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Guarner F, Sanders ME, Szajewska H, Cohen H, Eliakim R, Herrera-deGuise C, Karakan T, Merenstein D, Piscoya A, Ramakrishna B, Salminen S, Melberg J. World Gastroenterology Organisation Global Guidelines: Probiotics and Prebiotics. J Clin Gastroenterol 2024; 58:533-553. [PMID: 38885083 DOI: 10.1097/mcg.0000000000002002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 03/03/2024] [Indexed: 06/20/2024]
Affiliation(s)
| | - Mary Ellen Sanders
- International Scientific Association for Probiotics and Prebiotics, Centennial, CO
| | - Hania Szajewska
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
| | | | | | | | | | | | | | | | | | - Jim Melberg
- World Gastroenterology Organisation, Milwaukee, WI
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2
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Redfield R, Latt N, Munoz SJ. Minimal Hepatic Encephalopathy. Clin Liver Dis 2024; 28:237-252. [PMID: 38548436 DOI: 10.1016/j.cld.2024.01.004] [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
Minimal hepatic encephalopathy (MHE) is a pervasive frequent complication of cirrhosis of any etiology. The diagnosis of MHE is difficult as the standard neurologic examination is essentially within normal limits. None of the symptoms and signs of overt HE is present in a patient with MHE, such as confusion, disorientation, or asterixis. Progress has been made in diagnostic tools for detection of attention and cognitive deficits at the point of care of MHE. The development of MHE significantly impacts quality of life and activities of daily life in affected patients including driving motor vehicles and machine operation.
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Affiliation(s)
- Rachel Redfield
- Thomas Jefferson Hospital, Division of Gastroenterology, 132 S. 10th Street, Suite 480, Philadelphia, PA 19106, USA
| | - Nyan Latt
- Virtua Health System, Center for Liver Disease and Transplant Program, 63 Kresson Road, Suite 101, Cherry Hill, NJ 08034, USA
| | - Santiago J Munoz
- The Johns Hopkins University School of Medicine and Medical Institutions, Division of Gastroenterology and Hepatology, 600 N. Wolfe Street, Blalock Building, Suite 465, Baltimore, MD 21287, USA.
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Singh J, Ibrahim B, Han SH. Nontraditional Treatment of Hepatic Encephalopathy. Clin Liver Dis 2024; 28:297-315. [PMID: 38548441 DOI: 10.1016/j.cld.2024.01.007] [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
The pathophysiology of hepatic encephalopathy (HE) is complex, with hyperammonemia playing a central role in its development. Traditional therapies for HE have targeted ammonia and include medications such as lactulose and rifaximin. Although these agents are considered standard of care, nontraditional treatments seek to affect other factors in the pathogenesis of HE. Finally, procedural therapies include albumin dialysis, shunt closure, and the ultimate cure for HE, which is liver transplant. The treatments discussed provide alternative options for patients who have failed standard of care. However, more high-quality studies are needed to routinely recommend many of these agents.
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Affiliation(s)
- Jasleen Singh
- Department of Medicine, University of California at Los Angeles; Los Angeles, CA, USA.
| | - Brittney Ibrahim
- Department of Surgery, University of California at Los Angeles; Los Angeles, CA, USA
| | - Steven-Huy Han
- 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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Khalessi A, Pyrsopoulos NT. Pharmacologic Management of Hepatic Encephalopathy. Clin Liver Dis 2024; 28:287-296. [PMID: 38548440 DOI: 10.1016/j.cld.2024.01.006] [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 common cause of morbidity and mortality among patients with decompensated liver cirrhosis. In this article, we review the history, mechanism, and evidence for first-line pharmacologic therapies for hepatic encephalopathy including nonabsorbable disaccharides, antibiotics, and electrolyte management. We also review newer, second-line therapies including polyethylene glycol, albumin, branched-chain amino acids, probiotics and fecal microbiota transplant, zinc, and l-ornithine-l-aspartate.
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Affiliation(s)
- Ali Khalessi
- Rutgers New Jersey School of Medicine, 185 South Orange Avenue, MSB H-538, Newark, NJ 07103, USA
| | - Nikolaos T Pyrsopoulos
- Rutgers New Jersey School of Medicine, 185 South Orange Avenue, MSB H-538, Newark, NJ 07103, USA.
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Yang X, Lei L, Shi W, Li X, Huang X, Lan L, Lin J, Liang Q, Li W, Yang J. Probiotics are beneficial for liver cirrhosis: a systematic review and meta-analysis of randomized control trials. Front Med (Lausanne) 2024; 11:1379333. [PMID: 38618195 PMCID: PMC11010643 DOI: 10.3389/fmed.2024.1379333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 03/19/2024] [Indexed: 04/16/2024] Open
Abstract
Introduction Gut dysbiosis may play a pivotal role in the pathogenesis of cirrhosis and the severity of complications. Numerous studies have investigated the probiotics as treatments for cirrhosis. However, there is still a lack of definitive evidence confirming the beneficial effects of probiotics on cirrhosis. Methods Databases including PubMed, Embase, Web of Science, and the Cochrane Library were systematically searched for randomized controlled trials that compared the effects of probiotic intervention and control treatments, including placebo, no treatment, and active control, on cirrhosis, published from inception to February 2024. Outcomes included hepatic encephalopathy (HE) reversal, safety and tolerability of probiotics, liver function, quality of life, and other cirrhotic-related outcomes. A meta-analysis was conducted to synthesize evidence. Results Thirty studies were included. The quantitative synthesis results showed that compared with the control group, probiotics significantly reverse minimal hepatic encephalopathy (MHE) (risk ratio [RR] 1.54, 95% confidence interval [CI] 1.03 to 2.32) and improve HE (RR 1.94, 95% CI 1.24 to 3.06). Additionally, probiotics demonstrated higher safety and tolerability by causing a lower incidence of serious adverse events (RR 0.71, 95% CI 0.58 to 0.87). Probiotics could potentially improve liver function by reducing the Model for End-Stage Liver Disease (MELD) scores (standardized mean difference [SMD] -0.57, 95% CI -0.85 to -0.30), and displayed favorable changes in quality of life (SMD 0.51, 95% CI 0.27 to 0.75) and gut flora (SMD 1.67, 95% CI 1.28 to 2.06). Conclusion This systematic review and meta-analysis offers compelling evidence that probiotics are beneficial for cirrhosis by demonstrating reversal of HE, potential for liver function improvements, enhancements in quality of life, and regulation of gut dysbiosis. Furthermore, the apparent safety profile suggests that probiotics are a promising intervention for treating cirrhosis. Clinical trial registration number CRD42023478380.
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Affiliation(s)
- Xing Yang
- Health Management Research Institute, People’s Hospital of Guangxi Zhuang Autonomous Region and Guangxi Academy of Medical Sciences, Nanning, China
| | - Langhuan Lei
- Health Management Research Institute, People’s Hospital of Guangxi Zhuang Autonomous Region and Guangxi Academy of Medical Sciences, Nanning, China
| | - Wei Shi
- Health Management Research Institute, People’s Hospital of Guangxi Zhuang Autonomous Region and Guangxi Academy of Medical Sciences, Nanning, China
| | - Xiaozhen Li
- Health Management Center, People's Hospital of Guangxi Zhuang Autonomous Region and Guangxi Academy of Medical Sciences, Nanning, China
| | - Xiaozhi Huang
- Health Management Center, People's Hospital of Guangxi Zhuang Autonomous Region and Guangxi Academy of Medical Sciences, Nanning, China
| | - Liuyan Lan
- Office of Hospital Quality and Safety Management Committee, People's Hospital of Guangxi Zhuang Autonomous Region and Guangxi Academy of Medical Sciences, Nanning, China
| | - Jiali Lin
- Health Management Research Institute, People’s Hospital of Guangxi Zhuang Autonomous Region and Guangxi Academy of Medical Sciences, Nanning, China
| | - Qiuyu Liang
- Health Management Research Institute, People’s Hospital of Guangxi Zhuang Autonomous Region and Guangxi Academy of Medical Sciences, Nanning, China
| | - Wei Li
- Health Management Center, People's Hospital of Guangxi Zhuang Autonomous Region and Guangxi Academy of Medical Sciences, Nanning, China
| | - Jianrong Yang
- Health Management Research Institute, People’s Hospital of Guangxi Zhuang Autonomous Region and Guangxi Academy of Medical Sciences, Nanning, China
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Maharshi S, Sharma BC. Prophylaxis of hepatic encephalopathy: current and future drug targets. Hepatol Int 2024:10.1007/s12072-024-10647-9. [PMID: 38492132 DOI: 10.1007/s12072-024-10647-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/18/2024] [Indexed: 03/18/2024]
Abstract
Hepatic encephalopathy is described by a broad spectrum of neurological and psychiatric aberrations resulting due to advanced liver dysfunction. It is a neurological disorder due to hepatic insufficiency and/or portosystemic shunts. Its clinical presentation includes neuropsychiatric dysfunction ranging from subclinical changes to comatose state. It is a sign of poor prognosis in cirrhotics with a high 1-year mortality. Each episode of hepatic encephalopathy leads to high hospitalization rate, poor prognosis and raised burden of healthcare. Primary prophylaxis is prevention of initial occurrence and secondary prophylaxis is prevention of reappearance of hepatic encephalopathy in subjects who had prior history. Early detection and management of triggers is very important in the treatment of hepatic encephalopathy. The initial choice of treatment is still lactulose, as it is effective in minimal, overt, and recurrent hepatic encephalopathy. Rifaximin is equally effective as lactulose in managing hepatic encephalopathy and is better tolerated. Branch chain amino acids are beneficial in subjects who are protein intolerant. L-ornithine L-aspartate and probiotics are also useful in the management of hepatic encephalopathy. Rifaximin along with lactulose is effective in managing overt and recurrent hepatic encephalopathy. Large portosystemic shunts embolization and liver transplant is efficacious in certain group of patients. Nutritional therapy and fecal microbiota transplantation are newer therapies for hepatic encephalopathy but the evidences are limited, more research is required to prove their efficacy. Involvement of hospital pharmacists, telemedicine, and providing education are also beneficial in managing hepatic encephalopathy.
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Affiliation(s)
- Sudhir Maharshi
- Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India
| | - Barjesh Chander Sharma
- Department of Gastroenterology, G.B. Pant Hospital, Room No. 201, Academic Block, New Delhi, 110002, India.
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Ilie OD, Duta R, Nita IB, Dobrin I, Gurzu IL, Girleanu I, Huiban L, Muzica C, Ciobica A, Popescu R, Cianga P, Stanciu C, Cimpoesu D, Trifan A. A Comprehensive Overview of the Past, Current, and Future Randomized Controlled Trials in Hepatic Encephalopathy. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2143. [PMID: 38138246 PMCID: PMC10744451 DOI: 10.3390/medicina59122143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/01/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023]
Abstract
Background: Hepatic encephalopathy (HE) caused by cirrhosis has severe consequences on an individual's lifespan, leading to long-term liver complications and potentially life-threatening outcomes. Despite recent interest in this condition, the effectiveness of secondary prophylaxis involving rixafimin, lactulose, or L-ornithine L-aspartate (LOLA) may be hindered by the unique microbial profiles each patient possesses. Methods: Thus, in this manuscript, we aimed to search, identify, and gather all randomized controlled trials (RCTs) published between 2000-2023 (November) in four major academic databases such as PubMed, ISI Web of Science, Scopus, and ScienceDirect by using a controlled terminology and web strings that reunite six main keywords. We complementarily retrieved data on the ongoing RCTs. Results: Regardless of the relatively high number of results displayed (n = 75), 46.66% (n = 35) were initially deemed eligible after the first evaluation phase after removing duplicates, n = 40 (53.34%). At the second assessment stage, we eliminated 11.42% (n = 4) studies, of which n = 22 finally met the eligibility criteria to be included in the main body of the manuscript. In terms of RCTs, otherwise found in distinct stages of development, n = 3 target FMT and n = 1 probiotics. Conclusions: Although we benefit from the necessary information and technology to design novel strategies for microbiota, only probiotics and synbiotics have been extensively studied in the last decade compared to FMT.
