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Background: Acute liver failure is a life-threatening condition with sudden onset liver injury, decreased liver functions, hepatic encephalopathy, and coagulopathy in patients without preexisting liver disease. The objective of this study was to find out the clinical and etiological factors of acute liver failure in children.Methods: This study was a hospital based prospective observational study conducted from November 2017 to October 2019 at Pediatric Intensive Care Unit (PICU) of Postgraduate Department of Pediatrics, Government Medical College Srinagar, Kashmir. Fifty-one consecutive patients of ALF in the age group of 1 to 18 years were included in this study.Results: The most common clinical presentation in our study was jaundice which was present in all cases followed by anorexia (90.2%), vomiting (84.3%), fever (76.5%) and abdominal pain (64.7%). HE was present at admission in 54.9% cases and exaggerated DTR抯 was present in 49% cases. Of the other clinical manifestations, bleeding was present in 49% cases, ascites in 33.3% cases and edema in 5.9% cases. Infections (76.5%) were the most common cause of ALF in children followed by indeterminate (9.8%), autoimmune (5.9%), drug induced (3.9%), Wilson抯 disease (2%) and HLH (2%). In infectious etiology, the most common cause was Hepatitis A (66.7%) followed by Enteric fever (7.8%) and Hepatitis E (2%).Conclusions: The most common clinical manifestation of ALF in children is Jandice. Hepatitis A is the most common cause of ALF in children.
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RESUMEN El dengue es una enfermedad infecciosa frecuente en áreas tropicales como Perú. Este virus puede producir complicaciones poco reportadas y potencialmente fatales como la falla hepática aguda. Reportamos el caso de un niño de 7 años que presentó fiebre, cefalea y dolor abdominal. En la ecografía se encontró hepatomegalia y en los laboratorios se observó trombocitopenia severa y elevación de transaminasas. Durante la hospitalización fue diagnosticado como dengue severo y desarrolló falla hepática aguda, injuria renal y encefalopatía. A pesar del manejo de soporte y la ventilación asistida, desarrolló disfunción orgánica múltiple con refractariedad a fluidos y fuga capilar. La falla hepática aguda secundaria a dengue severo es una complicación rara con desenlace desfavorable.
ABSTRACT Dengue is a common infectious disease in tropical areas such as Peru. This virus can cause underreported and potentially fatal complications such as acute liver failure. We report the case of a 7-year-old boy who presented with fever, headache, and abdominal pain. On ultrasound, we found hepatomegaly and labs severe thrombocytopenia and elevated transaminases. During hospitalization he was diagnosed with severe dengue and developed acute liver failure, kidney injury, and encephalopathy. Although intensive care management and assisted ventilation, he developed multiple organ dysfunctions with fluid refractoriness and capillary leak. Acute liver failure secondary to severe dengue is a rare complication with an unfavorable outcome.
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The gut microbiome has a significant role in overall well-being. Various probiotics are currently used for the improvement of the gut microbiome; the current scoping review aimed to critically examine the effectiveness of Bifidobacterium longum W11 in healthy and disease states. A thorough search of the literature was done in three scientific databases (PubMed, ScienceDirect, and Google Scholar) to identify and retrieve in-vitro, pre-clinical, and clinical evidence that evaluated the effect of B. longum W11 probiotic. Two independent reviewers identified and screened articles, published from 2000 to 2023 from the databases. Data from eligible studies were extracted, compiled, critically evaluated for scientific strength, and presented in this scoping review. Initially, 663 articles were identified and after a complete screening and evaluation process, twenty-one articles (eight in-vitro and animal studies; thirteen clinical studies) were included. Pre-clinical data suggest that B. longum W11 can withstand the severe gastrointestinal environment and colonize the intestinal epithelial cells to a significant degree. Due to the presence of a specific EPS cluster gene, B. longum W11 is capable of producing unique exopolysaccharides that might be responsible for the adhesion and functional capabilities of B. longum W11. Additionally, the specific mutation in the rpoB gene confers the B. longum W11 resistance to all rifamycin derivatives (including rifaximin). Clinical studies involving individuals with constipation and irritable bowel syndrome have shown that B. longum W11 supplementation significantly improves the overall quality of life and reduces the severity of symptoms. Furthermore, B. longum W11 was found to be effective in minimal hepatic encephalopathy and active celiac disease conditions. Due to the antibiotic resistance, the simultaneous use of rifaximin and B. longum W11 in patients with uncomplicated diverticular disease condition resulted in greater improvement in various symptoms compared to rifaximin supplementation alone. These data suggest that B. longum W11 is a potential probiotic that can be administered along with antibiotics in various gastrointestinal disease conditions. This evidence suggests that B. longum W11 is a promising probiotic with potential applications in various functional and inflammatory GI-related complications. Further clinical studies and stringent systematic reviews are needed to strengthen the outcomes of the current study.
