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Sepehrinezhad A, Moghaddam NG, Shayan N, Sahab Negah S. Correlation of ammonia and blood laboratory parameters with hepatic encephalopathy: A systematic review and meta-analysis. PLoS One 2024; 19:e0307899. [PMID: 39226259 DOI: 10.1371/journal.pone.0307899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 07/12/2024] [Indexed: 09/05/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Emerging research suggests that hyperammonemia may enhance the probability of hepatic encephalopathy (HE), a condition associated with elevated levels of circulating ammonia in patients with cirrhosis. However, some studies indicate that blood ammonia levels may not consistently correlate with the severity of HE, highlighting the complex pathophysiology of this condition. METHODS A systematic review and meta-analysis through PubMed, Scopus, Embase, Web of Science, and Virtual Health Library were conducted to address this complexity, analyzing and comparing published data on various laboratory parameters, including circulating ammonia, blood creatinine, albumin, sodium, and inflammation markers in cirrhotic patients, both with and without HE. RESULTS This comprehensive review, which included 81 studies from five reputable databases until June 2024, revealed a significant increase in circulating ammonia levels in cirrhotic patients with HE, particularly those with overt HE. Notably, significant alterations were observed in the circulating creatinine, albumin, sodium, interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNFα) in HE patients. CONCLUSIONS These findings suggest an association between ammonia and HE and underscore the importance of considering other blood parameters such as creatinine, albumin, sodium, and pro-inflammatory cytokines when devising new treatment strategies for HE.
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Affiliation(s)
- Ali Sepehrinezhad
- Neuroscience Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Neuroscience, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Navidreza Shayan
- Neuroscience Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sajad Sahab Negah
- Neuroscience Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Neuroscience, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Shefa Neuroscience Research Center, Khatam Alanbia Hospital, Tehran, Iran
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Shetty A, Saab EG, Choi G. Social Impact of Hepatic Encephalopathy. Clin Liver Dis 2024; 28:273-285. [PMID: 38548439 DOI: 10.1016/j.cld.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Hepatic encephalopathy is a medical condition that stems from liver dysfunction, leading to the accumulation of toxins in the bloodstream. This can result in cognitive impairments, mood changes, and motor dysfunction. Its social impact includes challenges in employment, relationships, and daily functioning for affected individuals. Stigma and misunderstanding around the condition can further exacerbate the difficulties faced by both patients and their caregivers. Efforts to raise awareness, improve medical management, and provide support systems can help mitigate the social impact of hepatic encephalopathy.
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Affiliation(s)
- Akshay Shetty
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA.
| | - Elena G Saab
- School of Medicine, Wake Forest University, Winston Salem, NC, USA
| | - Gina Choi
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
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Wang J, Deng MJ, Shi PM, Peng Y, Wang XH, Tan W, Wang PQ, Chen YX, Yuan ZL, Ning BF, Xie WF, Yin C. Covert hepatic encephalopathy is associated with aggressive disease progression and poor survival in patients with cirrhosis. J Dig Dis 2023; 24:681-690. [PMID: 38108656 DOI: 10.1111/1751-2980.13246] [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: 08/24/2023] [Revised: 11/17/2023] [Accepted: 12/14/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVES Covert hepatic encephalopathy (CHE) negatively affects the health-related quality of life and increases the risk of overt HE (OHE) in patients with liver cirrhosis. However, the impact of CHE on long-term patient outcomes remains controversial. This study aimed to explore the association between CHE and disease progression and survival among cirrhotic patients. METHODS This was a single-center prospective study that enrolled 132 hospitalized patients with cirrhosis, with an average follow-up period of 45.02 ± 23.06 months. CHE was diagnosed using the validated Chinese standardized psychometric hepatic encephalopathy score. RESULTS CHE was detected in 35.61% cirrhotic patients. During the follow-up, patients with CHE had a higher risk of developing OHE (log-rank 5.840, P = 0.016), exacerbation of ascites (log-rank 4.789, P = 0.029), and portal vein thrombosis (PVT) (log-rank 8.738, P = 0.003). Cox multivariate regression analyses revealed that CHE was independently associated with the occurrence of OHE, exacerbation of ascites, and PVT. Furthermore, patients with progression of cirrhosis were more likely to be diagnosed as CHE (log-rank 4.462, P = 0.035). At the end of the follow-up, patients with CHE had a lower survival rate compared to those without CHE (log-rank 8.151, P = 0.004). CHE diagnosis (hazard ratio 2.530, P = 0.008), together with elder age and higher Child-Pugh score, were risk factors for impaired survival in cirrhotic patients. CONCLUSION CHE is associated with disease progression and poor survival in patients with cirrhosis, indicating that CHE may serve as an independent predictor of poor prognosis among these patients.