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Affiliation(s)
- Ovidiu-Dumitru Ilie
- Gastroenterology Group, CENEMED Platform for Interdisciplinary Research, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
| | - Raluca Duta
- Gastroenterology Group, CENEMED Platform for Interdisciplinary Research, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
| | - Ilinca-Bianca Nita
- Department of Medicine III, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
| | - Irina Dobrin
- Department of Medicine III, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
- Institute of Psychiatry “Socola”, Bucium Street No. 36, 700282 Iasi, Romania
| | - Irina-Luciana Gurzu
- Department of Preventive Medicine and Interdisciplinarity, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
| | - Irina Girleanu
- Department of Gastroenterology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” County Emergency Clinical Hospital, Independence Avenue No. 1, 700111 Iasi, Romania
| | - Laura Huiban
- Department of Gastroenterology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” County Emergency Clinical Hospital, Independence Avenue No. 1, 700111 Iasi, Romania
| | - Cristina Muzica
- Department of Gastroenterology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” County Emergency Clinical Hospital, Independence Avenue No. 1, 700111 Iasi, Romania
| | - Alin Ciobica
- Department of Biology, Faculty of Biology, “Alexandru Ioan Cuza” University, Carol I Avenue No. 20A, 700505 Iasi, Romania
- Centre of Biomedical Research, Romanian Academy, Carol I Avenue No. 8, 700506 Iasi, Romania
- Academy of Romanian Scientists, Splaiul Independentei No. 54, Sector 5, 050094 Bucharest, Romania
- Preclinical Department, “Apollonia” University, Păcurari Street No. 11, 700511 Iasi, Romania
| | - Roxana Popescu
- Department of Medical Genetics, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
- Department of Medical Genetics, “Saint Mary” Emergency Children’s Hospital, Vasile Lupu Street No. 62, 700309 Iasi, Romania
| | - Petru Cianga
- Department of Immunology, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
| | - Carol Stanciu
- Centre of Biomedical Research, Romanian Academy, Carol I Avenue No. 8, 700506 Iasi, Romania
| | - Diana Cimpoesu
- Gastroenterology Group, CENEMED Platform for Interdisciplinary Research, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
- Department of Emergency Medicine, “St. Spiridon” County Emergency Clinical Hospital, Independence Avenue No. 1, 700111 Iasi, Romania
| | - Anca Trifan
- Department of Gastroenterology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” County Emergency Clinical Hospital, Independence Avenue No. 1, 700111 Iasi, Romania
- Centre of Biomedical Research, Romanian Academy, Carol I Avenue No. 8, 700506 Iasi, Romania
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Jiang H, Xu N, Zhang W, Wei H, Chen Y, Jiang Q, Zhou Y. Do gut microbiome-targeted therapies improve liver function in cirrhotic patients? A systematic review and meta-analysis. J Gastroenterol Hepatol 2023; 38:1900-1909. [PMID: 37582506 DOI: 10.1111/jgh.16329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/19/2023] [Accepted: 08/02/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND AND AIM Microbiome-targeted therapies (MTTs) are considered as promising interventions for cirrhosis, but the impact of gut microbiome modulation on liver function and disease severity has not been fully assessed. We comprehensively evaluated the efficacy of MTTs in patients with liver cirrhosis. METHODS Data from randomized controlled trials were collected through MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and ClinicalTrial.gov from inception to February 20, 2023. Clinical outcomes were pooled and expressed in terms of risk ratios or mean differences (MD). Additional subgroup and sensitivity analyses were performed to validate the robustness of findings. A trial sequential analysis was applied to calculate the required information size and evaluate the credibility of the meta-analysis results. RESULTS Twenty-one studies with a total of 1699 cirrhotic patients were included for meta-analysis. MTTs were associated with a significant reduction in aspartate aminotransferase (MD, -3.62; 95% CI, -6.59 to -0.65), the risk of hepatic encephalopathy (risk ratio = 0.56, 95% CI: 0.46 to 0.68), model for end-stage liver disease score (MD, -0.90; 95% CI, -1.17 to -0.11), ammonia (MD, -11.86; 95% CI, -16.39 to -7.33), and endotoxin (MD, -0.14; 95% CI, -0.23 to -0.04). The trial sequential analysis yielded reliable results of these outcomes. No effects were observed on the changes of other hepatic function indicators. CONCLUSION MTTs appeared to be associated with a slowed deterioration in liver cirrhosis, which could provide reference for clinicians in treatment of cirrhotic patients based on their conditions.
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Affiliation(s)
- Honglin Jiang
- School of Public Health, Fudan University, Shanghai, China
- Key Laboratory of Public Health Safety, Ministry of Education, Fudan University, Shanghai, China
- Fudan University Center for Tropical Disease Research, Shanghai, China
| | - Ning Xu
- School of Public Health, Fudan University, Shanghai, China
- Key Laboratory of Public Health Safety, Ministry of Education, Fudan University, Shanghai, China
- Fudan University Center for Tropical Disease Research, Shanghai, China
| | - Wei Zhang
- Department of Reference, Medical Library of Fudan University, Shanghai, China
| | - Hongjian Wei
- Department of Gastroenterology, The Third People's Hospital of Hunan, Yueyang, China
| | - Yue Chen
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Qingwu Jiang
- School of Public Health, Fudan University, Shanghai, China
- Key Laboratory of Public Health Safety, Ministry of Education, Fudan University, Shanghai, China
- Fudan University Center for Tropical Disease Research, Shanghai, China
| | - Yibiao Zhou
- School of Public Health, Fudan University, Shanghai, China
- Key Laboratory of Public Health Safety, Ministry of Education, Fudan University, Shanghai, China
- Fudan University Center for Tropical Disease Research, Shanghai, China
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Xia Q, Lei Y, Wang J, Wang Q. Probiotic management and inflammatory factors as a novel treatment in cirrhosis: A systematic review and meta-analysis. Open Life Sci 2023; 18:20220741. [PMID: 37872967 PMCID: PMC10590617 DOI: 10.1515/biol-2022-0741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/18/2023] [Accepted: 09/04/2023] [Indexed: 10/25/2023] Open
Abstract
The interaction between intestinal microecological dysregulation, altered inflammatory factors, and cirrhosis is unclear. The aim of this systematic review and meta-analysis was to synthesize the results of previous studies to assess the efficacy of probiotics in the treatment of cirrhosis and their effect on inflammatory factors, as well as to explore the relationship between gut microecological dysregulation and liver disease to gain a deeper understanding of this interaction. Up to December 2022, eligible studies were identified by searching the following databases: National Knowledge Infrastructure (CNKI), Wanfang Data, Web of Science, PubMed, Embase, Medline, and the Cochrane Library. Statistical analysis was performed using software RevMan Version 5.4. A total of 33 eligible randomized controlled trials were included in the study, and data on probiotic strains, duration of intervention, measures in the control group, and outcomes were extracted and evaluated. Compared to the control group, the experimental group had significant improvements in overall efficacy. The results of the meta-analysis revealed that probiotic use significantly decreased biochemical parameters for liver function, including aspartate transaminase, alanine aminotransferase, and total bilirubin. Similar result was obtained in interleukin-6, tumor necrosis factor-α, and endotoxin. However, probiotic intervention did not significantly affect interleukin-2 and interleukin-10. The current meta-analysis illustrates that probiotic supplementation reduces inflammatory markers and biochemical parameters for liver function in patients with cirrhosis, suggesting that probiotic management may be a novel treatment for cirrhosis. Furthermore, the interaction of the gut microbiota, associated metabolites, and inflammation factors with cirrhosis may provide a promising therapeutic target for the pharmacological and clinical treatment of cirrhosis.
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Affiliation(s)
- Qinglan Xia
- Institute of Infection, Immunology and Tumor Microenvironment, Hubei Province Key Laboratory of Occupational Hazard Identification and Control, School of Medicine, Wuhan University of Science and Technology, Wuhan430065, China
| | - Yumeng Lei
- Institute of Infection, Immunology and Tumor Microenvironment, Hubei Province Key Laboratory of Occupational Hazard Identification and Control, School of Medicine, Wuhan University of Science and Technology, Wuhan430065, China
| | - Jiadun Wang
- Institute of Infection, Immunology and Tumor Microenvironment, Hubei Province Key Laboratory of Occupational Hazard Identification and Control, School of Medicine, Wuhan University of Science and Technology, Wuhan430065, China
| | - Qiang Wang
- Institute of Infection, Immunology and Tumor Microenvironment, Hubei Province Key Laboratory of Occupational Hazard Identification and Control, School of Medicine, Wuhan University of Science and Technology, Wuhan430065, China
- Asia General Hospital Affiliated to Wuhan University of Science and Technology, Wuhan430056, China
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10
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Giri S, Singh A, Angadi S, Kolhe K, Roy A. Prevalence of hepatic encephalopathy in patients with non-cirrhotic portal hypertension: A systematic review and meta-analysis. Indian J Gastroenterol 2023; 42:642-650. [PMID: 37589913 DOI: 10.1007/s12664-023-01412-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 06/02/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Hepatic encephalopathy, (HE) although commonly associated with cirrhosis, has also been reported in non-cirrhotic portal hypertension (NCPH). The importance of identifying and treating HE in NCPH lies in the fact that many patients may be wrongly diagnosed as having psychiatric or neurologic disorders. Hence, we aimed to systematically review the prevalence of HE in NCPH. METHODS A comprehensive search of three databases (Medline, Embase and Scopus) was conducted from inception to November 2022 for studies reporting on the prevalence of minimal HE (MHE) and overt HE (OHE) in patients with NCPH. Results were presented as pooled proportions with their 95% confidence intervals (CI). RESULTS Total 25 studies (n = 1487) were included after screening 551 records. The pooled prevalence of MHE in NPCH was 32.9% (95% CI: 26.7-39.0) without any difference between adult (32.9%, 95% CI: 23.5-42.3) and pediatric patients (32.6%, 95% CI: 26.1-39.1) (p = 0.941). There was no significant difference in the prevalence between patients with NCPH and compensated cirrhosis with odds ratio of 1.06 (95% CI: 0.77-1.44). The pooled event rate for prior history of OHE in NCPH was 1.2% (95% CI: 0.3-2.1). CONCLUSION Around one-third of the patients with NCPH have MHE, irrespective of age group. OHE is extremely rare in NCPH and is usually associated with a precipitating factor.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, 500 082, India
| | - Ankita Singh
- Department of Gastroenterology, Seth G S Medical College and K E M Hospital, Mumbai, 400 012, India
| | - Sumaswi Angadi
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, 500 082, India
| | - Kailash Kolhe
- Department of Gastroenterology, Narayana Hospital, Nanded, 431 602, India
| | - Akash Roy
- Institute of Gastrosciences and Liver Transplantation, Apollo Multispecialty Hospital, Kolkata, 700 054, India.
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11
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Gao J, Nie R, Chang H, Yang W, Ren Q. A meta-analysis of microbiome therapies for hepatic encephalopathy. Eur J Gastroenterol Hepatol 2023; 35:927-937. [PMID: 37505972 DOI: 10.1097/meg.0000000000002596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
Microbiome therapies may be reported to be effective in hepatic encephalopathy (HE). We thus did a meta-analysis of randomized controlled trials to assess the effect of microbiome therapies for HE. We systematically searched PubMed, Web of Science, EMBASE, and Cochrane Library for randomized controlled trials that compared the different treatments for HE including probiotics, symbiotics, and fecal microbiota transplant (FMT). Meta-analysis was performed to calculate pooled odds ratios (ORs) with corresponding 95% confidence intervals (CIs). Twenty-one studies met our inclusion criteria (N = 1746 participants). Probiotics, synbiotics and FMT significantly reversed minimal HE (MHE) (OR: 0.41, 95% CI: 0.19-0.90, P = 0.03), reduced overt HE (OHE) development (OR, 0.41; 95% CI: 0.28-0.61 P < 0.00001)and the frequency of serious adverse events(SAEs) (OR:0.14, 95% CI: 0.04-0.47, P = 0.001), meanwhile decreased ammonia levels (WMD: -9.26, 95% CI: -16.92 to -1.61; P = 0.02), NCT level (MD = -4.41, 95% CI: -0.87 to -0.22, P = 0.04) and hospitalization rates (OR, 0.38; 95% CI: 0.19-0.79, P = 0.009) compared with placebo/no treatment. Finally, we conclude that microbiome therapies were more effective in improving MHE and preventing progression to OHE, reducing the frequency of SAEs, and decreasing ammonia levels, NCT level, and hospitalization rates when compared to placebo/no treatment.