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Background: Changes in the liver function test may serve as an early marker for timely diagnosis and identification of patients who may develop severe dengue. The purpose of this study was to examine the link between dengue fever severity and liver function test. Methods: This prospective observational study was conducted in the Department of General Medicine, Madhesh Institute of health sciences, provincial hospital, Janakpurdham in which we included dengue positive patients (aged 18 years or more) based on NS1 antigen or high titer on IgM/IgG testing from July 2023 till August 2023. We excluded patients with diseases like malaria, cirrhosis of liver, enteric fever, viral hepatitis or any other disease or taking any medication which can derange LFT. Results: We included 96 patients fulfilling the study criteria. Of these, 71% had DF, 22% had DHF and 7% had DSS. Among liver enzymes, mean AST of the patients was significantly higher in DSS group of patients (775.19�.65 U/l), as compared to those in the DF and DHF group of patients, p value <0.01. Similarly, mean ALT of the patients was significantly higher in DSS group of patients (387.8�.6 U/l), as compared to those in the DF and DHF group of patients, p value<0.01. On the contrary, mean alkaline phosphatase levels were similar between the three patient groups. Conclusions: Based on the results our study, we conclude that raised AST and ALT levels were significantly associated with severity of DSS and DHF. Patients with dengue infection should have a baseline liver function test and subsequent LFT monitoring to detect early hepatic impairment.
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Objective:To investigate the effect of mitochondrial division of GABAergic neurons in substantia nigra pars reticulata(SNr)on motor dysfunction in mice with acute hepatic encephalopathy(AHE).Methods:AHE mice model was established by intraperitoneal injection of thioacetamide(TAA).The changes of liver lobules in AHE mice were observed by hematoxylin-eosin(HE)staining.The changes of serum aspartate aminotransferase(AST),alanine aminotransferase(ALT)and blood ammonia in AHE mice were detected by biochemical detection kit.Then,the motor function of AHE mice was observed by rod fatigue test,elevated cross maze test and open field test.Furthermore,the changes of mitochondrial area,perimeter,roundness and other morphological indicators in SNr of AHE mice were ob-served and analyzed by transmission electron microscopy.The expression of mitochondrial division and fusion related molecules in SNr of AHE mice was observed by Western Blot.Then,the expression of mitochondrial dynamic related protein 1(DRP1)in SNr of AHE mice was targeted by AAV virus.The mitochondrial membrane potential(MMP),ATP and reactive oxygen species(ROS)in SNr were detected by fluorescence enzyme marker,and the changes of motor function of mice were observed.Results:Compared with the control group,the motor function of AHE mice was signifi-cantly decreased,the mitochondrial division of SNr was significantly enhanced,and the expression of mitochondrial divi-sion related proteins was significantly increased.The MMP in SNr of AHE mice was significantly decreased,the ATP of cells was decreased,and the ROS was increased.After targeted inhibition of DRP1 expression in SNr of AHE mice,the movement was improved;further observation found that after the mitochondrial division in SNr of AHE mice was inhibi-ted,the MMP was significantly increased,the ATP of cells was increased,and the ROS was decreased,which demon-strated that the mitochondrial function was significantly improved.Conclusion:Targeted inhibition of mitochondrial di-vision of GABAergic neurons in SNr of AHE mice can improve mitochondrial morphology and function,thus alleviating their movement disorders.