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Affiliation(s)
- Jian Wang
- Department of Gastroenterology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Ming Jie Deng
- Department of Gastroenterology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Pei Mei Shi
- Department of Gastroenterology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Yu Peng
- Department of Gastroenterology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Xiao Hang Wang
- Department of Endoscopy, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Wei Tan
- Department of Gastroenterology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Pei Qin Wang
- Department of Endoscopy, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Yue Xiang Chen
- Department of Gastroenterology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Zong Li Yuan
- Department of Gastroenterology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Bei Fang Ning
- Department of Gastroenterology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Wei Fen Xie
- Department of Gastroenterology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Chuan Yin
- Department of Gastroenterology, Changzheng Hospital, Naval Medical University, Shanghai, China
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Ji J, Liu YY, Wu GW, Hu YL, Liang CH, Wang XD. Changes in dynamic and static brain fluctuation distinguish minimal hepatic encephalopathy and cirrhosis patients and predict the severity of liver damage. Front Neurosci 2023; 17:1077808. [PMID: 37056312 PMCID: PMC10086246 DOI: 10.3389/fnins.2023.1077808] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
PurposeMinimal hepatic encephalopathy (MHE) is characterized by mild neuropsychological and neurophysiological alterations that are not detectable by routine clinical examination. Abnormal brain activity (in terms of the amplitude of low-frequency fluctuation (ALFF) has been observed in MHE patients. However, little is known concerning temporal dynamics of intrinsic brain activity. The present study aimed to investigate the abnormal dynamics of brain activity (dynamic ALFF; dALFF) and static measures [static ALFF; (sALFF)] in MHE patients and to strive for a reliable imaging neuromarkers for distinguishing MHE patients from cirrhosis patients. In addition, the present study also investigated whether intrinsic brain activity predicted the severity of liver damage.MethodsThirty-four cirrhosis patients with MHE, 28 cirrhosis patients without MHE, and 33 age-, sex-, and education-matched healthy controls (HCs) underwent resting-state magnetic resonance imaging (rs-fMRI). dALFF was estimated by combining the ALFF method with the sliding-window method, in which temporal variability was quantized over the whole-scan timepoints and then compared among the three groups. Additionally, dALFF, sALFF and both two features were utilized as classification features in a support vector machine (SVM) to distinguish MHE patients from cirrhosis patients. The severity of liver damage was reflected by the Child–Pugh score. dALFF, sALFF and both two features were used to predict Child–Pugh scores in MHE patients using a general linear model.ResultsCompared with HCs, MHE patients showed significantly increased dALFF in the left inferior occipital gyrus, right middle occipital gyrus, and right insula; increased dALFF was also observed in the right posterior lobe of the cerebellum (CPL) and right thalamus. Compared with HCs, noMHE patients exhibited decreased dALFF in the right precuneus. In contrast, compared with noMHE patients, MHE patients showed increased dALFF in the right precuneus, right superior frontal gyrus, and right superior occipital gyrus. Furthermore, the increased dALFF values in the left precuneus were positively associated with poor digit-symbol test (DST) scores (r = 0.356, p = 0.038); however, dALFF in the right inferior temporal gyrus (ITG) was negatively associated with the number connection test–A (NCT-A) scores (r = -0.784, p = 0.000). A significant positive correlation was found between dALFF in the left inferior occipital gyrus (IOG) and high blood ammonia levels (r = 0.424, p = 0.012). Notably, dALFF values yielded a higher classification accuracy than sALFF values in distinguishing MHE patients from cirrhosis patients. Importantly, the dALFF values predicted the Child–Pugh score (r = 0.140, p = 0.030), whereas sALFF values did not in the current dataset. Combining two features had high accuracy in classification in distinguishing MHE patients from cirrhotic patients and yielded prediction in the severity of liver damage.ConclusionThese findings suggest that combining dALFF and sALFF features is a useful neuromarkers for distinguishing MHE patients from cirrhosis patients and highlights the important role of dALFF feature in predicting the severity of liver damage in MHE.