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Affiliation(s)
- Jie Gao
- Lanzhou University
- Department of Gastroenterology, the First Hospital of Lanzhou University
| | - Rui Nie
- Lanzhou University
- Department of Gastroenterology, the First Hospital of Lanzhou University
| | - Hong Chang
- Lanzhou University
- Department of Gastroenterology, the First Hospital of Lanzhou University
| | - Wei Yang
- Lanzhou University
- Department of Gastroenterology, the First Hospital of Lanzhou University
- Key Laboratory for Gastrointestinal Diseases of Gansu Province, Lanzhou University, Lanzhou, China
| | - Qian Ren
- Lanzhou University
- Department of Gastroenterology, the First Hospital of Lanzhou University
- Key Laboratory for Gastrointestinal Diseases of Gansu Province, Lanzhou University, Lanzhou, China
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12
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Faccioli J, Nardelli S, Gioia S, Riggio O, Ridola L. Primary Prophylaxis of Overt Hepatic Encephalopathy: Is It Time to Consider It? J Clin Med 2023; 12:3903. [PMID: 37373598 DOI: 10.3390/jcm12123903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
Hepatic encephalopathy (HE) represents one of the most frequent complications of liver cirrhosis and one of the most debilitating clinical manifestations of liver disease due to the accumulation of toxic substances in the blood and central nervous system [...].
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Affiliation(s)
- Jessica Faccioli
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Silvia Nardelli
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
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13
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Gairing SJ, Schleicher EM, Galle PR, Labenz C. Prediction and prevention of the first episode of overt hepatic encephalopathy in patients with cirrhosis. Hepatol Commun 2023; 7:02009842-202304010-00007. [PMID: 36930868 PMCID: PMC10027066 DOI: 10.1097/hc9.0000000000000096] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/13/2022] [Indexed: 03/19/2023] Open
Abstract
Hepatic encephalopathy (HE) is one of the most important complications of patients with liver cirrhosis. In addition, HE is associated with a dismal prognosis and has detrimental effects on patients' quality of life. Thus, it is of pivotal importance to identify patients at high risk for overt HE (OHE) in whom primary prophylaxis may be justified. In this narrative review, we aim to provide insight into predictors and prediction tools for a first-time episode of OHE and to scrutinize the current level of evidence of primary prophylaxis. In recent decades, several cognitive tests, composite scores, and blood-based biomarkers have been demonstrated to be predictive of a first-time episode of OHE. Among the best validated are the established tests for minimal HE, such as the Psychometric Hepatic Encephalopathy Score, determination of the critical flicker frequency, Stroop EncephalApp, or the Animal Naming Test. Individualized risk stratification using blood-based biomarkers and cross-sectional imaging (sarcopenia and spontaneous portosystemic shunts) is coming to the fore, but validation in larger multicenter cohorts is often lacking. On the basis of current evidence, a recommendation for primary prophylaxis of a first episode of OHE cannot be made in general. Only 2 studies have investigated the prevention of a first-time OHE episode as the primary endpoint. In this narrative review, we provide a concise overview of the current evidence levels on prediction tools and pharmacological prevention of a first episode of OHE. In addition, we give an outlook on future research targets to improve knowledge on this important topic.
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Affiliation(s)
- Simon J Gairing
- 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
| | - Eva M Schleicher
- 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
| | - 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
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14
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Smith ML, Wade JB, Wolstenholme J, Bajaj JS. Gut microbiome-brain-cirrhosis axis. Hepatology 2023; Publish Ahead of Print:01515467-990000000-00327. [PMID: 36866864 PMCID: PMC10480351 DOI: 10.1097/hep.0000000000000344] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/10/2023] [Indexed: 03/04/2023]
Abstract
Cirrhosis is characterized by inflammation, degeneration, and fibrosis of liver tissue. Along with being the most common cause of liver failure and liver transplant, cirrhosis is a significant risk factor for several neuropsychiatric conditions. The most common of these is HE, which is characterized by cognitive and ataxic symptoms, resulting from the buildup of metabolic toxins with liver failure. However, cirrhosis patients also show a significantly increased risk for neurodegenerative diseases such as Alzheimer and Parkinson diseases, and for mood disorders such as anxiety and depression. In recent years, more attention has been played to communication between the ways the gut and liver communicate with each other and with the central nervous system, and the way these organs influence each other's function. This bidirectional communication has come to be known as the gut-liver-brain axis. The gut microbiome has emerged as a key mechanism affecting gut-liver, gut-brain, and brain-liver communication. Clinical studies and animal models have demonstrated the significant patterns of gut dysbiosis when cirrhosis is present, both with or without concomitant alcohol use disorder, and have provided compelling evidence that this dysbiosis also influences the cognitive and mood-related behaviors. In this review, we have summarized the pathophysiological and cognitive effects associated with cirrhosis, links to cirrhosis-associated disruption of the gut microbiome, and the current evidence from clinical and preclinical studies for the modulation of the gut microbiome as a treatment for cirrhosis and associated neuropsychiatric conditions.
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Affiliation(s)
- Maren L Smith
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia, USA
- Alcohol Research Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - James B Wade
- Department of Psychiatry, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jennifer Wolstenholme
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia, USA
- Alcohol Research Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
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15
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Zhang X, Luo Q, Guan X, Tang Y, Chen X, Deng J, Fan J. Effects of fermented dairy products on inflammatory biomarkers: A meta-analysis. Nutr Metab Cardiovasc Dis 2023; 33:471-482. [PMID: 36710113 DOI: 10.1016/j.numecd.2022.12.014] [Citation(s) in RCA: 2] [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: 09/13/2022] [Revised: 11/25/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
AIM Fermented dairy products (FDPs) are made from raw milk under the action of specific microorganisms by lactic acid bacteria fermentation or co-fermentation of lactic acid bacteria, bifidobacteria, and yeast. The aim of this study was to explore the effects of FDPs on inflammatory biomarkers. DATA SYNTHESIS A comprehensive search was conducted on four electronic databases, including PubMed, Web of Science, Embase, and the Cochrane Library. Finally, fourteen trials (15 arms) were included in this meta-analysis: yogurt (n = 9), fermented milk (n = 4), and kefir (n = 2). Additionally, the random effects model or fixed-effects model was used to pool the study results. Firstly, the analysis indicated that FDPs' supplementation decreased the levels of C-reactive protein (CRP) (SMD = -0.21; 95% CI: -0.40, -0.02; P = 0.033) and increased interferon-gamma (IFN-γ) levels (SMD = 0.12; 95% CI: 0.01, 0.23; P = 0.033). Furthermore, we obtained some statistically significant results in the following subgroups: CRP decreased in participants with metabolic diseases. IFN-γ increased in the intervention that lasted ≥12 weeks, Asian, yogurt, and healthy population. Finally, there was no significant effect on tumor necrosis factor-alpha, interleukin (IL)-6, IL-10, and IL-2. CONCLUSIONS FDPs reduced CRP and increased IFN-γ, but they had no effect on other inflammatory markers. The results showed that the consumption of FDPs was slightly associated with reduced inflammation, but because of the limited literature, these results should be interpreted with caution.
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Affiliation(s)
- Xiaofeng Zhang
- Department of Nutrition and Food Hygiene, College of Public Health, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, Henan, 450001, China
| | - Qiuping Luo
- Department of Nutrition and Food Hygiene, College of Public Health, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, Henan, 450001, China
| | - Xiaoxian Guan
- Department of Nutrition and Food Hygiene, College of Public Health, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, Henan, 450001, China
| | - Yujun Tang
- Department of Nutrition and Food Hygiene, College of Public Health, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, Henan, 450001, China
| | - Xiaoli Chen
- Department of Nutrition and Food Hygiene, College of Public Health, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, Henan, 450001, China
| | - Jinlan Deng
- Department of Nutrition and Food Hygiene, College of Public Health, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, Henan, 450001, China
| | - Jianming Fan
- Department of Nutrition and Food Hygiene, College of Public Health, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, Henan, 450001, China.
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16
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Luo M, Xin RJ, Hu FR, Yao L, Hu SJ, Bai FH. Role of gut microbiota in the pathogenesis and therapeutics of minimal hepatic encephalopathy via the gut-liver-brain axis. World J Gastroenterol 2023; 29:144-156. [PMID: 36683714 PMCID: PMC9850958 DOI: 10.3748/wjg.v29.i1.144] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/23/2022] [Accepted: 12/14/2022] [Indexed: 01/04/2023] Open
Abstract
Minimal hepatic encephalopathy (MHE) is a frequent neurological and psychiatric complication of liver cirrhosis. The precise pathogenesis of MHE is complicated and has yet to be fully elucidated. Studies in cirrhotic patients and experimental animals with MHE have indicated that gut microbiota dysbiosis induces systemic inflammation, hyperammonemia, and endotoxemia, subsequently leading to neuroinflammation in the brain via the gut-liver-brain axis. Related mechanisms initiated by gut microbiota dysbiosis have significant roles in MHE pathogenesis. The currently available therapeutic strategies for MHE in clinical practice, including lactulose, rifaximin, probiotics, synbiotics, and fecal microbiota transplantation, exert their effects mainly by modulating gut microbiota dysbiosis. Microbiome therapies for MHE have shown promised efficacy and safety; however, several controversies and challenges regarding their clinical use deserve to be intensively discussed. We have summarized the latest research findings concerning the roles of gut microbiota dysbiosis in the pathogenesis of MHE via the gut-liver-brain axis as well as the potential mechanisms by which microbiome therapies regulate gut microbiota dysbiosis in MHE patients.
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Affiliation(s)
- Ming Luo
- Department of Gastroenterology, People’s Hospital of Ningxia Hui Autonomous Region, Yinchuan 750021, Ningxia Hui Autonomous Region, China
| | - Rui-Juan Xin
- Department of Gastroenterology, People’s Hospital of Ningxia Hui Autonomous Region, Yinchuan 750021, Ningxia Hui Autonomous Region, China
| | - Fang-Rui Hu
- Department of Gastroenterology, People’s Hospital of Ningxia Hui Autonomous Region, Yinchuan 750021, Ningxia Hui Autonomous Region, China
| | - Li Yao
- Department of Gastroenterology, People’s Hospital of Ningxia Hui Autonomous Region, Yinchuan 750021, Ningxia Hui Autonomous Region, China
| | - Sheng-Juan Hu
- Department of Gastroenterology, People’s Hospital of Ningxia Hui Autonomous Region, Yinchuan 750021, Ningxia Hui Autonomous Region, China
| | - Fei-Hu Bai
- Department of Gastroenterology, People’s Hospital of Ningxia Hui Autonomous Region, Yinchuan 750021, Ningxia Hui Autonomous Region, China
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17
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Huang L, Yu Q, Peng H, Zhen Z. Alterations of gut microbiome and effects of probiotic therapy in patients with liver cirrhosis: A systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e32335. [PMID: 36595801 PMCID: PMC9794299 DOI: 10.1097/md.0000000000032335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Alterations in the gut microbiome usually occur in liver cirrhosis. Gut microbiome dysregulation damages the liver and accelerates the development of liver fibrosis. Probiotic treatment has gradually become a major method for improving the prognosis of liver cirrhosis and reducing its complications. However, alterations in the gut microbiome have revealed different results, and the therapeutic effects of various probiotics are inconsistent. METHODS We searched the PubMed, Medline, EMBASE, ScienceDirect, and Cochrane databases up to August 2022 and conducted a systematic review and meta-analysis of 17 relevant studies. RESULTS The counts of Enterobacter (standardized mean difference [SMD] -1.79, 95% confidence interval [CI]: -3.08 to -0.49) and Enterococcus (SMD -1.41, 95% CI: -2.26 to -0.55) increased significantly in patients with cirrhosis, while the counts of Lactobacillus (SMD 0.63, 95% CI: 0.12-1.15) and Bifidobacterium (SMD 0.44, 95% CI: 0.12-0.77) decreased significantly. Blood ammonia (weighted mean difference [WMD] 14.61, 95% CI: 7.84-21.37) and the incidence of hepatic encephalopathy (WMD 0.40, 95% CI: 0.27-0.61) were significantly decreased in the probiotic group. As for mortality (MD 0.75, 95% CI: 0.48-1.16) and the incidence of spontaneous bacterial peritonitis (WMD -0.02, 95% CI: -0.07 to 0.03), no significant differences were found between the probiotic and placebo groups. CONCLUSION In summary, the gut microbiome in cirrhosis manifests as decreased counts of Lactobacillus and Bifidobacterium and increased counts of Enterobacter and Enterococcus. Targeted supplementation of probiotics in cirrhosis, including Lactobacillus combined with Bifidobacterium or Bifidobacterium alone, can reduce blood ammonia and the incidence of hepatic encephalopathy. The effect is similar to that of lactulose, but it has no obvious effect on mortality and spontaneous bacterial peritonitis.
