Polyethylene glycol versus lactulose in the treatment of hepatic encephalopathy: a systematic review and meta-analysis

Review article: Evaluation and care of the critically ill patient with cirrhosis

BACKGROUND

The increase in prevalence of liver disease globally will lead to a substantial incremental burden on intensive care requirements. While liver transplantation offers a potential life-saving intervention, not all patients are eligible due to limitations such as organ availability, resource constraints, ongoing sepsis or multiple organ failures. Consequently, the focus of critical care of patients with advanced and decompensated cirrhosis turns to liver-centric intensive care protocols, to mitigate the high mortality in such patients.

AIM

Provide an updated and comprehensive understanding of cirrhosis management in critical care, and which includes emergency care, secondary organ failure management (mechanical ventilation, renal replacement therapy, haemodynamic support and intensive care nutrition), use of innovative liver support systems, infection control, liver transplantation and palliative and end-of life care.

METHODS

We conducted a structured bibliographic search on PubMed, sourcing articles published up to 31 March 2024, to cover topics addressed. We considered data from observational studies, recommendations of society guidelines, systematic reviews, and meta-analyses, randomised controlled trials, and incorporated our clinical expertise in liver critical care.

RESULTS

Critical care management of the patient with cirrhosis has evolved over time while mortality remains high despite aggressive management with liver transplantation serving as a crucial but not universally available resource.

CONCLUSIONS

Implementation of organ support therapies, intensive care protocols, nutrition, palliative care and end-of-life discussions and decisions are an integral part of critical care of the patient with cirrhosis. A multi-disciplinary approach towards critical care management is likely to yield better outcomes.

Pharmacologic Management of Hepatic Encephalopathy

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.

Current vision on diagnosis and comprehensive care in hepatic encephalopathy

The first clinical guidelines on hepatic encephalopathy were published in 2009. Almost 14 years since that first publication, numerous advances in the field of diagnosis, treatment, and special condition care have been made. Therefore, as an initiative of the Asociación Mexicana de Gastroenterología A.C., we present a current view of those aspects. The manuscript described herein was formulated by 24 experts that participated in six working groups, analyzing, discussing, and summarizing the following topics: Definition of hepatic encephalopathy; recommended classifications; epidemiologic panorama, worldwide and in Mexico; diagnostic tools; conditions that merit a differential diagnosis; treatment; and primary and secondary prophylaxis. Likewise, these guidelines emphasize the management of certain special conditions, such as hepatic encephalopathy in acute liver failure and acute-on-chronic liver failure, as well as specific care in patients with hepatic encephalopathy, such as the use of medications and types of sedation, describing those that are permitted or recommended, and those that are not.

Old and New Precipitants in Hepatic Encephalopathy: A New Look at a Field in Continuous Evolution

Hepatic encephalopathy (HE) is a common complication in patients with advanced liver disease. It is a brain dysfunction characterized by neurological and psychiatric symptoms that significantly affects quality of life, morbidity and mortality of patients. HE has various precipitants that can potentially promote its onset, alone or in combination. Among the historically well-known precipitants, such as infections, gastrointestinal bleeding, dehydration, electrolyte disorders and constipation, recent studies have highlighted the role of malnutrition and portosystemic shunts as new precipitating factors of HE. The identification, management and correction of these factors are fundamental for effective HE treatment, in addition to pharmacological therapy with non-absorbable disaccharides and/or antibiotics.

Lack of Access to Rifaximin Upon Hospital Discharge Is Frequent and Results in Increased Hospitalizations for Hepatic Encephalopathy

BACKGROUND

Hepatic encephalopathy (HE) is a complication of cirrhosis. Rifaximin, added to lactulose, effectively maintains remission and reduces hospitalizations from HE compared with lactulose alone. Although the clinical evidence supports the use of rifaximin, concerns remain regarding the financial implications and subsequent impact on medication access and outcomes.

OBJECTIVE

The goal of this study was to determine whether medication access to rifaximin at hospital discharge reduces readmission and office visits related to HE.

METHODS

A retrospective study was conducted in compliance with local institutional review board including cirrhotic patients discharged with a rifaximin prescription for HE. Patients were stratified into 2 groups: those able to obtain rifaximin and those unable to obtain rifaximin upon discharge. The primary outcome was to evaluate the rate of HE recurrence in each group as defined as a composite of readmission or office visit for acute HE within 12 months of discharge.

RESULTS

Access to rifaximin significantly reduced the risk of hospital admission and office visit for acute HE over 12 months. A hospitalization or office visit occurred in 24.5% of patients in the medication access group compared with 50% in the group without medication access. Only 58% of patients had access to rifaximin at discharge.

CONCLUSION AND RELEVANCE

Rifaximin use was associated with significantly reduced risk of hospitalization and office visits for HE. At discharge, 42% of patients did not have access to rifaximin regardless of being prescribed the medication, identifying that copay is a significant barrier in allowing patients to have access to rifaximin.

Effect of care intervention based on susceptible pointers of care quality in patients with hepatic cerebropathy

OBJECTIVE

To investigate the effect of care intervention based on susceptible pointers of care quality in patients with hepatic cerebropathy.

METHODS

The clinical data of 106 patients with hepatic cerebropathy from January 2020 to June 2021 were retrospectively analyzed, and they were assigned to a study group (n=53) or a control group (n=53) in line with diverse care means. The control group received conventional care, and the study group received additional care intervention based on susceptible pointers of care quality. The liver function, blood ammonia, neural function, capacity of daily life, and quality of life were observed and contrasted in the two groups before and after the intervention. The implementation or occurrence of key indicators of care quality, the occurrence of adverse care events, and patient care satisfaction rate were documented in the two groups after intervention.

RESULTS

After the intervention, the liver function, neural function, capacity of everyday activities, quality of life and the implementation or occurrence of key pointers of care quality in the study group were superior to those in the control group (P<0.05). The blood ammonia and the incidence of adverse events in the study group were lower than those of the control group (P<0.05), and the care satisfaction rate of patients in the study group was higher than that of the control group (P<0.05).

CONCLUSION

Care intervention based on susceptible pointers of care quality can help patients with hepatic cerebropathy to enhance liver and neural function, decrease blood ammonia and have fewer adverse care events, and enhances quality of life, care quality, and care satisfaction of patients.

New Therapies of Liver Diseases: Hepatic Encephalopathy

Hepatic encephalopathy (HE) is a common complication of advanced liver disease which has profound implications in terms of the patients’ ability to fulfil their family and social roles, to drive and to provide for themselves. Recurrent and persistent HE is still a serious management challenge, translating into a significant burden for patients and their families, health services and society at large. The past few years have been characterized by significantly more attention towards HE and its implications; its definition has been refined and a small number of new drugs/alternative management strategies have become available, while others are underway. In this narrative review we summarize them in a pragmatic and hopefully useful fashion.