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Affiliation(s)
- Jiang Ji
- Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan, China
- Department of Radiology, The First Affiliated Hospital of Xinxiang Medical College, Xinxiang, China
| | - Yi-yang Liu
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guo-Wei Wu
- Chinese Institute for Brain Research, Beijing, China
| | - Yan-Long Hu
- Department of Radiology, The First Affiliated Hospital of Xinxiang Medical College, Xinxiang, China
| | - Chang-Hua Liang
- Department of Radiology, The First Affiliated Hospital of Xinxiang Medical College, Xinxiang, China
- *Correspondence: Chang-Hua Liang,
| | - Xiao-dong Wang
- Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan, China
- Xiao-dong Wang,
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Arenas YM, Martínez-García M, Llansola M, Felipo V. Enhanced BDNF and TrkB Activation Enhance GABA Neurotransmission in Cerebellum in Hyperammonemia. Int J Mol Sci 2022; 23:ijms231911770. [PMID: 36233065 PMCID: PMC9570361 DOI: 10.3390/ijms231911770] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 11/28/2022] Open
Abstract
Background: Hyperammonemia is a main contributor to minimal hepatic encephalopathy (MHE) in cirrhotic patients. Hyperammonemic rats reproduce the motor incoordination of MHE patients, which is due to enhanced GABAergic neurotransmission in the cerebellum as a consequence of neuroinflammation. In hyperammonemic rats, neuroinflammation increases BDNF by activating the TNFR1–S1PR2–CCR2 pathway. (1) Identify mechanisms enhancing GABAergic neurotransmission in hyperammonemia; (2) assess the role of enhanced activation of TrkB; and (3) assess the role of the TNFR1–S1PR2–CCR2–BDNF pathway. In the cerebellum of hyperammonemic rats, increased BDNF levels enhance TrkB activation in Purkinje neurons, leading to increased GAD65, GAD67 and GABA levels. Enhanced TrkB activation also increases the membrane expression of the γ2, α2 and β3 subunits of GABAA receptors and of KCC2. Moreover, enhanced TrkB activation in activated astrocytes increases the membrane expression of GAT3 and NKCC1. These changes are reversed by blocking TrkB or the TNFR1–SP1PR2–CCL2–CCR2–BDNF–TrkB pathway. Hyperammonemia-induced neuroinflammation increases BDNF and TrkB activation, leading to increased synthesis and extracellular GABA, and the amount of GABAA receptors in the membrane and chloride gradient. These factors enhance GABAergic neurotransmission in the cerebellum. Blocking TrkB or the TNFR1–SP1PR2–CCL2–CCR2–BDNF–TrkB pathway would improve motor function in patients with hepatic encephalopathy and likely with other pathologies associated with neuroinflammation.