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Affiliation(s)
- Long Huang
- Department of No. 1 Surgery, The First Hospital Affiliated to Anhui University of Traditional Chinese Medicine, Hefei, Anhui Province, China
- * Correspondence: Long Huang, The First Hospital Affiliated to Anhui University of Traditional Chinese Medicine, No. 117 Meishan Road, Hefei, Anhui Province 230031, China (e-mail: )
| | - Qingsheng Yu
- Department of No. 1 Surgery, The First Hospital Affiliated to Anhui University of Traditional Chinese Medicine, Hefei, Anhui Province, China
| | - Hui Peng
- Department of No. 1 Surgery, The First Hospital Affiliated to Anhui University of Traditional Chinese Medicine, Hefei, Anhui Province, China
| | - Zhou Zhen
- Department of Surgery, The Second Hospital Affiliated to Anhui University of Traditional Chinese Medicine, Hefei, Anhui Province, China
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Minimal Hepatic Encephalopathy Affects Daily Life of Cirrhotic Patients: A Viewpoint on Clinical Consequences and Therapeutic Opportunities. J Clin Med 2022; 11:jcm11237246. [PMID: 36498820 PMCID: PMC9736966 DOI: 10.3390/jcm11237246] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/21/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022] Open
Abstract
Minimal hepatic encephalopathy (MHE) is a frequent complication of hepatic encephalopathy (HE) and can affect up to 80% of patients with liver cirrhosis. It is characterized by the lack of obvious clinical signs and the presence of alterations detectable using psychometric or electrophysiological testing focused on attention, working memory, psychomotor speed and visuospatial ability. Ideally, each patient should be tested for this condition because, despite the absence of symptoms, it has severe repercussions on daily life activities. It may be responsible for an inability to drive, sleep disturbances, risk of falls and inability to work. Some studies have highlighted its prognostically unfavorable role on mortality and risk of "overt" HE (OHE). Finally, MHE severely affects the lives of patients and caregivers, altering their quality of life and their socioeconomic status. Several treatments have been proposed for MHE treatment, including non-absorbable disaccharides, poorly absorbable antibiotics, such as rifaximin, probiotics and branched-chain amino acids, with promising results. For this reason, early diagnosis and intervention with appropriate measures is essential, with the aim of improving both performance on psychometric tests, as well as clinical aspects related to this condition.
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19
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Hepatic Encephalopathy: Current and Emerging Treatment Modalities. Clin Gastroenterol Hepatol 2022; 20:S9-S19. [PMID: 35940731 DOI: 10.1016/j.cgh.2022.04.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/13/2022] [Accepted: 04/13/2022] [Indexed: 02/07/2023]
Abstract
Hepatic encephalopathy (HE) is a potentially reversible neurocognitive complication of cirrhosis. It has been reported in at least 30% of patients with cirrhosis and imposes a significant economic burden on caregivers and the healthcare system. Ammonia has been recognized as the culprit in HE development, and all the currently approved treatments mostly act on this toxin to help with HE resolution. After a brief overview of HE characteristics and pathophysiology, this review explores the current accepted treatments for this debilitating complication of cirrhosis. This is followed by an overview of the novel available therapies and a brief focus on future treatment modalities for HE.
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20
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Bajaj JS, Fagan A, McGeorge S, Sterling RK, Rogal S, Sikaroodi M, Gillevet PM. Area Deprivation Index and Gut-Brain Axis in Cirrhosis. Clin Transl Gastroenterol 2022; 13:e00495. [PMID: 35537854 PMCID: PMC9236605 DOI: 10.14309/ctg.0000000000000495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 04/22/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Neighborhood deprivation has been associated with chronic diseases and with gut microbial alterations. Although cirrhosis is associated with gut microbiome changes and hepatic encephalopathy (HE), their association is unclear. METHODS Demographics and cirrhosis details (model for end-stage liver disease [MELD], prior HE, and medications) were recorded from outpatients with cirrhosis. Area deprivation index (ADI), which ranks neighborhoods by socioeconomic disadvantage, was recorded as state decile and national percentile (high = worse for both) and dichotomized on the median. Patients underwent cognitive testing to diagnose minimal HE (MHE). Stool microbiota was analyzed using 16S ribosomal RNA for α/β-diversity. Multivariable analysis was used to evaluate the factors independently associated with MHE. RESULTS A total of 321 people with cirrhosis (60 years, 78% men, 75% non-Hispanic White, 24% non-Hispanic African American, 4% Hispanic) were included. 45% had prior HE and 56% MHE. For ADI, the national percentile was 49.1 ± 21.8 while the state decile was 6.1 ± 2.3. ADI was not associated with race, ethnicity, MELD, or HE-related variables on regression. Regarding microbiota, α-diversity was lower in MHE and prior HE patients but similar across ADI rankings. Low vs high ADIs were associated with different β-diversity in univariable but not multivariable analyses. Multivariable analyses showed positive associations with MELD, prior HE, and lactate producers ( Lactobacillus and Lacticaseibacillus ) and negative associations with short-chain fatty acid producers ( Blautia , Lachnoclostridium , and Anaerobutyricum ) with MHE. DISCUSSION Cirrhosis-related variables may be more influential in determining gut microbiome composition and cognitive impairment than ADI. Therefore, the focus should be on improving cirrhosis care, regardless of ADI, but studies evaluating other measures of social determinants are needed in cirrhosis.
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Affiliation(s)
- Jasmohan S. Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Andrew Fagan
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Sara McGeorge
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Richard K. Sterling
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Shari Rogal
- Department of Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Masoumeh Sikaroodi
- Microbiome Analysis Center, George Mason University, Manassas, Virginia, USA
| | - Patrick M. Gillevet
- Microbiome Analysis Center, George Mason University, Manassas, Virginia, USA
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21
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Gairing SJ, Anders J, Kaps L, Nagel M, Michel M, Kremer WM, Hilscher M, Galle PR, Schattenberg JM, Wörns MA, Labenz C. Evaluation of IL-6 for Stepwise Diagnosis of Minimal Hepatic Encephalopathy in Patients With Liver Cirrhosis. Hepatol Commun 2022; 6:1113-1122. [PMID: 35032100 PMCID: PMC9035565 DOI: 10.1002/hep4.1883] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 11/28/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022] Open
Abstract
Diagnosis of minimal hepatic encephalopathy (MHE) requires psychometric testing, which is time-consuming and often neglected in clinical practice. Elevated Interleukin-6 (IL-6) serum levels have been linked to MHE. The aim of this study was to investigate the usefulness of IL-6 as a biomarker in a stepwise diagnostic algorithm to detect MHE in patients with liver cirrhosis. A total of 197 prospectively recruited patients without clinical signs of hepatic encephalopathy (HE) served as the development cohort. Another independent cohort consisting of 52 patients served for validation purposes. Psychometric Hepatic Encephalopathy Score (PHES) was applied for the diagnosis of MHE. Fifty (25.4%) patients of the development cohort presented with MHE. Median IL-6 levels were more than twice as high in patients with MHE than in patients without HE (16 vs. 7 pg/mL; P < 0.001). On multivariable logistic regression analysis, higher IL-6 levels (odds ratio 1.036; 95% confidence interval [CI] 1.009-1.064; P = 0.008) remained independently associated with the presence of MHE. IL-6 levels ≥ 8pg/mL discriminated best between patients with and without MHE in receiver operating characteristic (ROC) analysis (area under the ROC 0.751). With a cutoff value of ≥7 pg/mL, further elaborate testing with PHES could be avoided in 38% of all patients with a sensitivity of 90% (95% CI 77%-96%) and a negative predictive value (NPV) of 93% (95% CI 84%-98%). This diagnostic accuracy was confirmed in the validation cohort (sensitivity 94%; NPV 93%). Conclusion: Using IL-6 serum levels as a biomarker in a stepwise diagnostic algorithm to detect MHE could substantially reduce the number of patients requiring testing with PHES and in turn the workload. IL-6 may have especially helped in patients who are unable to perform other screening tests.
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Affiliation(s)
- Simon Johannes Gairing
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Cirrhosis Center MainzUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Julian Anders
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany
| | - Leonard Kaps
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Cirrhosis Center MainzUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Michael Nagel
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Cirrhosis Center MainzUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Maurice Michel
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Cirrhosis Center MainzUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Wolfgang Maximilian Kremer
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Cirrhosis Center MainzUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Max Hilscher
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Cirrhosis Center MainzUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Peter Robert Galle
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Cirrhosis Center MainzUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Jörn M Schattenberg
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Metabolic Liver Research ProgramUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Marcus-Alexander Wörns
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Cirrhosis Center MainzUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany.,Department of Gastroenterology, Hematology, Oncology and EndocrinologyKlinikum Dortmund GmbHDortmundGermany
| | - Christian Labenz
- Department of Internal Medicine IUniversity Medical Center of the Johannes Gutenberg-UniversityMainzGermany.,Cirrhosis Center MainzUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
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22
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Özbaş B, Keskin O, Hecker H, Karahan I, Özbaş C, Kalkan Ç, Kartal A, Önder FO, Öncü BK, Gençdal G, Akyildiz M, Günşar F, Idilman R, Weissenborn K, Özütemiz Ö, Yurdaydin C. Determination of Turkish norms of psychometric tests for diagnosing minimal hepatic encephalopathy and proposal of a high sensitive screening test battery. Hepatol Int 2021; 15:1442-1455. [PMID: 34085147 DOI: 10.1007/s12072-021-10207-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Psychometric hepatic encephalopathy score (PHES) needs local standardization. AIMS This study aimed at standardizing PHES for Turkish patients and compare them with German norms; to determine minimal hepatic encephalopathy (mHE) prevalence with two different methods [PHES battery and Critical Flicker Frequency (CFF)] and to assess whether sub-tests of the battery can be used for screening for mHE. METHODS Healthy volunteers (n = 816; 400 male) and cirrhotics (n = 124; 58 male) were included. For mHE diagnosis PHES score threshold was set at ≤ - 5 points and that of CFF at < 39 Hz. For comparing German and Turkish norms, datasets were combined. Multiple backward procedure was applied to assess effects of age, sex and education on single tests of the battery. Receiver operating characteristic (ROC) curves were created for assessing diagnostic capabilities of subtests of the battery. RESULTS PHES norms for Turks were developed. MHE prevalence in compensated cirrhotics was 29.8% and 27.4% with PHES and CFF tests, respectively, with low compatibility (kappa coefficient 0.389); mHE prevalence decreased to 16% when both tests were combined. Turks performed worse vs Germans in the digit symbol (DS) and serial dotting (SD) subtests but performed better in other subtests. In ROC analyzes of subtests, the combination of DS + SD tests achieved an AUROC of 0.974 versus PHES. CONCLUSIONS Use of two methods for diagnosing mHE is important for research purposes. From a clinical perspective, sensitivity with acceptable specificity may suffice for screening instruments for mHE. Combined use of DS and SD subtests of the PHES battery appears suitable for this purpose.
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Affiliation(s)
- Burak Özbaş
- Department of Internal Medicine, Ankara University Medical School, Ankara, Turkey
| | - Onur Keskin
- Department of Gastroenterology, Ankara University Medical School, Ankara, Turkey
| | - Hartmut Hecker
- Department of Biometrics, Hannover Medical School, Hannover, Germany
| | - Irfan Karahan
- Department of Internal Medicine, Ankara University Medical School, Ankara, Turkey
| | - Cansu Özbaş
- Department of Public Health, Gazi University Medical School, Ankara, Turkey
| | - Çağdaş Kalkan
- Department of Gastroenterology, Ankara University Medical School, Ankara, Turkey
| | - Aysun Kartal
- Department of Gastroenterology, Ankara University Medical School, Ankara, Turkey
| | - Fatih Oğuz Önder
- Department of Internal Medicine, Ankara University Medical School, Ankara, Turkey
| | - Burcu Kahveci Öncü
- Department of Psychiatry, Ankara University Medical School, Ankara, Turkey
| | - Genco Gençdal
- Department of Gastroenterology and Hepatology, Koç University Medical School, Istanbul, Turkey
| | - Murat Akyildiz
- Department of Gastroenterology and Hepatology, Koç University Medical School, Istanbul, Turkey
| | - Fulya Günşar
- Department of Gastroenterology, Ege University Medical School, Izmir, Turkey
| | - Ramazan Idilman
- Department of Gastroenterology, Ankara University Medical School, Ankara, Turkey
| | | | - Ömer Özütemiz
- Department of Gastroenterology, Ege University Medical School, Izmir, Turkey
| | - Cihan Yurdaydin
- Department of Gastroenterology, Ankara University Medical School, Ankara, Turkey.
- Department of Gastroenterology and Hepatology, Koç University Medical School, Istanbul, Turkey.
