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Smith ML, Wade JB, Wolstenholme J, Bajaj JS. Gut microbiome-brain-cirrhosis axis. Hepatology 2024; 80:465-485. [PMID: 36866864 PMCID: PMC10480351 DOI: 10.1097/hep.0000000000000344] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [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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Gairing SJ, Mangini C, Zarantonello L, Jonasson E, Dobbermann H, Sultanik P, Galle PR, Labenz J, Thabut D, Marquardt JU, Bloom PP, Lauridsen MM, Montagnese S, Labenz C. Proton pump inhibitor use and risk of hepatic encephalopathy: A multicentre study. JHEP Rep 2024; 6:101104. [PMID: 39035069 PMCID: PMC11260370 DOI: 10.1016/j.jhepr.2024.101104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/16/2024] [Accepted: 04/23/2024] [Indexed: 07/23/2024] Open
Abstract
Background & Aims Data on the association between proton pump inhibitor (PPI) use and hepatic encephalopathy (HE) are conflicting, and data from multicentre studies are scarce. The aim of this study was to dissect the potential association between PPI use and minimal (MHE) and overt HE (OHE). Methods Data from patients with cirrhosis recruited at seven centres across Europe and the US were analysed. MHE was defined by the psychometric hepatic encephalopathy score (PHES). PPI use was recorded on the day of testing with PHES. Patients were followed for OHE development and death/liver transplantation. Results A total of 1,160 patients with a median MELD of 11 were included (Child-Pugh stages: A 49%/B 39%/C 11%). PPI use was noted in 58% of patients. Median follow-up time was 18.1 months, during which 230 (20%) developed an OHE episode, and 224 (19%) reached the composite endpoint of death/liver transplantation. In multivariable analyses, PPI use was neither associated with the presence of MHE at baseline nor OHE development during follow-up. These findings were consistent in subgroup analyses of patients with Child-Pugh A or B cirrhosis and after excluding patients with a history of OHE. PPI use was also not associated with a higher risk of OHE, neither in patients with an indication for treatment nor in patients without an indication. Conclusions PPI use is not associated with a higher risk of HE in patients with cirrhosis. Based on these findings, at present, a prescription should not be prohibited in case of a generally accepted indication. Impact and implications Data on the association between proton pump inhibitor (PPI) use and hepatic encephalopathy (HE) are conflicting. In this study, PPI use was not associated with a higher risk of minimal HE at baseline or overt HE during follow-up in patients with cirrhosis. Based on these findings, prescription of a PPI for a generally accepted indication should not be prohibited in patients with cirrhosis.
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Affiliation(s)
- Simon Johannes 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
| | - Chiara Mangini
- Department of Medicine, University of Padova, Padova, Italy
| | | | - Elise Jonasson
- Department of Gastroenterology and Hepatology, Hospital of South West Jutland, Esbjerg, Denmark
| | - Henrike Dobbermann
- Department of Medicine I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Philippe Sultanik
- Service d'hépato-gastroentérologie, Sorbonne Université, Hôpital Pitié-Salpêtrière Assistance Publique Hôpitaux de Paris, Paris, France
| | - Peter Robert 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
| | - Joachim Labenz
- Department of Medicine, Diakonie Hospital Jung-Stilling, Siegen, Germany
| | - Dominique Thabut
- Service d'hépato-gastroentérologie, Sorbonne Université, Hôpital Pitié-Salpêtrière Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jens Uwe Marquardt
- Department of Medicine I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Patricia P. Bloom
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, United States
| | - Mette Munk Lauridsen
- Department of Gastroenterology and Hepatology, Hospital of South West Jutland, Esbjerg, Denmark
| | - Sara Montagnese
- Department of Medicine, University of Padova, Padova, Italy
- Chronobiology Section, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - 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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Gairing SJ, Mangini C, Zarantonello L, Gioia S, Nielsen EJ, Danneberg S, Lok AS, Sultanik P, Galle PR, Labenz J, Thabut D, Marquardt JU, Bloom PP, Lauridsen MM, Montagnese S, Nardelli S, Labenz C. Minimal hepatic encephalopathy is associated with a higher risk of overt hepatic encephalopathy and poorer survival. J Intern Med 2024; 295:331-345. [PMID: 37983845 DOI: 10.1111/joim.13747] [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] [Indexed: 11/22/2023]
Abstract
BACKGROUND AND AIMS Minimal hepatic encephalopathy (MHE) is a frequent complication in patients with liver cirrhosis. Its impact on predicting the development of overt hepatic encephalopathy (OHE) and survival has not been studied in large multicenter studies. METHODS Data from patients recruited at eight centers across Europe and the United States were analyzed. MHE was detected using the psychometric hepatic encephalopathy score (PHES). A subset was also tested with the simplified animal naming test (S-ANT1). Patients were followed for OHE development and death/liver transplantation (LTx). RESULTS A total of 1462 patients with a median model of end-stage liver disease of 11 were included (Child-Pugh (CP) stages: A 47%/B 41%/C 12%). Median follow-up time was 19 months, during which 336 (23%) patients developed an OHE episode and 464 (32%) reached the composite end point of death/LTx (369 deaths, 95 LTx). In multivariable analyses, MHE (defined by PHES) was associated with the development of OHE (subdistribution hazard ratio 1.74, p < 0.001) and poorer LTx-free survival (hazard ratio 1.53, p < 0.001) in the total cohort as well as in the subgroup of patients without a history of OHE. In subgroup analyses, MHE (defined by PHES) was associated with OHE development in patients with CP B, whereas there was no association in patients with CP A or C. In the subgroup of patients with available S-ANT1, MHE (defined by S-ANT1) was independently associated with OHE development. Combined testing (PHES+S-ANT1) was superior to single testing for predicting OHE and poorer LTx-free survival. CONCLUSIONS This large multicenter study demonstrates that screening for MHE is a useful tool for predicting OHE and poorer survival.