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Sørensen M, Walls AB, Dam G, Bak LK, Andersen JV, Ott P, Vilstrup H, Schousboe A. Low cerebral energy metabolism in hepatic encephalopathy reflects low neuronal energy demand. Role of ammonia-induced increased GABAergic tone. Anal Biochem 2022; 654:114766. [PMID: 35654134 DOI: 10.1016/j.ab.2022.114766] [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: 09/06/2021] [Revised: 05/11/2022] [Accepted: 05/26/2022] [Indexed: 11/01/2022]
Abstract
Hepatic encephalopathy (HE) is a frequent and devastating but generally reversible neuropsychiatric complication secondary to chronic and acute liver failure. During HE, brain energy metabolism is markedly reduced and it remains unclear whether this is due to external or internal energy supply limitations, or secondary to depressed neuronal cellular functions - and if so, which mechanisms that are in play. The extent of deteriorated cerebral function correlates to blood ammonia levels but the metabolic link to ammonia is not clear. Early studies suggested that high levels of ammonia inhibited key tricarboxylic acid (TCA) cycle enzymes thus limiting mitochondrial energy production and oxygen consumption; however, later studies by us and others showed that this is not the case in vivo. Here, based on a series of translational studies from our group, we advocate the view that the low cerebral energy metabolism of HE is likely to be caused by neuronal metabolic depression due to an elevated GABAergic tone rather than by restricted energy availability. The increased GABAergic tone seems to be secondary to synthesis of large amounts of glutamine in astrocytes for detoxification of ammonia with the glutamine acting as a precursor for elevated neuronal synthesis of vesicular GABA.
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Affiliation(s)
- Michael Sørensen
- Department of Hepatology & Gastroenterology, Aarhus University Hospital, Denmark; Department of Internal Medicine, Viborg Regional Hospital, Denmark.
| | - Anne Byriel Walls
- Department of Drug Design & Pharmacology, University of Copenhagen, Denmark
| | - Gitte Dam
- Department of Hepatology & Gastroenterology, Aarhus University Hospital, Denmark
| | - Lasse Kristoffer Bak
- Department of Drug Design & Pharmacology, University of Copenhagen, Denmark; Department of Clinical Biochemistry, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | - Peter Ott
- Department of Hepatology & Gastroenterology, Aarhus University Hospital, Denmark
| | - Hendrik Vilstrup
- Department of Hepatology & Gastroenterology, Aarhus University Hospital, Denmark
| | - Arne Schousboe
- Department of Drug Design & Pharmacology, University of Copenhagen, Denmark
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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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Risk of recurrent hepatic encephalopathy in patients with liver cirrhosis: a German registry study. Eur J Gastroenterol Hepatol 2021; 33:1185-1193. [PMID: 32658009 DOI: 10.1097/meg.0000000000001822] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND AIMS Patients with hepatic encephalopathy (HE) show low quality of life, recurrent hospitalizations and an increased mortality. We aimed to assess the natural course of patients after a recent episode of overt HE and to identify risk factors for HE recurrence in Germany. METHODS Fifteen sites took part in a prospective, observational study including patients with liver cirrhosis who had been hospitalized for HE within 3 months before recruitment. Clinical data, psychometric hepatic encephalopathy score (PHES) and critical flicker frequency were assessed quarterly for 1 year. Primary endpoint was HE recurrence requiring hospitalization, all-cause-mortality was treated as a competing risk factor. RESULTS From January 2014 to March 2016, a total of 115 patients were recruited. Overall 14 premature deaths were documented. For 78 subjects follow-up data were available in accordance with the protocol. After a median of 118 days, more than half of the per-protocol cohort was readmitted to hospital due to HE (N = 34) or died (N = 11). The risk for hospitalization was significantly increased in patients who had been recruited by liver transplant centers (P = 0.003), had had frequent HE relapses prior to recruitment (P = <0.0001) or an abnormal PHES result of <-4 (P = 0.044). Abnormal PHES results barely missed level of significance as an independent risk factor for re-hospitalization in a multivariable competing risk model (P = 0.093). CONCLUSION Patients with a history of HE are at high risk for the development of recurrent overt HE demanding hospitalization. The PHES test may aid in detection, monitoring and risk stratification of recurrent HE.