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23
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Bloom PP, Tapper EB, Young VB, Lok AS. Microbiome therapeutics for hepatic encephalopathy. J Hepatol 2021; 75:1452-1464. [PMID: 34453966 PMCID: PMC10471317 DOI: 10.1016/j.jhep.2021.08.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/20/2021] [Accepted: 08/02/2021] [Indexed: 12/13/2022]
Abstract
Hepatic encephalopathy (HE) is a complication of cirrhosis characterised by neuropsychiatric and motor dysfunction. Microbiota-host interactions play an important role in HE pathogenesis. Therapies targeting microbial community composition and function have been explored for the treatment of HE. Prebiotics, probiotics and faecal microbiota transplant (FMT) have been used with the aim of increasing the abundance of potentially beneficial taxa, while antibiotics have been used to decrease the abundance of potentially harmful taxa. Other microbiome therapeutics, including postbiotics and absorbents, have been used to target microbial products. Microbiome-targeted therapies for HE have had some success, notably lactulose and rifaximin, with probiotics and FMT also showing promise. However, there remain several challenges to the effective application of microbiome therapeutics in HE, including the resilience of the microbiome to sustainable change and unpredictable clinical outcomes from microbiota alterations. Future work in this space should focus on rigorous trial design, microbiome therapy selection, and a personalised approach to HE.
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Affiliation(s)
- Patricia P Bloom
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, USA.
| | - Elliot B Tapper
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, USA
| | - Vincent B Young
- Department of Internal Medicine, Division of Infectious Disease, University of Michigan, USA; Department of Microbiology and Immunology, University of Michigan, USA
| | - Anna S Lok
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, USA
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24
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Preparation and Functional Properties of Synbiotic Yogurt Fermented with Lactobacillus brevis PML1 Derived from a Fermented Cereal-Dairy Product. BIOMED RESEARCH INTERNATIONAL 2021; 2021:1057531. [PMID: 34435040 PMCID: PMC8380496 DOI: 10.1155/2021/1057531] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/12/2021] [Accepted: 07/27/2021] [Indexed: 11/17/2022]
Abstract
Nowadays, production of functional foods has become very essential. Inulin is one of the most functional hydrocolloid compounds used in such products. In the present study, the production of a synbiotic yogurt containing 1, 2.5, and 5% (w/v) inulin has been investigated. The yogurt was fermented with Lactobacillus brevis PML1 derived from Tarkhineh, an Iranian cereal-dairy fermented food. Furthermore, the physicochemical properties, antioxidant activity, sensory attributes, and microbial viability properties were investigated on the 0th, 7th, and 14th days of storage after fermentation. The viable cells of L. brevis PML1 reached 108 CFU/g, and the product resisted to simulated digestive juices. Moreover, the synbiotic yogurt impressively increased the production of antimicrobial compounds and had the most profound antimicrobial effect on S. typhimurium. The physiochemical properties were in the normal range, and the fat content of the synbiotic yogurt was reduced remarkably. The antioxidant capacity of the fermented yogurt was significantly increased (p < 0.05), which was equal to those of DPPH (69.18 ± 1.00%) and BHA (89.16 ± 2.00%). The viability of L. brevis PML1 was increased during storage. Sensory analysis showed that there were significant differences in terms of the impressive parameters between the samples and the control (p < 0.05). Addition of 2.5% inulin not only improved the physical properties but also retained the viability of the probiotic after 14 days of storage, in addition to the viability of L. brevis with a viability count above 6 log CFU/g in the yogurt. Therefore, a novel synbiotic product containing L. brevis PML1, which can exert the desired properties, can be used as a suitable carrier for the delivery of the probiotic strain, exerting its beneficial health effects.
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25
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Abstract
Malnutrition is common in alcohol-associated hepatitis (AH); almost all patients with severe AH have some component of malnutrition. The classic phenotype of malnutrition in AH is sarcopenia, but this has become more difficult to discern clinically as patients have become more obese. Patients with AH are often drinking 10 to 15 standard drinks per day. This substantial alcohol consumption becomes a major source of calories, but these are considered "empty" calories that contain little nutritional value. Malnutrition is associated with liver complications, such as hepatic encephalopathy, and worse liver outcomes. Nutrition support can improve nutrition status and reduce complications.
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Affiliation(s)
- Craig J. McClain
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, KY;,UofL Alcohol Research Center, University of Louisville, Louisville, KY;,Department of Medicine, University of Louisville, Louisville, KY;,Hepatobiology and Toxicology Center, University of Louisville, Louisville, KY;,Robely Rex Veterans Affairs Medical Center, Louisville, KY 40207
| | - Cristian D. Rios
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, KY
| | - Sally Condon
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, KY
| | - Luis S. Marsano
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, KY;,Department of Medicine, University of Louisville, Louisville, KY
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26
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Moran S, López-Sánchez M, Milke-García MDP, Rodríguez-Leal G. Current approach to treatment of minimal hepatic encephalopathy in patients with liver cirrhosis. World J Gastroenterol 2021; 27:3050-3063. [PMID: 34168407 PMCID: PMC8192295 DOI: 10.3748/wjg.v27.i22.3050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/01/2021] [Accepted: 04/21/2021] [Indexed: 02/06/2023] Open
Abstract
Minimal hepatic encephalopathy (MHE) corresponds to the earliest stage of hepatic encephalopathy (HE). MHE does not present clinically detectable neurological-psychiatric abnormalities but is characterized by imperceptible neurocognitive alterations detected during routine clinical examination via neuropsychological or psychometrical tests. MHE may affect daily activities and reduce job performance and quality of life. MHE can increase the risk of accidents and may develop into overt encephalopathy, worsening the prognosis of patients with liver cirrhosis. Despite a lack of consensus on the therapeutic indication, interest in finding novel strategies for prevention or reversion has led to numerous clinical trials; their results are the main objective of this review. Many studies address the treatment of MHE, which is mainly based on the strategies and previous management of overt HE. Current alternatives for the management of MHE include measures to maintain nutritional status while avoiding sarcopenia, and manipulation of intestinal microbiota with non-absorbable disaccharides such as lactulose, antibiotics such as rifaximin, and administration of different probiotics. This review analyzes the results of clinical studies that evaluated the effects of different treatments for MHE.
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Affiliation(s)
- Segundo Moran
- Laboratory of Hepatology Research, Centro Médico Nacional, Siglo XXI, Mexican Institute of Social Security, Mexico City 06720, Mexico
| | - Marlene López-Sánchez
- Laboratory of Hepatology Research, Centro Médico Nacional, Siglo XXI, Mexican Institute of Social Security, Mexico City 06720, Mexico
| | | | - Gustavo Rodríguez-Leal
- Laboratory of Hepatology Research, Centro Médico Nacional, Siglo XXI, Mexican Institute of Social Security, Mexico City 06720, Mexico
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27
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Lazebnik LB, Golovanova EV, Alekseenko SA, Bueverov AO, Plotnikova EY, Dolgushina AI, Ilchenko LY, Ermolova TV, Tarasova LV, Lee ED, Tsyganova YV, Akhmedov VA, Ageeva EA, Losev VM, Kupriyanova IN, Serikova SN, Korochanskaya NV, Vologzhanina LG, Zimmerman YS, Sas EI, Zhuravel SV, Okovitiy SV, Osipenko MF, Radchenko VG, Soldatova GS, Sitkin SI, Seliverstov PV, Shavkuta GV, Butova EN, Kozhevnikova SA. Russian Consensus “Hyperammonemia in Adults” (Version 2021). EXPERIMENTAL AND CLINICAL GASTROENTEROLOGY 2021:97-118. [DOI: 10.31146/1682-8658-ecg-187-3-97-118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Justification Given the large number of reports on the peculiarities of liver lesions during the Sars-Cov-2 infection [1], a team of experts who participated in the 23rd Congress of the Scientific Society of Gastroenterologists of Russia and 15 National Congress of Therapists of November 19, 2020 decided to make additions to the Russian Consensus of “Hyperammonemia in Adults” published early 2020 [2, 3].
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Affiliation(s)
- L. B. Lazebnik
- “Moscow State University of Medicine and Density n. a. A. I. Evdokimov”
| | - E. V. Golovanova
- “Moscow State University of Medicine and Density n. a. A. I. Evdokimov”
| | | | - A. O. Bueverov
- I. M. Sechenov first Moscow state medical university (Sechenov university); Moscow regional research and clinical Institute of M. F. Vladimirsky
| | - E. Yu. Plotnikova
- Federal State Budgetary Institution of Higher Education Kemerovo state medical University of the Ministry of health of Russia
| | - A. I. Dolgushina
- “South-Ural State Medical University” of the Ministry of Health of Russia
| | - L. Yu. Ilchenko
- Pirogov Russian National Research Medical University (RNRMU)
| | - T. V. Ermolova
- North- Western state medical University named after I. I. Mechnikov, Ministry of health of the Russian Federation
| | - L. V. Tarasova
- BI of HE “The Surgut State University”; “The Chuvashian State University”
| | - E. D. Lee
- Multifocal Medicine Center of The Central Bank of Russian Federation
| | | | - V. A. Akhmedov
- “Omsk State Medical University” of the Ministry of Health
| | | | | | - I. N. Kupriyanova
- “Ural state medical University” of the Ministry of health of the Russian Federation
| | - S. N. Serikova
- State Budgetary Institution of Health Care “Region Clinic Hospital Nr 2” Health Ministry of Krasnodar Region
| | - N. V. Korochanskaya
- State Budgetary Institution of Health Care “Region Clinic Hospital Nr 2” Health Ministry of Krasnodar Region
| | - L. G. Vologzhanina
- “Perm State Medical University named E. A. Wagner” of the Ministry of Health of Russia
| | - Ya. S. Zimmerman
- “Perm State Medical University named E. A. Wagner” of the Ministry of Health of Russia
| | - E. I. Sas
- Military Medical Academy named after S. M. Kirov
| | - S. V. Zhuravel
- “Moscow State University of Medicine and Density n. a. A. I. Evdokimov”; Scientific Research Institute of Emergency Medicine of N. V. Sklifosovskiy of Healthcare Department of Moscow
| | - S. V. Okovitiy
- Saint Petersburg State Chemical Pharmaceutical University (SPCPA)
| | - M. F. Osipenko
- Public budgetary educational institution of higher education “Novosibirsk State Medical University” of the Ministry of Healthcare of the Russia
| | | | | | - S. I. Sitkin
- North- Western state medical University named after I. I. Mechnikov, Ministry of health of the Russian Federation; Federal Medical and Biological Agency “State Research Institute of Highly Pure Biopreparations”
| | - P. V. Seliverstov
- North- Western state medical University named after I. I. Mechnikov, Ministry of health of the Russian Federation
| | - G. V. Shavkuta
- Rostov State Medical University of the Ministry of Health of Russia
| | - E. N. Butova
- Rostov State Medical University of the Ministry of Health of Russia
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Abstract
Type C hepatic encephalopathy (HE) is a brain dysfunction caused by severe hepatocellular failure or presence of portal-systemic shunts in patients with liver cirrhosis. In its subclinical form, called “minimal hepatic encephalopathy (MHE), only psychometric tests or electrophysiological evaluation can reveal alterations in attention, working memory, psychomotor speed and visuospatial ability, while clinical neurological signs are lacking. The term “covert” (CHE) has been recently used to unify MHE and Grade I HE in order to refer to a condition that is not unapparent but also non overt. “Overt” HE (OHE) is characterized by personality changes, progressive disorientation in time and space, acute confusional state, stupor and coma. Based on its time course, OHE can be divided in Episodic, Recurrent or Persistent. Episodic HE is generally triggered by one or more precipitant factors that should be found and treated. Unlike MHE, clinical examination and clinical decision are crucial for OHE diagnosis and West Haven criteria are widely used to assess the severity of neurological dysfunction. Primary prophylaxis of OHE is indicated only in the patient with gastrointestinal bleeding using non-absorbable antibiotics (Rifaximin) or non-absorbable disaccharides (Lactulose). Treatment of OHE is based on the identification and correction of precipitating factors and starting empirical ammonia-lowering treatment with Rifaximin and Lactulose (per os and enemas). The latter should be used for secondary prophylaxis, adding Rifaximin if HE becomes recurrent. In recurrent/persistent HE, the treatment options include fecal transplantation, TIPS revision and closure of eventual splenorenal shunts. Treatment of MHE should be individualized on a case-by-case basis.