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Affiliation(s)
- Simon Johannes 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
| | - Chiara Mangini
- Department of Medicine, University of Padova, Padova, Italy
| | | | - Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Elise Jonasson Nielsen
- Department of Gastroenterology and Hepatology, Hospital of South West Jutland, Esbjerg, Denmark
| | - Sven Danneberg
- Department of Medicine I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Anna S Lok
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Philippe Sultanik
- Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière Assistance Publique Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Peter Robert 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
| | - Joachim Labenz
- Department of Medicine, Diakonie Hospital Jung-Stilling, Siegen, Germany
| | - Dominique Thabut
- Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière Assistance Publique Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Jens Uwe Marquardt
- Department of Medicine I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Patricia P Bloom
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Mette Munk Lauridsen
- Department of Gastroenterology and Hepatology, Hospital of South West Jutland, Esbjerg, Denmark
| | - Sara Montagnese
- Department of Medicine, University of Padova, Padova, Italy
- Chronobiology Section, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Silvia Nardelli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - 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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Gairing SJ, Mangini C, Zarantonello L, Gioia S, Nielsen EJ, Danneberg S, Gabriel M, Ehrenbauer AF, Bloom PP, Ripoll C, Sultanik P, Galle PR, Labenz J, Thabut D, Zipprich A, Lok AS, Weissenborn K, Marquardt JU, Lauridsen MM, Nardelli S, Montagnese S, Labenz C. Prevalence of Minimal Hepatic Encephalopathy in Patients With Liver Cirrhosis: A Multicenter Study. Am J Gastroenterol 2023; 118:2191-2200. [PMID: 36940426 DOI: 10.14309/ajg.0000000000002251] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/01/2023] [Indexed: 03/22/2023]
Abstract
INTRODUCTION The prevalence of minimal hepatic encephalopathy (MHE), in particular in different subgroups, remains unknown. This study aimed to analyze the prevalence of MHE in different subgroups to identify patients at high risk and to pave the way for personalized screening approaches. METHODS In this study, data of patients recruited at 10 centers across Europe and the United States were analyzed. Only patients without clinical signs of hepatic encephalopathy were included. MHE was detected using the Psychometric Hepatic Encephalopathy Score (PHES, cut-off < or ≤-4 depending on local norms). Clinical and demographic characteristics of the patients were assessed and analyzed. RESULTS In total, 1,868 patients with cirrhosis with a median model for end-stage liver disease (MELD) of 11 were analyzed (Child-Pugh [CP] stages: A 46%, B 42%, and C 12%). In the total cohort, MHE was detected by PHES in 650 patients (35%). After excluding patients with a history of overt hepatic encephalopathy, the prevalence of MHE was 29%. In subgroup analyses, the prevalence of MHE in patients with CP A was low (25%), whereas it was high in CP B or C (42% and 52%). In patients with a MELD score <10, the prevalence of MHE was only 25%, but it was 48% in patients with a MELD score ≥20. Standardized ammonia levels (ammonia level/upper limit of normal of each center) correlated significantly, albeit weakly with PHES (Spearman ρ = -0.16, P < 0.001). DISCUSSION The prevalence of MHE in patients with cirrhosis was high but varied substantially between diseases stages. These data may pave the way for more individualized MHE screening approaches.