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Cheng Y, Zhang G, Zhang X, Li Y, Li J, Zhou J, Huang L, Xie S, Shen W. Identification of minimal hepatic encephalopathy based on dynamic functional connectivity. Brain Imaging Behav 2021; 15:2637-2645. [PMID: 33755921 DOI: 10.1007/s11682-021-00468-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 12/26/2022]
Abstract
To investigate whether dynamic functional connectivity (DFC) metrics can better identify minimal hepatic encephalopathy (MHE) patients from cirrhotic patients without any hepatic encephalopathy (noHE) and healthy controls (HCs). Resting-state functional MRI data were acquired from 62 patients with cirrhosis (MHE, n = 30; noHE, n = 32) and 41 HCs. We used the sliding time window approach and functional connectivity analysis to extract the time-varying properties of brain connectivity. Three DFC characteristics (i.e., strength, stability, and variability) were calculated. For comparison, we also calculated the static functional connectivity (SFC). A linear support vector machine was used to differentiate MHE patients from noHE and HCs using DFC and SFC metrics as classification features. The leave-one-out cross-validation method was used to estimate the classification performance. The strength of DFC (DFC-Dstrength) achieved the best accuracy (MHE vs. noHE, 72.5%; MHE vs. HCs, 84%; and noHE vs. HCs, 88%) compared to the other dynamic features. Compared to static features, the classification accuracies of the DFC-Dstrength feature were improved by 10.5%, 8%, and 14% for MHE vs. noHE, MHE vs. HC, and noHE vs. HCs, respectively. Based on the DFC-Dstrength, seven nodes were identified as the most discriminant features to classify MHE from noHE, including left inferior parietal lobule, left supramarginal gyrus, left calcarine, left superior frontal gyrus, left cerebellum, right postcentral gyrus, and right insula. In summary, DFC characteristics have a higher classification accuracy in identifying MHE from cirrhosis patients. Our findings suggest the usefulness of DFC in capturing neural processes and identifying disease-related biomarkers important for MHE identification.
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Affiliation(s)
- Yue Cheng
- Department of Radiology, Tianjin First Center Hospital, Tianjin, 300192, China
| | - Gaoyan Zhang
- College of Intelligence and Computing, Tianjin Key Laboratory of Cognitive Computing and Application, Tianjin University, Tianjin, 300072, China.
| | - Xiaodong Zhang
- Department of Radiology, Tianjin First Center Hospital, Tianjin, 300192, China
| | - Yuexuan Li
- College of Intelligence and Computing, Tianjin Key Laboratory of Cognitive Computing and Application, Tianjin University, Tianjin, 300072, China
| | - Jingli Li
- Department of Radiology, Tianjin First Center Hospital, Tianjin, 300192, China
| | - Jiamin Zhou
- Department of Radiology, Tianjin First Center Hospital, Tianjin, 300192, China
| | - Lixiang Huang
- Department of Radiology, Tianjin First Center Hospital, Tianjin, 300192, China
| | - Shuangshuang Xie
- Department of Radiology, Tianjin First Center Hospital, Tianjin, 300192, China
| | - Wen Shen
- Department of Radiology, Tianjin First Center Hospital, Tianjin, 300192, China
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Michel M, Spinelli F, Grambihler A, Labenz C, Nagel M, Kaps L, Huber Y, Galle PR, Wörns MA, Schattenberg JM. Health-related quality of life in patients with autoimmune hepatitis. Qual Life Res 2021; 30:2853-2861. [PMID: 33978892 PMCID: PMC8481193 DOI: 10.1007/s11136-021-02850-0] [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] [Accepted: 04/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Autoimmune hepatitis (AIH) is a rare chronic liver disease. Impaired health-related quality of life (HRQL) contributes to the overall disease burden. At current, only limited data related to the impact of treatment response on HRQL are available. OBJECTIVE The aim of the study was to determine the impact of biochemical remission on HRQL. METHODS Patients with AIH were prospectively enrolled between July 2018 and June 2019. A liver disease-specific tool, the chronic liver disease questionnaire (CLDQ) and the generic EQ-5D-5L were used to quantify HRQL. Treatment response was assessed biochemically by measurement of immunoglobulin G, ALT and AST. The cohort was divided into two groups according to their biochemical remission status in either complete vs. incomplete remission. Clinical as well as laboratory