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29
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Bajaj JS, Shamsaddini A, Fagan A, McGeorge S, Gavis E, Sikaroodi M, Brenner LA, Wade JB, Gillevet PM. Distinct gut microbial compositional and functional changes associated with impaired inhibitory control in patients with cirrhosis. Gut Microbes 2021; 13:1953247. [PMID: 34346283 PMCID: PMC8344770 DOI: 10.1080/19490976.2021.1953247] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/07/2021] [Accepted: 06/28/2021] [Indexed: 02/07/2023] Open
Abstract
Most cirrhosis etiologies, such as alcohol, hepatitis C, and obesity, involve behavior that require the loss of inhibitory control. Once cirrhosis develops, patients can also develop cognitive impairment due to minimal hepatic encephalopathy (MHE). Both processes could have distinct imprints on the gut-liver-brain axis. Determine the impact of inhibitory control versus traditional cirrhosis-related cognitive performance on gut microbial composition and function. Outpatients with cirrhosis underwent two tests for MHE: inhibitory control test (MHEICT, computerized associated with response inhibition) and psychometric hepatic encephalopathy score (MHEPHES, paper-pencil HE-specific associated with subcortical impairment) along with stool collection for metagenomics. MHEICT/not, MHEPHES/not, and discordant (positive on one test but negative on the other) were analyzed for demographics, bacterial species, and gut-brain modules (GBM) using multi-variable analyses. Ninety-seven patients [47 (49%) MHEPHES, 76 (78%) MHEICT, 41 discordant] were enrolled. MHEPHES/not: Cirrhosis severity was worse in MHEPHES without differences in alpha/beta diversity on bacterial species or GBMs. Pathobionts (Enterobacteriaceae) and γ-amino-butryic acid (GABA) synthesis GBM were higher in MHEPHES. MHEICT/not: We found similar cirrhosis severity and metagenomic alpha/beta diversity in MHEICT versus not. However, alpha/beta diversity of GBMs were different in MHEICT versus No-MHE patients. Alistipes ihumii, Prevotella copri, and Eubacterium spp. were higher, while Enterococcus spp. were uniquely lower in MHEICT versus no-MHE and discordant comparisons. GBMs belonging to tryptophan, menaquinone, GABA, glutamate, and short-chain fatty acid synthesis were also unique to MHEICT. Gut microbial signature of impaired inhibitory control, which is associated with addictive disorders that can lead to cirrhosis, is distinct from cirrhosis-related cognitive impairment.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | | | - Andrew Fagan
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Sara McGeorge
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Edith Gavis
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | | | - Lisa A. Brenner
- Departments of Physical Medicine and Rehabilitation, Psychiatry, & Neurology, VA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado, and University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - James B Wade
- Department of Psychiatry, Virginia Commonwealth University, Richmond, Virginia, USA
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30
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Ramachandran L, Dontaraju VS, Patel K. Lactobacillus-Associated Spontaneous Bacterial Peritonitis in a Liver Cirrhosis Patient on Probiotics. Cureus 2020; 12:e11896. [PMID: 33415048 PMCID: PMC7781884 DOI: 10.7759/cureus.11896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The efficacy of over the counter probiotics has been an area of scientific debate. While the benefits of probiotics are heavily disputed, probiotics are considered generally safe. We present a case of a liver cirrhosis patient, who presented with hepatic encephalopathy. The patient was taking daily probiotics and receiving weekly therapeutic paracentesis. His workup revealed spontaneous bacterial peritonitis (SBP). Despite starting the patient on empiric ceftriaxone and vancomycin, the patient's leukocytosis did not improve. The paracentesis fluid and blood cultures grew Lactobacillus gasseri. Antibiotics were switched to piperacillin/tazobactam, after which the patient improved clinically. The case highlights the importance of vigilance in using probiotics, especially in liver cirrhosis patients. Also, patients with Lactobacillus-associated SBP may not improve with empiric antibiotic treatment of cephalosporins.
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Affiliation(s)
| | | | - Kushal Patel
- Internal Medicine, Javon Bea Hospital, Rockford, USA
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31
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Marx W, Scholey A, Firth J, D’Cunha NM, Lane M, Hockey M, Ashton MM, Cryan JF, O’Neil A, Naumovski N, Berk M, Dean OM, Jacka F. Prebiotics, probiotics, fermented foods and cognitive outcomes: A meta-analysis of randomized controlled trials. Neurosci Biobehav Rev 2020; 118:472-484. [DOI: 10.1016/j.neubiorev.2020.07.036] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 06/15/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023]
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32
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Han W, Zhang H, Han Y, Duan Z. Cognition-tracking-based strategies for diagnosis and treatment of minimal hepatic encephalopathy. Metab Brain Dis 2020; 35:869-881. [PMID: 32495311 PMCID: PMC7354280 DOI: 10.1007/s11011-020-00539-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 01/23/2020] [Indexed: 12/11/2022]
Abstract
Minimal hepatic encephalopathy (MHE), which shows mild cognitive impairment, is a subtle complication of cirrhosis that has been shown to affect daily functioning and quality of life. However, until 2014, relevant guidelines do not give much attention to the diagnosis and treatment of MHE, resulting in patients being ignored and denied the benefits of treatment. In this review, we summarize recent cognition-based research about (1) alteration of nerve cells, including astrocytes, microglial cells and neurons, in mild cognitive impairment in MHE; (2) comparison of methods in detecting cognitive impairment in MHE; and (3) comparison of methods for therapy of cognitive impairment in MHE. We hope to provide information about diagnosis and treatment of cognitive impairment in patients with MHE.
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Affiliation(s)
- Weijia Han
- Difficult & Complicated Liver Diseases and Artificial Liver Center, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
- Beijing Municipal Key Laboratory of Liver Failure and Artificial Liver Treatment Research, Beijing, China
| | - Huanqian Zhang
- Yidu Central Hospital of Weifang Medical College, Shandong, China
| | - Ying Han
- Department of Immunologic Liver Disease, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Zhongping Duan
- Difficult & Complicated Liver Diseases and Artificial Liver Center, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China.
- Beijing Municipal Key Laboratory of Liver Failure and Artificial Liver Treatment Research, Beijing, China.
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33
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Ryu AJ, Rahimi RS, Leise MD. The Current Hepatic Encephalopathy Pipeline. J Clin Exp Hepatol 2020; 10:377-385. [PMID: 32655239 PMCID: PMC7335727 DOI: 10.1016/j.jceh.2020.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 01/06/2020] [Indexed: 02/08/2023] Open
Abstract
Hepatic encephalopathy (HE) is a complication of acute or chronic liver failure; its mechanism is complex, involving multiple organ systems, and is still being elucidated. The standard of care, lactulose, has remained generally unchanged for decades. However, in recent years, better understanding of the pathophysiology has yielded new therapeutic targets for this reversible condition. These novel treatments act both on traditional pathways established in the ammonia hypothesis and through more recently discovered mechanisms. Here, we review contemporary investigational therapies for HE. We used narrative reviews and searched ClinicalTrials.gov database for the condition "hepatic encephalopathy" through August 29, 2019. Our review yielded six key areas of therapeutic focus: (1) antibiotics against urease-producing gut bacteria, (2) intravenous ammonia scavengers, (3) modified synthetic probiotics, (4) fecal microbiota transplant, (5) brain steroid-modulating agents, and 6) nonlactulose laxatives. Active trials are ongoing in each of these therapeutic areas.
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Key Words
- CHESS, clinical hepatic encephalopathy staging scale
- FMT, fecal microbiota transplant
- HE, hepatic encephalopathy
- HESA, hepatic encephalopathy scoring algorithm
- MAD, multiple-ascending dose
- MES, modified encephalopathy scale
- ORT, object recognition test
- PEG, polyethylene glycol-3350
- SAD, single-ascending dose
- SEV, saccadic eye velocity
- ammonia
- antibiotics
- fecal microbiota transplant
- hepatic encephalopathy
- lactulose
- therapy
- trials
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Affiliation(s)
- Alexander J. Ryu
- Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, United States
| | - Robert S. Rahimi
- Division of Hepatology, Baylor Scott & White Health, Dallas, TX, United States
| | - Michael D. Leise
- Division of Gastroenterology & Hepatology, Mayo Clinic College of Medicine, Rochester, MN, United States
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34
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Effect of daily probiotic yogurt consumption on inflammation: A systematic review and meta-analysis of randomized Controlled Clinical trials. ACTA ACUST UNITED AC 2020. [DOI: 10.1016/j.obmed.2020.100221] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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35
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Bajaj JS, Torre A, Rojas ML, Fagan A, Nandez IE, Gavis EA, De Leon Osorio O, White MB, Fuchs M, Sikaroodi M, Gillevet PM. Cognition and hospitalizations are linked with salivary and faecal microbiota in cirrhosis cohorts from the USA and Mexico. Liver Int 2020; 40:1395-1407. [PMID: 32181561 DOI: 10.1111/liv.14437] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/15/2020] [Accepted: 03/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Gut microbiota are affected by diet and ethnicity, which impacts cognition and hospitalizations in cirrhosis. AIM Study interactions of diet with microbiota and impact on hospitalizations and cognition in American and Mexican cohorts. METHODS Controls and age-balanced patients with compensated/decompensated cirrhosis were included and followed for 90-day hospitalizations. A subset underwent minimal hepatic encephalopathy (MHE) testing. Parameters such as dietary, salivary and faecal microbiota (diversity, taxa analysis, cirrhosis dysbiosis ratio CDR:high = good) between/within countries were analysed. Regression analyses for hospitalizations and MHE were performed. RESULTS In all, 275 age-balanced subjects (133 US [40 Control, 50 Compensated, 43 Decompensated] and 142 Mexican [41 Control, 49 Compensated, 52 Decompensated]) were enrolled. MELD/cirrhosis severity was comparable. Diet showed lower protein and animal fat intake in all decompensated patients, but this was worse in Mexico. Diversity was lower in stool and saliva in decompensated patients, and worse in Mexican cohorts. Prevotellaceae were lower in decompensated cirrhosis, particularly those with lower animal fat/protein consumption across countries. Hospitalizations were higher in Mexico vs the USA (26% vs 14%, P = .04). On regression, Prevotellaceae, Ruminococcaceae and Lachnospiraceae lowered hospitalization risk independent of MELD and ascites. MHE testing was performed in 120 (60/country and 20/subgroup) subjects and MHE rate was similar. MELD and decompensation increased while CDR and Prevotellaceae decreased the risk of MHE. CONCLUSIONS Changes in diet and microbiota, especially related to animal fat and protein intake and Prevotellaceae, are associated with MHE and hospitalizations in Mexican patients with cirrhosis compared to an American cohort. Nutritional counselling to increase protein intake in cirrhosis could help prevent these hospitalizations.
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Affiliation(s)
- Jasmohan S Bajaj
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Aldo Torre
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Mayra L Rojas
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Andrew Fagan
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Ivvone E Nandez
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Edith A Gavis
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Omar De Leon Osorio
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Melanie B White
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Michael Fuchs
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
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36
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Reja M, Phelan LP, Senatore F, Rustgi VK. Social Impact of Hepatic Encephalopathy. Clin Liver Dis 2020; 24:291-301. [PMID: 32245534 DOI: 10.1016/j.cld.2020.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Hepatic encephalopathy (HE) is a multifaceted disorder, with effects stretching far beyond office visits and hospitalizations. Patients with HE suffer from varying degrees of altered consciousness, intellectual disability, and personality changes. A large social impact exists for patients with HE. Quality of life and activities of daily living, such as work capacity, driving ability, and sleep quality, have been shown to be affected. Additionally, caregiver and financial burdens are highly prevalent. Multiple tools exist to assess quality of life, including the CLD-Q questionnaire. Common treatments for HE, including rifaximin and lactulose, have been shown to improve overall quality of life.
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Affiliation(s)
- Mishal Reja
- Department of Medicine, Rutgers Robert Wood Johnson University Hospital, Clinical Academic Building (CAB), 125 Paterson Street, Suite 5100B, New Brunswick, NJ 08901, USA.
| | - Lauren Pioppo Phelan
- Department of Medicine, Rutgers Robert Wood Johnson University Hospital, Clinical Academic Building (CAB), 125 Paterson Street, Suite 5100B, New Brunswick, NJ 08901, USA
| | - Frank Senatore
- Department of Gastroenterology, Rutgers Robert Wood Johnson University Hospital, Clinical Academic Building, 125 Paterson Street, Suite 5100B, New Brunswick, NJ 08901, USA
| | - Vinod K Rustgi
- Center for Liver Diseases and Masses, Robert Wood Johnson Medical School, Clinical Academic Building (CAB), 125 Paterson Street, Suite 5100B, New Brunswick, NJ 08901, USA.