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Hepatic encephalopathy is a clinical syndrome of central nervous system dysfunction caused by liver insufficiency.It severely affects the quality of life of patients and may lead to death.Accurate prediction of the risk of developing hepatic encephalopathy is crucial for early intervention and treatment.In order to identify the risk of hepatic encephalopathy in patients in advance,many studies have been devoted to efforts to develop tools and methods to identify the risk of hepatic encephalopathy as early as possible,so as to develop preventive and early management strategies.Most conventional hepatic encephalopathy risk prediction models currently assess the prob-ability of a patient developing hepatic encephalopathy by analysing factors such as clinical data and biochemical indicators,however,their accuracy,sensitivity and positive predictive value are not high.The application of artificial intelligence to clinical predictive modelling is a very hot and promising area,which can use large amounts of data and complex algorithms to improve the accuracy and efficiency of diagnosis and prognosis.To date,there have been few studies using AI techniques to predict hepatic encephalopathy.Therefore,this paper reviews the research progress of hepatic encephalopathy risk prediction models,and also discusses the prospect of AI application in hepatic encephalopathy risk prediction models.It also points out the challenges and future research directions of AI in HE risk prediction model research in order to promote the development and clinical application of hepatic encephalopathy risk prediction models.
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ObjectiveTo investigate the influencing factors for overt hepatic encephalopathy （OHE） in patients with hepatitis B cirrhosis after transjugular intrahepatic portosystemic shunt （TIPS）， and to construct an individualized risk prediction model. MethodsA total of 302 patients with hepatitis B cirrhosis who underwent TIPS in Department of Gastroenterology， The General Hospital of Western Theater Command， from January 2017 to December 2021 were enrolled， and according to the presence or absence of OHE after surgery， they were divided into non-OHE group with 237 patients and OHE group with 65 patients. The two groups were compared in terms of general data， laboratory markers， Child-Turcotte-Pugh （CTP） score， MELD combined with serum sodium concentration （MELD-Na） score， and albumin-bilirubin （ALBI） score before surgery. The independent-samples t test or the Mann-Whitney U test was used for comparison of continuous data between two groups， and the chi-square test was used for comparison of categorical data between two groups. The univariate and multivariate logistic regression analyses were used to identify the influencing factors for OHE after TIPS in patients with hepatitis B cirrhosis， and independent influencing factors were used to construct a nomogram model. The receiver operating characteristic （ROC） curve analysis and the calibration curve analysis were used to evaluate the discriminatory ability and calibration of the model， and the decision curve analysis and the clinical impact curve （CIC） were used to evaluate the clinical effectiveness of the model . ResultsAge （odds ratio ［OR］=1.035， 95% confidence interval ［CI］： 1.004 — 1.066， P<0.05）， white blood cell count （WBC）/platelet count （PLT） ratio （OR=33.725， 95%CI： 1.220 — 932.377， P<0.05）， international normalized ratio （INR） （OR=5.149， 95%CI： 1.052 — 25.207， P<0.05）， and pre-albumin （PAB） （OR=0.992， 95%CI： 0.983 — 1.000， P<0.05） were independent predictive factors for OHE after TIPS in patients with hepatitis B cirrhosis. The nomogram model constructed based on age， WBC/PLT ratio， INR， and PAB had an area under the ROC curve of 0.716 （95%CI： 0.649 — 0.781）， with a sensitivity of 78.5% and a specificity of 56.1%. ConclusionThe nomogram model constructed based on age， WBC/PLT ratio， INR， and PAB can help to predict the risk of OHE after TIPS in patients with hepatitis B cirrhosis.
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ObjectiveTo investigate the influencing factors for death within 30 days in patients with decompensated hepatitis B cirrhosis and hepatic encephalopathy. MethodsA retrospective analysis was performed for 616 patients with hepatitis B cirrhosis and hepatic encephalopathy in Beijing Ditan Hospital from January 2008 to April 2018， and all patients were followed up for 30 days. According to their prognosis， they were divided into survival group with 488 patients and death group with 128 patients. The Mann-Whitney U test was used for comparison of continuous data between two groups， and the chi-square test or the Fisher’s exact test was used for comparison of categorical data between two groups. The Cox regression analysis was used to investigate the independent risk factors for death within 30 days in patients with hepatitis B cirrhosis and hepatic encephalopathy. ResultsThe multivariate Cox regression analysis showed that age （hazard ratio ［HR］=1.029， 95% confidence interval ［CI］： 1.014 — 1.044， P<0.001）， Model for End-Stage Liver Disease （MELD） score （HR=1.118， 95%CI： 1.098 — 1.139， P<0.001）， and neutrophil-to-lymphocyte ratio （NLR） （HR=1.036， 95%CI： 1.015 — 1.057， P=0.001） were independent risk factors for death within 30 days in patients with hepatitis B cirrhosis and hepatic encephalopathy. The stratified analysis showed that the patients with a MELD score of≥20 and an NLR of≥4 had a higher risk of death， with a 30-day mortality rate of 57.1% （80/140）. The patients with a MELD score of<20 and an NLR of<4 had a 30-day mortality rate of 3.9% （9/232）. ConclusionAge， MELD score， and NLR are independent risk factors for death within 30 days in patients with hepatitis B cirrhosis and hepatic encephalopathy， and patients with a MELD score of≥20 and an NLR of≥4 tend to have a high risk of death.
