UCD patients on dietary and pharmacological treatment had a less diverse faecal microbiome, and the faecal microbiome of PKU patients on a protein restricted diet with amino acid supplementation showed reduced richness compared to healthy adults without a specific diet. The differences in the microbiome composition of UCD patients compared to healthy controls were in part related to lactulose use. Other genomic process encodings involved in ammonia metabolism, did not seem to differ. Since manipulation of the microbiome is possible, this could be a potential treatment modality. We propose as a first next step, to study the impact of these faecal microbiome alterations on metabolic stability. TAKE HOME MESSAGE The faecal microbiome of UCD patients was less diverse compared to PKU patients and even more compared to healthy controls.
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Key Words
- 16S rRNA, taxonomic marker genes, common to all bacteria
- ADI, Arginine Deimination. Bacteria derive energy from the deamination of arginine to citrulline and citrulline cleavage to ornithine plus carbamoyl phosphate. The latter is then converted into ATP and carbon dioxide, or used for pyrimidine biosynthesis. This route also generates two moles of ammonia (one from the arginine-citrulline conversion, the second from carbamoyl phosphate hydrolysis)
- ARG1d, arginase 1 (ARG1) deficiency
- ASLd, argininosuccinate lyase (ASL) deficiency
- ASSd, argininosuccinate synthetase (ASS) deficiency
- ASV, Amplified Sequence Variant. A specific nucleotide sequence representing a bacterial lineage
- Alpha Diversity, the species diversity in a microbial sample. Used to represent the taxonomic diversities of individual samples
- Ammonium scavengers, agents developed for the reduction of blood ammonia concentration used for the treatment of patients with urea cycle disorders. Sodiumbenzoate and phenylbutyrate are ammonium scavengers
- BCAA, branched chain amino acids: isoleucine, leucine and valine
- DEGs, differentially expressed genes
- DESeq, an R package to analyse count data from high-throughput sequencing assays such as RNA-Seq and test for differential expression
- EAA supplement, essential amino acids supplement containing L-histidine, L-isoleucine, L-leucine, l-lysine, L-methionine, L-phenylalanine, L-threonine, L-tryptofaan and L-valine with optional L-cystine and L-tyrosine added (depending on what product is used)
- FPD, Faiths Phylogenetic Diversity, alpha diversity metric accounting for genetic diversity
- Faecal
- Genus, a taxonomic rank
- Gut
- Hyperammonemia
- Metagenome, microbiome collective genome
- Microbiome
- OTCd, ornithine transcarbamylase deficiency
- PCoA, Principal Coordinate Analysis. PCoA is aimed at graphically representing a resemblance matrix between p elements (individuals, variables, objects, among others). By using PCoA we can visualize individual and/or group differences. Individual differences can be used to show outliers
- PFAA, precursor free amino acid supplement, in this case phenylalanine free
- PKU, Phenylketonuria
- Phenylketonuria
- Proteolytic capacity, the capacity to break proteins down into smaller polypeptides or amino acids. In this study: enzymes involved in protein degradation
- RT-qPCR, real-time quantitative polymerase chain reaction
- Sodium BPA, sodium phenylbutyrate
- UCD, urea cycle defect
- Urea cycle defect
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Affiliation(s)
- C Timmer
- Department of Dietetics and Nutritional science and Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - M Davids
- Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - M Nieuwdorp
- Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - J H M Levels
- Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - J G Langendonk
- Department of Dietetics and Department of Internal Medicine, Center of Lysosomal and Metabolic Diseases, Erasmus University Medical Center, Erasmus MC, Rotterdam, the Netherlands
| | - M Breederveld
- Department of Dietetics and Department of Internal Medicine, Center of Lysosomal and Metabolic Diseases, Erasmus University Medical Center, Erasmus MC, Rotterdam, the Netherlands
| | - N Ahmadi Mozafari
- Department of Dietetics and Department of Internal Medicine, Center of Lysosomal and Metabolic Diseases, Erasmus University Medical Center, Erasmus MC, Rotterdam, the Netherlands
| | - M Langeveld
- Department of Dietetics and Nutritional science and Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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Liu J, Xu Y, Jiang B. Novel Insights Into Pathogenesis and Therapeutic Strategies of Hepatic Encephalopathy, From the Gut Microbiota Perspective. Front Cell Infect Microbiol 2021; 11:586427. [PMID: 33692964 PMCID: PMC7937792 DOI: 10.3389/fcimb.2021.586427] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 01/08/2021] [Indexed: 01/10/2023] Open
Abstract
Since the 1950s, gradual changes in the gut microbiota of patients with hepatic encephalopathy have been observed. Previous research has indicated potential associations between the gut and brain, and the gut microbiota is becoming a hot topic in research on diseases of the nervous system. However, for the past few decades, studies of hepatic encephalopathy have been restricted to controlling the gut microbiota during macroscopic manipulation, such as probiotic intervention, while its clinical use remains controversial, and the cellular mechanisms underlying this condition are still poorly understood. This thesis seeks to comprehensively understand and explain the role of gut microbiota in hepatic encephalopathy as well as analyze the effects of intervention by regulating the gut microbiota. Evidence is presented that shows that dysbiosis of the gut microbiota is the primary pathological driver of hepatic encephalopathy and impacts pathologic progression via complex regulatory networks. As a result, suggestions were identified for future mechanistic research and improvements in therapeutic strategies for hepatic encephalopathy.