parameters and comorbidities were analysed using univariable and multivariable analysis to identify predictors of poor HRQL. RESULTS A total of 116 AIH patients were included (median age: 55; 77.6% female), of which 9.5% had liver cirrhosis. In this cohort, 38 (38.4%) showed a complete and 61 (61.6%) an incomplete biochemical remission at study entry. The HRQL was significantly higher in patients with a complete as compared to an incomplete biochemical remission (CLDQ overall score: 5.66 ± 1.15 vs. 5.10 ± 1.35; p = 0.03). In contrast, the generic EQ-5D-5L UI-value was not different between the groups. Multivariable analysis identified AST (p = 0.02) and an incomplete biochemical remission (p = 0.04) as independent predictors of reduced HRQL (CLDQ total value). CONCLUSION Patients with a complete biochemical remission had a significantly higher HRQL. Liver-related quality of life in patients living with AIH is dependent on the response to immunosuppressive treatment.
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Affiliation(s)
- Maurice Michel
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Francesca Spinelli
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Annette Grambihler
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Christian Labenz
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Michael Nagel
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Leonard Kaps
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Yvonne Huber
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Peter R. Galle
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Marcus-Alexander Wörns
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Jörn M. Schattenberg
- grid.410607.4Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany ,grid.410607.4I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
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Oral intake and plasma citrulline predict quality of life in patients with intestinal failure. Nutrition 2020; 79-80:110855. [DOI: 10.1016/j.nut.2020.110855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 01/31/2020] [Accepted: 04/16/2020] [Indexed: 01/18/2023]
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Lauridsen MM, Jepsen P, Wernberg CW, Schaffalitzky de Muckadell OB, Bajaj JS, Vilstrup H. Validation of a Simple Quality-of-Life Score for Identification of Minimal and Prediction of Overt Hepatic Encephalopathy. Hepatol Commun 2020; 4:1353-1361. [PMID: 32923838 PMCID: PMC7471424 DOI: 10.1002/hep4.1555] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/07/2020] [Accepted: 05/17/2020] [Indexed: 12/28/2022] Open
Abstract
Minimal hepatic encephalopathy (MHE) is underdiagnosed because most clinics refrain from psychometric testing. Diagnostic activities need to go up so patients with MHE can get the treatment their condition requires. The sickness impact profile questionnaire for covert hepatic encephalopathy (SIPCHE) score is based on quality‐of‐life outcomes and has been proposed as a simple, patient‐administered diagnostic score for grade 1 and MHE. Validate the SIPCHE for MHE identification and overt hepatic encephalopathy (OHE) prediction. 110 patients with liver cirrhosis (age 60 years, Model for End‐Stage Liver Disease score of 11.4, 80% blue‐collar) provided information for SIPCHE scoring: gender, age, and four SIP statements: “I do not maintain balance (physically),” “I act irritable or impatient with myself,” “I am not doing any of the usual physical recreation or activities,” and “I am eating much less than usual.” MHE was diagnosed using an abnormal continuous reaction time test and/or portosystemic encephalopathy syndrome test score. Patients were followed for 2.7 years on average. SIPCHE score positivity had high sensitivity (82%) but low specificity (38%) for MHE detection. Patients with an abnormal SIPCHE had a higher incidence of OHE during follow‐up (35% vs. 14%, P = 0.05). OHE prediction sensitivity was 87% and exclusion sensitivity was 85%. The patients with an abnormal SIPCHE had twice as many subsequent episodes of OHE, and despite their high mortality, also a higher risk. An abnormal SIPCHE had a high sensitivity and low specificity for MHE identification. An abnormal SIPCHE was associated with a more than doubled risk of OHE, even with death as a competing event. SIPCHE could be used as a high‐sensitivity, low‐cost, surrogate marker of MHE in clinics without availability of psychometric tests and allow more patients to benefit from anti‐MHE treatment.