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ObjectiveTo investigate the role and possible mechanism of action of rhubarb decoction （RD） retention enema in improving inflammatory damage of brain tissue in a rat model of mild hepatic encephalopathy （MHE）. MethodsA total of 60 male Sprague-Dawley rats were divided into blank group （CON group with 6 rats） and chronic liver cirrhosis modeling group with 54 rats using the complete randomization method. After 12 weeks， 40 rats with successful modeling which were confirmed to meet the requirements for MHE model by the Morris water maze test were randomly divided into model group （MOD group）， lactulose group （LT group）， low-dose RD group （RD1 group）， middle-dose RD group （RD2 group）， and high-dose RD group （RD3 group）， with 8 rats in each group. The rats in the CON group and the MOD group were given retention enema with 2 mL of normal saline once a day； the rats in the LT group were given retention enema with 2 mL of lactulose at a dose of 22.5% once a day； the rats in the RD1， RD2， and RD3 groups were given retention enema with 2 mL RD at a dose of 2.5， 5.0， and 7.5 g/kg， respectively， once a day. After 10 days of treatment， the Morris water maze test was performed to analyze the spatial learning and memory abilities of rats. The rats were analyzed from the following aspects： behavioral status； the serum levels of alanine aminotransferase （ALT）， aspartate aminotransferase （AST）， interleukin-1β （IL-1β）， interleukin-6 （IL-6）， and tumor necrosis factor-α （TNF-α） and the level of blood ammonia； pathological changes of liver tissue and brain tissue； the mRNA and protein expression levels of phosphatidylinositol 3-kinase （PI3K）， protein kinase B （AKT）， and mammalian target of rapamycin （mTOR） in brain tissue. A one-way analysis of variance was used for comparison of continuous data between multiple groups， and the least significant difference t-test was used for further comparison between two groups. ResultsCompared with the MOD group， the RD1， RD2， and RD3 groups had a significantly shorter escape latency （all P<0.01）， significant reductions in the levels of ALT， AST， IL-1β， IL-6， TNF-α， and blood ammonia （all P<0.05）， significant alleviation of the degeneration， necrosis， and inflammation of hepatocytes and brain cells， and significant reductions in the mRNA and protein expression levels of PI3K， AKT， and mTOR in brain tissue （all P<0.05）， and the RD3 group had a better treatment outcome than the RD1 and RD2 groups. ConclusionRetention enema with RD can improve cognitive function and inflammatory damage of brain tissue in MHE rats， possibly by regulating the PI3K/AKT/mTOR signaling pathway.
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Background Patients with liver cirrhosis may show minimal hepatic encephalopathy (MHE) with mild cognitive impairment and motor incoordination. Rats with chronic hyperammonemia reproduce these alterations. Motor incoordination in hyperammonemic rats is due to increased GABAergic neurotransmission in cerebellum, induced by neuroinflammation, which enhances TNFα-TNFR1-S1PR2-CCL2-BDNF-TrkB pathway activation. The initial events by which hyperammonemia triggers activation of this pathway remain unclear. MHE in cirrhotic patients is triggered by a shift in inflammation with increased IL-17. The aims of this work were: (1) assess if hyperammonemia increases IL-17 content and membrane expression of its receptor in cerebellum of hyperammonemic rats; (2) identify the cell types in which IL-17 receptor is expressed and IL-17 increases in hyperammonemia; (3) assess if blocking IL-17 signaling with anti-IL-17 ex-vivo reverses activation of glia and of the TNFα-TNFR1-S1PR2-CCL2-BDNF-TrkB pathway. Results IL-17 levels and membrane expression of the IL-17 receptor are increased in cerebellum of rats with hyperammonemia and MHE, leading to increased activation of IL-17 receptor in microglia, which triggers activation of STAT3 and NF-kB, increasing IL-17 and TNFα levels, respectively. TNFα released from microglia activates TNFR1 in Purkinje neurons, leading to activation of NF-kB and increased IL-17 and TNFα also in these cells. Enhanced TNFR1 activation also enhances activation of the TNFR1-S1PR2-CCL2-BDNF-TrkB pathway which mediates microglia and astrocytes activation. Conclusions All these steps are triggered by enhanced activation of IL-17 receptor in microglia and are prevented by ex-vivo treatment with anti-IL-17. IL-17 and IL-17 receptor in microglia would be therapeutic targets to treat neurological impairment in patients with MHE.