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Abstract
Purpose of Review The burden of malnutrition is high in patients with cirrhosis, especially in those with hepatic encephalopathy (HE). This has a bearing on increased morbidity and mortality. Heightened attention needs to be paid to screen the patients at high nutritional risk both in the outpatient and hospitalized settings. This review summarizes the current evidence for nutritional support in HE patients and compares the recommendations about nutritional requirement as laid out by various organizations. Recent Findings On survey of the literature, there is a consensus on avoiding protein restriction of the diets in HE patients along with uniform recommendations on caloric requirements. An exciting field of manipulating the gut microbiome in nutritional sciences may hold promise as well as there may be a future role for branched chain amino acids in nutritional management of HE patients. Summary Even though the data suggest that nutritional improvement lead to better outcomes including lower readmission rates in cirrhosis, operationalizing these into practice remains a challenge. To achieve this, a multi-disciplinary approach with nutritional education of the frontline care providers, earlier nutritional risk screening of patients, involvement of the nutrition professionals as part of the team and repeated dietary counseling for the patient and caregiver/s is required. Ultimately, this may need more focus, resource allocation and uniform guidelines across all countries to make this a success.
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Fermented foods and inflammation: A systematic review and meta-analysis of randomized controlled trials. Clin Nutr ESPEN 2020; 35:30-39. [DOI: 10.1016/j.clnesp.2019.10.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 10/17/2019] [Accepted: 10/21/2019] [Indexed: 02/07/2023]
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Cornide-Petronio ME, Álvarez-Mercado AI, Jiménez-Castro MB, Peralta C. Current Knowledge about the Effect of Nutritional Status, Supplemented Nutrition Diet, and Gut Microbiota on Hepatic Ischemia-Reperfusion and Regeneration in Liver Surgery. Nutrients 2020; 12:E284. [PMID: 31973190 PMCID: PMC7071361 DOI: 10.3390/nu12020284] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/13/2020] [Accepted: 01/15/2020] [Indexed: 02/06/2023] Open
Abstract
Ischemia-reperfusion (I/R) injury is an unresolved problem in liver resection and transplantation. The preexisting nutritional status related to the gut microbial profile might contribute to primary non-function after surgery. Clinical studies evaluating artificial nutrition in liver resection are limited. The optimal nutritional regimen to support regeneration has not yet been exactly defined. However, overnutrition and specific diet factors are crucial for the nonalcoholic or nonalcoholic steatohepatitis liver diseases. Gut-derived microbial products and the activation of innate immunity system and inflammatory response, leading to exacerbation of I/R injury or impaired regeneration after resection. This review summarizes the role of starvation, supplemented nutrition diet, nutritional status, and alterations in microbiota on hepatic I/R and regeneration. We discuss the most updated effects of nutritional interventions, their ability to alter microbiota, some of the controversies, and the suitability of these interventions as potential therapeutic strategies in hepatic resection and transplantation, overall highlighting the relevance of considering the extended criteria liver grafts in the translational liver surgery.
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Affiliation(s)
| | - Ana Isabel Álvarez-Mercado
- Department of Biochemistry and Molecular Biology II, School of Pharmacy, University of Granada, 18071 Granada, Spain;
- Institute of Nutrition and Food Technology “José Mataix,” Center of Biomedical Research, University of Granada, Avda. del Conocimiento s/n, 18016 Armilla, Granada, Spain
- Instituto de Investigación Biosanitaria ibs, GRANADA, Complejo Hospitalario Universitario de Granada, 18014 Granada, Spain
| | - Mónica B. Jiménez-Castro
- Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), 08036 Barcelona, Spain; (M.E.C.-P.); (M.B.J.-C.)
| | - Carmen Peralta
- Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), 08036 Barcelona, Spain; (M.E.C.-P.); (M.B.J.-C.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 08036 Barcelona, Spain
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40
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KASL clinical practice guidelines for liver cirrhosis: Varices, hepatic encephalopathy, and related complications. Clin Mol Hepatol 2020; 26:83-127. [PMID: 31918536 PMCID: PMC7160350 DOI: 10.3350/cmh.2019.0010n] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 02/06/2023] Open
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41
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Fallahzadeh MA, Rahimi RS. Hepatic Encephalopathy and Nutrition Influences: A Narrative Review. Nutr Clin Pract 2019; 35:36-48. [PMID: 31872484 DOI: 10.1002/ncp.10458] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Hepatic encephalopathy (HE) is a potentially reversible neurocognitive condition seen in patients with advanced liver disease. The overt form of HE has been reported in up to 45% of patients with cirrhosis. This debilitating condition is associated with increased morbidity and mortality and imposes a significant burden on the caregivers and healthcare system. After providing an overview of HE epidemiology and pathophysiology, this review focuses on the interaction of HE and frailty, nutrition requirements and recommendations in cirrhotic patients with HE, and current dietary and pharmacologic options for HE treatment.
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Affiliation(s)
- Mohammad Amin Fallahzadeh
- Division of Hepatology, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
| | - Robert S Rahimi
- Division of Hepatology, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
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42
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Manipulation of microbiota with probiotics as an alternative for treatment of hepatic encephalopathy. Nutrition 2019; 73:110693. [PMID: 32065881 DOI: 10.1016/j.nut.2019.110693] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/21/2019] [Accepted: 11/08/2019] [Indexed: 12/18/2022]
Abstract
Hepatic encephalopathy is a cerebral alteration mainly caused by hepatic insufficiency or portosystemic shunt. It ranges from minimal neurologic manifestations to coma in its overt stage. The multifactorial pathophysiology of hepatic encephalopathy has rendered numerous treatment alternatives, among which the modification of dysbiosis and hyperammonemia are currently considered to be effective, not only clinically, but also regarding cost. Recent work has developed knowledge of probiotics in different clinical settings including the relationship of the gut microenvironment to liver cirrhosis. The aim of this review was to analyze the results of clinical trials on the effect of different probiotics on hepatic encephalopathy.
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43
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Hanai T, Shiraki M, Watanabe S, Imai K, Suetsugu A, Takai K, Moriwaki H, Shimizu M. Prognostic significance of minimal hepatic encephalopathy in patients with liver cirrhosis in Japan: A propensity score-matching analysis. J Gastroenterol Hepatol 2019; 34:1809-1816. [PMID: 30779213 DOI: 10.1111/jgh.14635] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 02/13/2019] [Accepted: 02/16/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Minimal hepatic encephalopathy (MHE) represents the mildest form of the hepatic encephalopathy spectrum. This study aimed to clarify the prognostic significance of MHE in cirrhotic patients. METHODS This retrospective study evaluated 357 consecutive patients with liver cirrhosis. MHE was diagnosed using a neuropsychiatric test. A propensity score-matching analysis was employed to adjust significant differences in the baseline characteristics between patients with and without MHE. RESULTS Of 269 eligible patients, 56 patients (21%) were diagnosed as having MHE. The Child-Pugh score, model for end-stage liver disease score, and serum ammonia levels were significantly increased, while serum albumin levels were reduced in patients with MHE. By contrast, no significant difference was found between the two groups in matched patients. During the median follow-up period of 13.4 months, 67 patients (24.9%) died. Overall survival rates were significantly lower in patients with MHE (median, 25.4 vs 48.8 months; P < 0.001). Multivariate analysis revealed that male sex (hazard ratio [HR], 1.78; 95% confidence interval [CI], 1.03-3.18; P = 0.038), stage III/IV hepatocellular carcinoma (HR, 6.32; 95% CI, 3.30-12.79; P < 0.001), the Child-Pugh score (HR, 1.35; 95% CI, 1.12-1.62; P = 0.002), and MHE (HR, 1.92; 95% CI, 1.09-3.29; P = 0.024) were independently associated with mortality in all patients as well as in matched patients. CONCLUSION Minimal hepatic encephalopathy is associated with an increased risk of mortality in patients with liver cirrhosis, independent of hepatocellular carcinoma stage or Child-Pugh score.
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Affiliation(s)
- Tatsunori Hanai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan.,Division for Regional Cancer Control, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Makoto Shiraki
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Satoshi Watanabe
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kenji Imai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Atsushi Suetsugu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Koji Takai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan.,Division for Regional Cancer Control, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hisataka Moriwaki
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
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44
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Critical flickering frequency test: a diagnostic tool for minimal hepatic encephalopathy. Eur J Gastroenterol Hepatol 2019; 31:1030-1034. [PMID: 31274595 DOI: 10.1097/meg.0000000000001375] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Minimal hepatic encephalopathy (MHE) is underestimated. It affects 30-55% of patients with liver cirrhosis and can change their daily functions. Psychometric tests are sensitive in diagnosing MHE, but interpretation is difficult. Availability of a simpler diagnostic tool for MHE is mandatory. Critical flicker frequency (CFF) is a simple diagnostic test. AIM The aim of this study was to assess the diagnostic accuracy of CFF test for MHE. PATIENTS AND METHODS A total of 86 patients with cirrhosis with negative history of overt hepatic encephalopathy were included. History, clinical examination, laboratory investigations, and abdominal ultrasonography data were collected. Arabic version of number connection test, serial dotting test, and line tracing test were done. Total psychometric hepatic encephalopathy score (PHES) was used to diagnose MHE. CFF was done for all patients with MHE diagnosis at 39 Hz. RESULTS Of the 86 patients, 45 (52.3%) had MHE with PHES. Patients with MHE had significantly older age, presentation with jaundice, ascites, lower hemoglobin level, lower serum albumin, prolonged INR, higher Child class and score (P≤0.001), and higher model of end stage liver disease score (P=0.001) than patients without MHE. In comparison with PHES, CFF has a sensitivity of 91.1±8.32%, specificity of 92.7±7.96%, positive predictive value of 93.2±7.44%, and negative predictive value of 90.4±8.91%. In receiver operating characteristic curve, CFF is excellent in diagnosis of MHE, with area under the curve 0.937 (P<0.001). CONCLUSION MHE is common among patients with liver cirrhosis. CFF is a simple, rapid, noninvasive test for diagnosis of MHE, with a very good accuracy at 39 Hz.
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45
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Campion D, Giovo I, Ponzo P, Saracco GM, Balzola F, Alessandria C. Dietary approach and gut microbiota modulation for chronic hepatic encephalopathy in cirrhosis. World J Hepatol 2019; 11:489-512. [PMID: 31293718 PMCID: PMC6603507 DOI: 10.4254/wjh.v11.i6.489] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/16/2019] [Accepted: 05/21/2019] [Indexed: 02/06/2023] Open
Abstract
Hepatic encephalopathy (HE) is a common and serious neuropsychiatric complication of cirrhosis, acute liver failure, and porto-systemic shunting. HE largely contributes to the morbidity of patients with liver disease, severely affecting the quality of life of both patients and their relatives and being associated with poor prognosis. Its presentation is largely variable, manifesting with a broad spectrum of cognitive abnormalities ranging from subtle cognitive impairment to coma. The pathogenesis of HE is complex and has historically been linked with hyperammonemia. However, in the last years, it has become evident that the interplay of multiple actors, such as intestinal dysbiosis, gut hyperpermeability, and neuroinflammation, is of crucial importance in its genesis. Therefore, HE can be considered a result of a dysregulated gut-liver-brain axis function, where cognitive impairment can be reversed or prevented by the beneficial effects induced by “gut-centric” therapies, such as non-absorbable disaccharides, non-absorbable antibiotics, probiotics, prebiotics, and fecal microbiota transplantation. In this context dietary modifications, by modulating the intestinal milieu, can also provide significant benefit to cirrhotic patients with HE. This review will provide a comprehensive insight into the mechanisms responsible for gut-liver-brain axis dysregulation leading to HE in cirrhosis. Furthermore, it will explore the currently available therapies and the most promising future treatments for the management of patients with HE, with a special focus on the dietary approach.
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Affiliation(s)
- Daniela Campion
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza di Torino Hospital, University of Turin, 10126 Turin, Italy
| | - Ilaria Giovo
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza di Torino Hospital, University of Turin, 10126 Turin, Italy
| | - Paola Ponzo
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza di Torino Hospital, University of Turin, 10126 Turin, Italy
| | - Giorgio M Saracco
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza di Torino Hospital, University of Turin, 10126 Turin, Italy
| | - Federico Balzola
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza di Torino Hospital, University of Turin, 10126 Turin, Italy
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza di Torino Hospital, University of Turin, 10126 Turin, Italy
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Effect of probiotic and synbiotic supplementation on inflammatory markers in health and disease status: A systematic review and meta-analysis of clinical trials. Clin Nutr 2019; 39:789-819. [PMID: 31060892 DOI: 10.1016/j.clnu.2019.04.004] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 03/31/2019] [Accepted: 04/01/2019] [Indexed: 02/06/2023]
Abstract
The current systematic review and meta-analysis investigated the effect of probiotic/synbiotic on a wide range of inflammatory and anti-inflammatory markers in healthy and various disease conditions. PubMed, SCOPUS and Web of Science databases were searched. All clinical trials which investigated the effect of oral administration of probiotic or synbiotic on inflammatory markers (C-reactive protein (CRP), interleukin (IL) 1β, IL-4, IL-6, IL-8, IL-10, IL-12, tumor necrosis factor (TNF) α, interferon (IFN) γ and transforming growth factor (TGF) β) for more than one week with concurrent control groups were included. One-hundred sixty seven publications was analysed. Results were as follows: CRP decreased in healthy, metabolic disorders, inflammatory bowel disease (IBD), arthritis and critically ill condition but not in renal failure. IL-1B: no change in healthy subjects and arthritis. TNF-α: decreased in healthy, fatty liver, IBD and hepatic cirrhosis, no change in diabetes, metabolic syndrome (MS) + PCOS (polycystic ovary syndrome) and arthritis. IL-6: no change in healthy, metabolic disorders and arthritis, increased in cirrhosis and renal failure, decreased in PCOS + MS. IL-10: no change in healthy, IBD and metabolic disorders, increased in arthritis. IL-4, IL-8, IL-12, IFN-g and TGF-b: no change in healthy subjects. In conclusion, probiotic/synbiotic decreased some of the inflammatory markers. The intervention was most effective in CRP and TNF-α reduction in healthy or disease state. Moreover, the intervention decreased inflammation most effectively in the following disease conditions, respectively: IBD, arthritis, fatty liver. PROSPERO REGISTRATION NUMBER: CRD42018088688.