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Affiliation(s)
- Simon Johannes 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
| | - Chiara Mangini
- Department of Medicine, University of Padova, Padova, Italy
| | | | - Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Elise Jonasson Nielsen
- Department of Gastroenterology and Hepatology, Hospital of South West Jutland, Esbjerg, Denmark
| | - Sven Danneberg
- Department of Medicine I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Maria Gabriel
- Clinic for Neurology, Hannover Medical School, Hannover, Germany
| | | | - Patricia P Bloom
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Cristina Ripoll
- Department of Internal Medicine IV, Jena University Hospital, Jena, Germany
- First Department of Internal Medicine, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Philippe Sultanik
- Service d'hépato-gastroentérologie, Sorbonne Université, Hôpital Pitié-Salpêtrière Assistance Publique Hôpitaux de Paris, Paris, France
| | - Peter Robert 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
| | - Joachim Labenz
- Department of Medicine, Diakonie Hospital Jung-Stilling, Siegen, Germany
| | - Dominique Thabut
- Service d'hépato-gastroentérologie, Sorbonne Université, Hôpital Pitié-Salpêtrière Assistance Publique Hôpitaux de Paris, Paris, France
| | - Alexander Zipprich
- Department of Internal Medicine IV, Jena University Hospital, Jena, Germany
- First Department of Internal Medicine, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Anna S Lok
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Jens Uwe Marquardt
- Department of Medicine I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Mette Munk Lauridsen
- Department of Gastroenterology and Hepatology, Hospital of South West Jutland, Esbjerg, Denmark
| | - Silvia Nardelli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Sara Montagnese
- Department of Medicine, University of Padova, Padova, Italy
- Chronobiology Section, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - 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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Bajaj JS, Lai JC, Tandon P, O'Leary JG, Wong F, Garcia-Tsao G, Vargas HE, Kamath PS, Biggins SW, Limon-Miro A, Shaw J, Mbachi C, Chew M, Golob Deeb J, Thacker LR, Reddy KR. Role of Oral Health, Frailty, and Minimal Hepatic Encephalopathy in the Risk of Hospitalization: A Prospective Multi-Center Cohort of Outpatients With Cirrhosis. Clin Gastroenterol Hepatol 2023; 21:1864-1872.e2. [PMID: 36328307 PMCID: PMC11057906 DOI: 10.1016/j.cgh.2022.10.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/23/2022] [Accepted: 10/17/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND & AIMS Hospitalizations are a sentinel event in cirrhosis; however, the changing demographics in patients with cirrhosis require updated hospitalization prediction models. Periodontitis is a risk factor for liver disease and potentially progression. The aim of this study was to determine factors, including poor oral health, associated with 3-month hospitalizations in a multi-center cohort of outpatients with cirrhosis. METHODS North American Consortium for Study of End-stage Liver Disease (NACSELD-3), a new study cohort, recruits outpatients with cirrhosis. Cirrhosis details, demographics, minimal hepatic encephalopathy (MHE), frailty, and comorbid conditions including oral health were collected. All patients were followed for 3 months for nonelective hospitalizations. Multi-variable models were created for this outcome using demographics, cirrhosis details, oral health, MHE, frailty, and comorbid conditions with K-fold internal validation using 25%/75% split. RESULTS A total of 442 outpatients (70% men; 37% compensated; Model for End-stage Liver Disease-Sodium, 12; 42% ascites; and 33% prior HE) were included. MHE was found in 70%, frailty in 10%; and both in 8%. In terms of oral health, 15% were edentulous and 10% had prior periodontitis. Regarding 3-month hospitalizations, 14% were admitted for mostly liver-related reasons. These patients were more likely to be decompensated with higher cirrhosis complications, MHE, frailty and periodontitis history. Multi-variable analysis showed prior periodontitis (P = .026), composite MHE + frailty score (P = .0016), ascites (P = .004), prior HE (P = .008), and hydrothorax (P = .004) were associated with admissions using the training and validation subsets. CONCLUSIONS In a contemporaneous, prospective, multi-center cohort study in outpatients with cirrhosis, poor oral health is significantly associated with 3-month hospitalizations independent of portal hypertensive complications, MHE, and frailty. Potential strategies to reduce hospitalizations should consider oral evaluation in addition to MHE and frailty assessment in practice pathways.
