Prevalence of Minimal Hepatic Encephalopathy in Patients With Liver Cirrhosis: A Multicenter Study

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.

Prevalence and risk factors for minimal hepatic encephalopathy in cirrhotic patients with different etiologies

“…16,17,[19][20][21] However, either no further analysis was performed, or further investigation of risk factors for MHE in some studies subsequently ruled out the etiology. 20,21 On the contrary, studies have also shown that the prevalence of MHE in patients with alcoholic cirrhosis is significantly higher than that in patients with other causes of cirrhosis at the time of the preliminary analysis; moreover, as an independent influencing factor, there is a synergistic effect with cirrhosis, exacerbating cognitive impairment in affected patients. Although HCV infection is associated with cognitive impairment, no significant difference has been found in multiple factors.…”

“…43 Previous studies have been fairly consistent in showing that age, years of education, and MELD-Na scores are risk factors for MHE, and the results of our preliminary analysis were in agreement with this. [20][21][22] In addition, because etiology was found to be an independent risk factor for the occurrence of MHE in our preliminary analysis, we considered it separately according to etiology. Except for studies that explicitly included patients with specific etiologies, few studies to date have explored risk factors separately according to etiology.…”

“…[16][17][18][19][20][21][22] Additionally, several studies examining the risk factors for MHE have reached inconsistent conclusions on whether the etiology of cirrhosis is a risk factor for the occurrence of MHE. [20][21][22] In summary, it remains unclear whether there is a difference in the prevalence of MHE among patients with cirrhosis of different etiologies and whether etiology directly influences the occurrence of MHE. More evidence is needed in this area, especially in China, where 0.5% of the population has cirrhosis, resulting in a significant disease burden.…”

“…[12][13][14][15] In other studies, however, the prevalence of MHE in patients with alcoholic cirrhosis or hepatitis C virus (HCV)-related cirrhosis was higher than that in patients with cirrhosis of other etiologies. [16][17][18][19][20][21][22] Additionally, several studies examining the risk factors for MHE have reached inconsistent conclusions on whether the etiology of cirrhosis is a risk factor for the occurrence of MHE. [20][21][22] In summary, it remains unclear whether there is a difference in the prevalence of MHE among patients with cirrhosis of different etiologies and whether etiology directly influences the occurrence of MHE.…”

Iatrogenic liver diseases: a new concept, with practices to be condemned

“…It is recommended that all patients with liver cirrhosis undergo regular screening for MHE, especially those who have a history of hepatic encephalopathy, driving is a part of their daily activities, or have undergone a liver transplant. Screening should also be considered in patients with advanced liver disease or those who are at high risk for developing MHE (40).…”