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Affiliation(s)
- Mette Munk Lauridsen
- Department of Gastroenterology and Hepatology University Hospital of South Denmark Esbjerg Denmark
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology Aarhus University Hospital Aarhus Denmark
| | | | | | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition Virginia Commonwealth University and McGuire VA Medical Center Richmond VA
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology Aarhus University Hospital Aarhus Denmark
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Ye M, Guo Z, Li Z, Lin X, Li J, Jiang G, Teng Y, Qiu Y, Han L, Lv X. Aberrant inter-hemispheric coordination characterizes the progression of minimal hepatic encephalopathy in patients with HBV-related cirrhosis. NEUROIMAGE-CLINICAL 2020; 25:102175. [PMID: 31954985 PMCID: PMC6965735 DOI: 10.1016/j.nicl.2020.102175] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/26/2019] [Accepted: 01/10/2020] [Indexed: 12/19/2022]
Abstract
Patients with hepatitis B virus (HBV)-related cirrhosis (HBV-RC) and minimal hepatic encephalopathy (MHE) exhibit alterations in homotopic inter-hemispheric functional connectivity (FC) and corpus callosum (CC) degeneration. However, the progression of inter-hemispheric dysconnectivity in cirrhotic patients from no MHE (NMHE) to MHE and its association with the progression of diseased-related cognitive impairment remain uncharacterized. We hypothesized that inter-hemispheric dysconnectivity exists in NMHE patients and further deteriorates at the MHE stage, which is associated with performance measured by psychometric hepatic encephalopathy scores (PHES) that can characterize cirrhotic patients with NMHE and MHE. Using inter-hemispheric homotopic FC and CC (and its subfields) volumetric measurements in 31 patients with HBV-RC (17 with NMHE and 14 with MHE) and 37 healthy controls, we verified that MHE patients had significant attenuated inter-hemispheric homotopic FC in the bilateral cuneus, post-central gyrus, inferior parietal lobule, and superior temporal gyms, as well as CC degeneration in total CC, CC2, CC3, and CC4 (each comparison had a corrected P < 0.05). In contrast, NMHE patients had relatively less severe inter-hemispheric homotopic FC and no CC degeneration. In addition, the degeneration of the CC and inter-hemispheric homotopic functional disconnections correlated with poor PHES performances in all cirrhotic patients (NMHE and MHE). Furthermore, impairment of inter-hemispheric homotopic FC partially mediated the association between CC degeneration and worse PHES performance. Notably, a combination of inter-hemispheric homotopic FC and CC volumes had higher discriminative values according to the area under the curve (AUC) score (AUC = 0.908, P < 0.001) to classify patients into MHE or NMHE groups when compared with either alone. Our findings shed light on the progression of inter-hemispheric dysconnectivity in relation to the progression of disease-related cognitive impairment in patients with HBV-RC.
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Affiliation(s)
- Min Ye
- Department of Geriatrics, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China; Department of Geriatrics, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Zheng Guo
- Department of Oncology, The First Affiliated Hospital of Ganzhou Medical University, Ganzhou, Guangdong, China
| | - Zhipeng Li
- Department of Medical Imaging, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Xiaoshan Lin
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jing Li
- Department of Medical Imaging, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Guihua Jiang
- Department of Medical Imaging, Guangdong No. 2 Provincial People's Hospital, Guangzhou, Guangdong, China
| | - Yun Teng
- Department of Radiology, Lianjiang people' hospital, Zhanjiang, Guangdong, China
| | - Yingwei Qiu
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, Guangdong, China.
| | - Lujun Han
- Department of Medical Imaging, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.