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Affiliation(s)
- Jasmohan S Bajaj
- Department of Medicine, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia.
| | - Jennifer C Lai
- Department of Medicine, University of California, San Francisco, California
| | - Puneeta Tandon
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Florence Wong
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Hugo E Vargas
- Department of Medicine, Mayo Clinic, Phoenix, Arizona
| | | | - Scott W Biggins
- Department of Medicine, University of Washington, Seattle, Washington
| | - Ana Limon-Miro
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jawaid Shaw
- Department of Medicine, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia
| | - Chimezie Mbachi
- Department of Medicine, West Haven VA Medical Center, West Haven, Connecticut
| | - Michael Chew
- Department of Medicine, West Haven VA Medical Center, West Haven, Connecticut
| | - Janina Golob Deeb
- Department of Periodontics, Virginia Commonwealth University, Richmond, Virginia
| | - Leroy R Thacker
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - K Rajender Reddy
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Gairing SJ, Schleicher EM, Labenz C. Diabetes mellitus - risk factor and potential future target for hepatic encephalopathy in patients with liver cirrhosis? Metab Brain Dis 2022; 38:1691-1700. [PMID: 36001211 DOI: 10.1007/s11011-022-01068-4] [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: 05/09/2022] [Accepted: 08/08/2022] [Indexed: 10/15/2022]
Abstract
Hepatic encephalopathy (HE) is one of the major complications of cirrhosis, and its presence is associated with poor survival. Several risk factors for HE are well established, including age, history of HE, portosystemic shunts, or poorer liver function. In recent years, diabetes mellitus (DM) has emerged as another potential risk factor for the development of HE. This may be important for many patients, as the incidence of type 2 DM (T2DM) is increasing worldwide and, consequently, the incidence of NAFLD-related cirrhosis is rising simultaneously. In addition, DM is a critical factor in the progression of other liver diseases, such as alcohol-related liver disease. Thus, the number of patients with cirrhosis and comorbid T2DM will also increase. To date, the prevalence of DM already ranges between 22 - 40% in patients with cirrhosis. DM-associated factors that may influence the risk of HE include systemic inflammation, insulin resistance with increased muscle protein breakdown as well as autonomic dysfunction with prolonged intestinal transit time and small intestinal bacterial overgrowth. Currently, the evidence for an association between DM and both minimal and overt HE is weak and it seems likely that only poor glycemic control has an impact on HE risk. In addition, there are some early signs indicating that DM may impair the response of patients with HE to pharmacological therapies such as rifaximin. Thus, improvements in the management of glycemic control may be a candidate future target to reduce the risk of HE. In this concise review, we summarize the current evidence on the association between DM and HE and its potential future implications.
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Affiliation(s)
- Simon Johannes Gairing
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg- University, Mainz, Germany
| | - Eva Maria Schleicher
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, 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, Langenbeckstrasse 1, 55131, Mainz, Germany.
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg- University, Mainz, Germany.
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Gairing SJ, Müller L, Kloeckner R, Galle PR, Labenz C. Review article: post-TIPSS hepatic encephalopathy-current knowledge and future perspectives. Aliment Pharmacol Ther 2022; 55:1265-1276. [PMID: 35181894 DOI: 10.1111/apt.16825] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/23/2022] [Accepted: 02/02/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND In light of the global rise in the burden of chronic liver diseases and liver cirrhosis, the number of patients suffering from decompensation events is expected to increase. Transjugular intrahepatic portosystemic shunts (TIPSS) provide effective long-term symptom control and may prolong transplant-free survival in portal hypertension-driven recurrent ascites and variceal bleeding. New-onset or recurrent hepatic encephalopathy (HE) after TIPSS insertion (post-TIPSS HE) represents the most severe post-interventional complication. AIMS To provide insight into the epidemiology and risk factors for post-TIPSS HE and scrutinize the current state of the art in treatment and drug therapy options. METHODS We conducted a literature search on post-TIPSS HE in patients with liver cirrhosis. RESULTS Post-TIPSS HE occurs in up to 54.5% of cases and particularly early recurrent HE is associated with a dismal prognosis. In recent years, several risk factors for the development of post-TIPSS HE have been identified. These include not only parameters reflecting liver function (model for end-stage liver disease score/Child-Pugh score) as well as cognitive dysfunction caused by minimal HE but also extrahepatic factors such as sarcopenia and common medications such as proton pump inhibitors. In addition, new data on the benefit of rifaximin and of smaller stent grafts emerged and may improve the prevention of post-TIPSS HE. CONCLUSIONS Careful selection of TIPSS candidates is of utmost importance to reduce the risk of post-TIPSS HE. In this narrative review, we provide a concise overview of the current epidemiology and risk factors of the treatment options for post-TIPSS HE.
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Affiliation(s)
- Simon Johannes 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
| | - Lukas Müller
- Department of Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Roman Kloeckner
- Department of Radiology, 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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Proton Pump Inhibitors in Patients With Liver Cirrhosis: Evidence to Improve Their Battered Reputation. Am J Gastroenterol 2021; 116:2304. [PMID: 34279008 DOI: 10.14309/ajg.0000000000001394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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9
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Response to Labenz and Labenz. Am J Gastroenterol 2021; 116:2304. [PMID: 34404082 DOI: 10.14309/ajg.0000000000001406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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