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Introducción: La encefalopatía hepática mínima (EHM), es una enfermedad definida por la existencia de varias alteraciones neurofisiológicas, indetectables a la exploración neurológica y el examen clínico. Dentro de las estrategias diagnosticas para la EHM se contemplan las pruebas psicométricas (PHE), pero para su aplicación es indispensable la estandarización previamente en la población de estudio. Objetivo: El estudio se propuso determinar la tabla de la normalidad de las PHE para diagnosticar la encefalopatía hepática subclínica en una muestra de la población dominicana. Método: Se realizó un estudio descriptivo, prospectivo y transversal en un hospital de referencia nacional. Se analizaron 134 personas clasificados por grupos de edades (18-70 años de edad) y años de escolaridad. Se diseñó una tabla de 5x5. Se estudió la influencia de la edad, sexo, uso de espejuelo y de los años de escolarización en el rendimiento de cada uno de las PHE, para lo cual se utilizaron las siguientes pruebas estadísticas: análisis de varianza (ANOVA), prueba t de Student y regresión lineal. Resultado: La escolaridad y la edad fueron variables determinantes en el desempeño de las 5 pruebas psicométricas. Pero, la correlación univariable de la edad con el desempeño de la prueba TMS no hubo diferencias intra e inter grupos estadísticamente significativas (p>0.171). Conclusión: se confecciono la fórmula de predicción de resultados de los test psicométricos. Ninguno sobrepasó el punto de corte de la puntuación que oscila entre los -4 y los +2 puntos.
Introduction: Minimal hepatic encephalopathy (MHE) is a disease defined by the existence of several neurophysiological alterations, undetectable by neurological examination and clinical examination. Among the diagnostic strategies for EHM, psychometric tests (PHE) are contemplated, but for their application, prior standardization in the study population is essential. Objective: The study will need to determine the normality table of PHE to detect subclinical hepatic encephalopathy in a sample of the Dominican population. Method: A descriptive, prospective and cross-sectional study was carried out in a national reference hospital. 134 people classified by age groups (18-70 years of age) and years of schooling were analyzed. A 5x5 board is recommended. The influence of age, sex, use of glasses and years of schooling on the performance of each one of the PHEs was studied, for which the following statistical tests were used: analysis of variance (ANOVA), Student's t test and linear regression. Result: Schooling and age were determining variables in the performance of the 5 psychometric tests. But, the univariate coincidence of age with the performance of the TMS test, there were no statistically significant intra and inter group differences (p>0.171). Conclusion: the formula for predicting the results of the psychometric tests was made. None exceeded the cut-off point of the score that oscillates between -4 and +2 points.
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Humanos , Masculino , Femenino , Adolescente , Adulto , Persona de Mediana Edad , Anciano , Encefalopatía Hepática/diagnóstico , Cirrosis Hepática , República Dominicana , Pruebas Neuropsicológicas/estadística & datos numéricosRESUMEN
Aim: To describe the clinical picture, diagnosis, and treatment of a patient with encephalopathy as a manifestation of manganese-induced non-Wilsonian hepatolenticular degeneration (NWHD) in a high-complexity care center in a Latin American country. Case description: A 55-year-old male patient from the United States with a history of liver disease associated with alcohol consumption was admitted to the emergency department due to diarrhea, hematemesis, and psychomotor agitation. During his stay, his state of consciousness deteriorated, requiring orotracheal intubation. In his diagnostic study, cerebrospinal fluid tests were negative for infectious etiologies; the endoscopic examinations showed no marks of portal hypertension bleeding, while ammonium and tests for metabolic causes were normal. However, areas of hyperintensity in the basal ganglia were documented on brain MRI, with normal ceruloplasmin serum and urine copper levels, which ruled out Wilson's disease and determined the diagnosis of manganese-induced NWHD. Conclusion: NWHD is a rare cause of chronic encephalopathy with clinical manifestations of extrapyramidal symptoms secondary to basal ganglia dysfunction due to severe liver disease. Its diagnosis becomes a challenge, given that manganese deposits produce it, and no biomarkers can establish the level of exposure to this metal. Brain MRI is indispensable in reflecting these deposits in the basal ganglia.