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47
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Román E, Nieto JC, Gely C, Vidal S, Pozuelo M, Poca M, Juárez C, Guarner C, Manichanh C, Soriano G. Effect of a Multistrain Probiotic on Cognitive Function and Risk of Falls in Patients With Cirrhosis: A Randomized Trial. Hepatol Commun 2019; 3:632-645. [PMID: 31061952 PMCID: PMC6492476 DOI: 10.1002/hep4.1325] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/30/2019] [Indexed: 12/11/2022] Open
Abstract
Probiotics can modulate gut microbiota, intestinal permeability, and immune response and could therefore improve cognitive dysfunction and help avoid potential consequences, such as falls, in patients with cirrhosis. The aim of this study was to evaluate the effect of a multistrain probiotic on cognitive function, risk of falls, and inflammatory response in patients with cirrhosis. Consecutive outpatients with cirrhosis and cognitive dysfunction (defined by a Psychometric Hepatic Encephalopathy Score [PHES] < -4) and/or falls in the previous year were randomized to receive either a sachet of a high-concentration multistrain probiotic containing 450 billion bacteria twice daily for 12 weeks or placebo. We evaluated the changes in cognitive function (PHES); risk of falls (Timed Up and Go [TUG] test, gait speed, and incidence of falls); systemic inflammatory response; neutrophil oxidative burst; intestinal barrier integrity (serum fatty acid-binding protein 6 [FABP-6] and 2 [FABP-2] and zonulin and urinary claudin-3); bacterial translocation (lipopolysaccharide-binding protein [LBP]); and fecal microbiota. Thirty-six patients were included. Patients treated with the probiotic (n = 18) showed an improvement in the PHES (P = 0.006), TUG time (P = 0.015) and gait speed (P = 0.02), and a trend toward a lower incidence of falls during follow-up (0% compared with 22.2% in the placebo group [n = 18]; P = 0.10). In the probiotic group, we observed a decrease in C-reactive protein (P = 0.01), tumor necrosis factor alpha (P = 0.01), FABP-6 (P = 0.009), and claudin-3 (P = 0.002), and an increase in poststimulation neutrophil oxidative burst (P = 0.002). Conclusion: The multistrain probiotic improved cognitive function, risk of falls, and inflammatory response in patients with cirrhosis and cognitive dysfunction and/or previous falls.
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Affiliation(s)
- Eva Román
- Department of Gastroenterology Hospital de la Santa Creu i Sant Pau Barcelona Spain.,Escola Universitària d'Infermeria EUI-Sant Pau Barcelona Spain.,Institut de Recerca IIB-Sant Pau Barcelona Spain.,CIBERehd Instituto de Salud Carlos III Madrid Spain
| | | | | | - Sílvia Vidal
- Institut de Recerca IIB-Sant Pau Barcelona Spain.,Department of Immunology Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona Barcelona Spain
| | - Marta Pozuelo
- Fundació Hospital Universitari Vall d'Hebron-Institut de Recerca Barcelona Spain
| | - Maria Poca
- Department of Gastroenterology Hospital de la Santa Creu i Sant Pau Barcelona Spain.,CIBERehd Instituto de Salud Carlos III Madrid Spain
| | - Cándido Juárez
- Institut de Recerca IIB-Sant Pau Barcelona Spain.,Department of Immunology Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona Barcelona Spain
| | - Carlos Guarner
- Department of Gastroenterology Hospital de la Santa Creu i Sant Pau Barcelona Spain.,CIBERehd Instituto de Salud Carlos III Madrid Spain
| | - Chaysavanh Manichanh
- Fundació Hospital Universitari Vall d'Hebron-Institut de Recerca Barcelona Spain.,CIBERehd Instituto de Salud Carlos III Madrid Spain
| | - Germán Soriano
- Department of Gastroenterology Hospital de la Santa Creu i Sant Pau Barcelona Spain.,CIBERehd Instituto de Salud Carlos III Madrid Spain
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Rathi S, Chopra M, Chouduri G, Sharma P, Madan K, Chhabra M, Rai RR, Govil A, Konar A, Goenka M, Agarwal M, Mukherjee J, Thorat V, Salunkhe S, Abraham P, Nagral A, Jhaveri A, Bhat N, Varghese J, R.S. A, Ravishankar, Reddy DC, Dhiman RK. Prevalence of Minimal Hepatic Encephalopathy in Patients With Liver Cirrhosis: A Cross-Sectional, Clinicoepidemiological, Multicenter, Nationwide Study in India: The PREDICT Study. J Clin Exp Hepatol 2019; 9:476-483. [PMID: 31516264 PMCID: PMC6728606 DOI: 10.1016/j.jceh.2018.09.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 09/19/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The study aimed at assessing the prevalence and clinical profile of minimal hepatic encephalopathy (MHE) in patients with cirrhosis using neuropsychological assessment and at understanding the management practices of MHE in the Indian clinical setting. METHODS This cross-sectional, clinicoepidemiological study conducted at 20 sites enrolled liver cirrhosis patients with Grade 0 hepatic encephalopathy according to West-Haven Criteria. Patients were subjected to mini-mental state examination and those with a score of ≥24 were assessed using psychometric hepatic encephalopathy score. Short Form-36 questionnaire was administered to assess the impact on health-related quality of life. RESULTS Of the 1260 enrolled patients, 1114 were included in the analysis. The mean age was 49.5 years and majority were males (901 [81%]). The prevalence of MHE was found to be 59.7% (665/1114) based on the psychometric hepatic encephalopathy score of ≤-5. Alcohol-related liver disease was the most common etiology (482 [43.27%]) followed by viral infection (239 [21.45%]). Past smokers as well as those currently smoking were more likely to have MHE than nonsmokers. A significant association was found between tobacco chewing, smoking, alcohol consumption, diabetes, and the presence of MHE. Multivariable analysis revealed smoking as the only parameter associated with MHE. A total of 300 (26.9%) patients were on prophylaxis with lactulose/lactitol or rifaximin. These patients were less likely to have MHE as compared to those not on prophylaxis (odds ratio, 0.67; 95% confidence interval, 0.50-0.88; P = 0.005). CONCLUSION The disease burden of MHE is quite substantial in patients with cirrhosis with no apparent cognitive defect. Smoking, whether past or current, has significant association with the presence of MHE. Although MHE has been shown to adversely affect quality of life, prophylaxis for MHE is not routinely practiced in the Indian setting.The study has been registered under clinical trials registry of India (CTRI/2014/01/004306).
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Key Words
- ALD, alcohol-related liver disease
- CI, confidence interval
- DST, Digit Symbol Test
- FCT, figure connection test
- HE, hepatic encephalopathy
- HRQL, health-related quality of life
- MCS, mental component summary
- MELD, model for end-stage liver disease
- MHE, minimal hepatic encephalopathy
- MMSE, mini-mental state examination
- NCT, number connection test
- PCS, physical component summary
- PHES
- PHES, psychometric hepatic encephalopathy score
- SF-36, Short Form-36
- cirrhosis
- covert hepatic encephalopathy
- hepatic encephalopathy
- lactulose
- minimal hepatic encephalopathy
- quality of life
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Affiliation(s)
- Sahaj Rathi
- Postgraduate Institute of Medical Research, Chandigarh, India
| | - Madhu Chopra
- Postgraduate Institute of Medical Research, Chandigarh, India
| | | | | | - Kaushal Madan
- Institute of Digestive and Hepatobiliary Sciences, Medanta – The Medicity, Gurgoan, India
| | | | | | - Anurag Govil
- Santokba Durlabhji Memorial Hospital, Jaipur, India
| | | | | | | | | | | | | | - Philip Abraham
- PD Hinduja Hospital and Medical Research Centre, Mumbai, India
| | | | | | - Naresh Bhat
- Columbia Asia Referral Hospital, Bangalore, India
| | | | - Arun R.S.
- Madras Medical Mission, Chennai, India
| | | | | | - Radha K. Dhiman
- Postgraduate Institute of Medical Research, Chandigarh, India,Address for correspondence: Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
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Ridola L, Nardelli S, Gioia S, Riggio O. How to Design a Multicenter Clinical Trial in Hepatic Encephalopathy. J Clin Exp Hepatol 2019; 9:137-145. [PMID: 30765947 PMCID: PMC6363957 DOI: 10.1016/j.jceh.2018.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 02/20/2018] [Indexed: 12/12/2022] Open
Abstract
The design of clinical trials on Hepatic Encephalopathy (HE) is not an easy task, in fact there are several issues related to the performance of clinical trials in HE that have impeded progress in the field, mainly because most of the studies on HE therapy were performed before the era of rigorous Randomized Controlled Trials (RCTs). In this review we discuss the major problems affecting previously published trials on HE treatments aiming to provide evidences, suggestions and indications to prepare well designed RCTs in three different settings: (1) management of hospitalized patients with episodic HE; (2) secondary prophylaxis in patients following an episode of HE; and (3) management of minimal/covert HE.
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Affiliation(s)
- Lorenzo Ridola
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Italy
- Address for correspondence: Lorenzo Ridola, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica, 04110 Latina, Italy.
| | - Silvia Nardelli
- Department of Clinical Medicine, Sapienza University of Rome, Italy
| | - Stefania Gioia
- Department of Clinical Medicine, Sapienza University of Rome, Italy
| | - Oliviero Riggio
- Department of Clinical Medicine, Sapienza University of Rome, Italy
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50
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Ridola L, Nardelli S, Gioia S, Riggio O. Quality of life in patients with minimal hepatic encephalopathy. World J Gastroenterol 2018; 24:5446-5453. [PMID: 30622374 PMCID: PMC6319138 DOI: 10.3748/wjg.v24.i48.5446] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 11/08/2018] [Accepted: 11/09/2018] [Indexed: 02/06/2023] Open
Abstract
Minimal hepatic encephalopathy (MHE) represents the mildest type of hepatic encephalopathy (HE). This condition alters the performance of psychometric tests by impairing attention, working memory, psychomotor speed, and visuospatial ability, as well as electrophysiological and other functional brain measures. MHE is a frequent complication of liver disease, affecting up to 80% of tested patients, depending of the diagnostic tools used for the diagnosis. MHE is related to falls, to an impairment in fitness to drive and the development of overt HE, MHE severely affects the lives of patients and caregivers by altering their quality of life (QoL) and their socioeconomic status. MHE is detected in clinically asymptomatic patients through appropriate psychometric tests and neurophysiological methods which highlight neuropsychological alterations such as video-spatial orientation deficits, attention disorders, memory, reaction times, electroencephalogram slowing, prolongation of latency evoked cognitive potentials and reduction in the critical flicker frequency. Several treatments have been proposed for MHE treatment such as non-absorbable disaccharides, poorly absorbable antibiotics such rifaximin, probiotics and branched chain amino acids. However, because of the multiple diagnosis methods, the various endpoints of treatment trials and the variety of agents used in trials, to date the treatment of MHE is not routinely recommended apart from on a case-by-case basis. Aim of this review is analyze the burden of MHE on QoL of patients and provide a brief summary of therapeutic approaches.
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Affiliation(s)
- Lorenzo Ridola
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina 04100, Italy
| | - Silvia Nardelli
- Department of Clinical Medicine, Sapienza University of Rome, Rome 00185, Italy
| | - Stefania Gioia
- Department of Clinical Medicine, Sapienza University of Rome, Rome 00185, Italy
| | - Oliviero Riggio
- Department of Clinical Medicine, Sapienza University of Rome, Rome 00185, Italy
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