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Affiliation(s)
- Jiachen Liu
- Xiangya Medical College of Central South University, Changsha, China
| | - Yantao Xu
- Xiangya Medical College of Central South University, Changsha, China
| | - Bimei Jiang
- Department of Pathophysiology, Sepsis Translational Medicine Key Laboratory of Hunan Province, Xiangya School of Medicine, Central South University, Changsha, China
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Liang X, Wen L, Wu Y, Hao Y, Wang S, Hu X. Retention enema with traditional Chinese medicine for hepatic encephalopathy: A protocol for a systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e22517. [PMID: 33019454 PMCID: PMC7535768 DOI: 10.1097/md.0000000000022517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Hepatic encephalopathy (HE) is one of the common complications of many serious liver diseases. Western medicine treatment is mainly symptomatic treatment such as neutralizing blood ammonia and protecting liver, which has poor curative effect, easy repetition and high mortality. Retention enema with traditional Chinese medicine (TCM) has been used on treatment of HE in China for many years. And it has been clinically proved that retention enema with TCM is effective and safe. But there is absent convincing evidence-based medicine to confirm the efficacy of retention enema with TCM for HE. Thus, we aimed to conduct this meta-analysis to summarize the efficacy of retention enema with TCM in patients with HE. METHODS The study only selects clinical randomized controlled trials of retention enema with TCM for HE. We will search each database from the built-in until December 31, 2020. The English literature mainly searches Cochrane Library, Pubmed, EMBASE, and Web of Science. While the Chinese literature comes from CNKI, CBM, VIP, and Wanfang database. Meanwhile, we will retrieve clinical trial registries and gray literature. Two researchers worked independently on literature selection, data extraction and quality assessment. The dichotomous data is represented by relative risk (RR), and the continuous is expressed by mean difference (MD) or standard mean difference (SMD), eventually the data is synthesized using a fixed effect model (FEM) or a random effect model (REM) depending on the heterogeneity. The total effective rate, blood ammonia and the total bilirubin were evaluated as the main outcomes. While several secondary outcomes were also evaluated in this study. The statistical analysis of this Meta-analysis was conducted by RevMan software version 5.3. RESULTS This study will synthesize and provide high-quality evidence based on the data of the currently published retention enema with TCM for the treatment of HE. CONCLUSION This meta-analysis aims to evaluate the benefits of retention enema with TCM for the treatment of HE reported in randomized controlled trials, and provide more options for clinicians and patients with HE. REGISTRATION NUMBER INPLASY202080107.
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Affiliation(s)
- Xiao Liang
- Department of Infectious Diseases, Hospital of Chengdu University of Traditional Chinese Medicine
- National Integrative Medicine Clinical Base for Infectious Diseases, Chengdu 610072
| | - Lihong Wen
- Emergency Department, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu 610072
| | - Yifang Wu
- Department of Infectious Diseases, Hospital of Chengdu University of Traditional Chinese Medicine
- National Integrative Medicine Clinical Base for Infectious Diseases, Chengdu 610072
| | - Yanmin Hao
- Intensive Care Unit, Anyang District Hospital, Anyang 455000, PR China
| | - Shaobo Wang
- Department of Infectious Diseases, Hospital of Chengdu University of Traditional Chinese Medicine
- National Integrative Medicine Clinical Base for Infectious Diseases, Chengdu 610072
| | - Xiaoyu Hu
- Department of Infectious Diseases, Hospital of Chengdu University of Traditional Chinese Medicine
- National Integrative Medicine Clinical Base for Infectious Diseases, Chengdu 610072
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