| | - Xiaofei Lv
- Department of Medical Imaging, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
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Labenz C, Toenges G, Schattenberg JM, Nagel M, Huber Y, Marquardt JU, Galle PR, Wörns MA. Health-related quality of life in patients with compensated and decompensated liver cirrhosis. Eur J Intern Med 2019; 70:54-59. [PMID: 31530418 DOI: 10.1016/j.ejim.2019.09.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 08/04/2019] [Accepted: 09/09/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Compensated (Child-Pugh [CP] A) and decompensated (CP B/C) liver cirrhosis significantly differs in terms of impairment of health-related quality of life (HRQoL). However, sufficient data on potentially treatable factors associated with HRQoL in both stages of the disease are still lacking. Consequently, aims of this study were to determine differences in HRQoL between patients with compensated and decompensated liver cirrhosis and to identify potentially treatable factors associated with HRQoL. METHODS 218 patients with liver cirrhosis were enrolled into this study. Chronic Liver Disease Questionnaire (CLDQ) was used to assess HRQoL. Covert hepatic encephalopathy (CHE) was diagnosed according to a combination of Psychometric Hepatic Encephalopathy Score and Critical Flicker Frequency. Frailty was assessed by Clinical Frailty Scale (CFS). RESULTS HRQoL differed between patients with CP A (n = 133) and CP B/C (n = 85) liver cirrhosis (CLDQ total score: 5.6 vs. 4.8, p < 0.001). Multivariate analysis identified a history of falls in the recent year, presence of CHE, female gender, active smoking, higher CFS, and higher serum levels of CRP as independent predictors of impaired HRQoL (all p < 0.05) in patients with CP A liver cirrhosis. In patients with CP B/C liver cirrhosis, female gender, a history of overt hepatic encephalopathy, and lower hemoglobin were independently associated with impaired HRQoL (all p < 0.05). CONCLUSIONS Predictors of impaired HRQoL differ in patients with CP A or CP B/C liver cirrhosis. Focusing on treatable factors in routine clinical practice may improve HRQoL in all stages of liver cirrhosis.
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Affiliation(s)
- Christian Labenz
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Gerrit Toenges
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Jörn M Schattenberg
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Michael Nagel
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Yvonne Huber
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Jens U Marquardt
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Peter R Galle
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Marcus-Alexander Wörns
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.
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15
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Allampati SK, Mullen KD. Understanding the impact of neurologic complications in patients with cirrhosis. SAGE Open Med 2019; 7:2050312119832090. [PMID: 30834114 PMCID: PMC6396044 DOI: 10.1177/2050312119832090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/29/2019] [Indexed: 12/15/2022] Open
Abstract
Patients with cirrhosis may experience neurologic complications, including hepatic encephalopathy. Hepatic encephalopathy may be classified as covert (mild symptoms (e.g. lack of awareness)) or overt (moderate to severe symptoms (e.g. confusion or coma)), and symptoms may overlap with other neurologic conditions (e.g. epilepsy, stroke). Managing hepatic encephalopathy includes identifying and treating precipitating factors (e.g. dehydration). First-line treatment for patients with overt hepatic encephalopathy is typically lactulose; to reduce the risk of overt hepatic encephalopathy recurrence, lactulose plus the nonsystemic antibiotic rifaximin is recommended. Rifaximin reduced the risk of breakthrough overt hepatic encephalopathy by 58% versus placebo over 6 months (p < 0.001; 91% of patients in each group were on concomitant lactulose). However, neither pharmacologic hepatic encephalopathy treatment nor liver transplantation may completely reverse neurologic impairment in patients with hepatic encephalopathy. Additional neurologic considerations for patients with cirrhosis include preventing falls, as well as managing sleep-related issues, hyponatremia, and cerebral edema. Thus, monitoring neurologic impairment is an important component in the management of patients with cirrhosis.
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Affiliation(s)
- Sanath K Allampati
- Department of Internal Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Kevin D Mullen
- Department of Internal Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
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