Objetivo: Describir la presentación clínica, el diagnóstico y el tratamiento de un paciente con encefalopatía como manifestación de degeneración hepatolenticular no wilsoniana producida por manganeso, en un centro de alta complejidad de un país latinoamericano. Descripción del caso: Paciente masculino de 55 años, procedente de Estados Unidos, con antecedente de enfermedad hepática asociada con consumo de alcohol, quien ingresó al servicio de urgencias por un cuadro de diarrea, hematemesis y agitación psicomotora. Durante la estancia presentó deterioro en el estado de consciencia, por lo que requirió intubación orotraqueal. En su estudio diagnóstico, las pruebas de líquido cefalorraquídeo fueron negativas para etiologías infecciosas, en los estudios endoscópicos no tenía estigmas de sangrado portal hipertensivo y el amonio y los estudios para causas metabólicas fueron normales. Sin embargo, se documentaron áreas de hiperintensidad en los ganglios de la base en la resonancia magnética cerebral, con niveles de ceruloplasmina sérica y cobre urinario normales, lo que descartó enfermedad de Wilson y definió el diagnóstico de degeneración hepatolenticular no wilsoniana por depósitos de manganeso. Conclusión: La degeneración hepatolenticular no wilsoniana es una causa infrecuente de encefalopatía crónica con manifestaciones clínicas de extrapiramidalismo, secundaria a disfunción de los ganglios de la base por enfermedad hepática grave. Su diagnóstico se convierte en un reto, dado que se produce por depósitos de manganeso y no existen biomarcadores que puedan establecer el nivel de exposición a este metal. La resonancia magnética cerebral juega, por tanto, un papel indispensable al reflejar esos depósitos en los ganglios de la base.
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En 1983 el National Institutes of Health USA (NIH) declaró que el trasplante hepático orto tópico (THO) era una alternativa tera-péutica eficaz para pacientes con enfermedades hepáticas avan-zadas. Desde entonces, se han realizado cerca de 100 000 THO en el mundo, en más de 200 centros distintos. El THO (tanto en hepatopatías crónicas avanzadas como en hepatitis fulminante) tiene por objetivo primordial prolongar la sobrevida de los pa-cientes afectados, logrando una buena calidad de vida posterior al trasplante. Las tasas promedio de sobrevida actuarial de pacientes a 1 y 5 años son de aproximadamente 85% y 80% respectivamente. Los resultados generales del THO dependen de la causa primaria del daño hepático del receptor y del estado clínico del paciente al momento de la operación1. El trasplante hepático como tratamiento permite mejorar la ca-lidad de vida de pacientes con hepatopatías en fase terminal, está considerado en algunos pacientes con hepatopatía crónica avanzada de diferente etiología y en pacientes con insuficiencia hepática aguda grave no reversible con las medidas de trata-miento convencional. Las principales patologías que son motivo de trasplante hepático son: cirrosis hepática de diversa etiología (59% de los pacientes trasplantados), tumores hepáticos (21%), cuadros colestásicos (5%) e insuficiencia hepática aguda grave (3%)2. Por todo lo anteriormente mencionado, la Unidad Técnica de Nutrición del Hospital de Especialidades Carlos Andrade Marín ha visto la necesidad de realizar el siguiente protocolo con el fin de estandarizar un adecuado manejo nutricional para la preven-ción, tratamiento y complicaciones de pacientes en estadio cirró-tico terminal que requieran un trasplante hepático.
In 1983 the NIH (National Institutes of Health, USA) declared that orthotopical liver transplantation (ORT) was an effective therapeutic alternative for patients with advanced liver diseases. Since then, nearly 100,000 OLTs have been performed world-wide, in more than 200 different centers. OLT (both in advanced chronic liver disease and in fulminant hepatitis) has the primary objective of prolonging the survival of affected patients, achie-ving a good quality of life after transplantation.The average 1-year and 5-year actuarial patient survival rates are approximately 85% and 80%, respectively. The general re-sults of OLT depend on the primary cause of the recipient's liver damage and the clinical status of the patient at the time of the operation1.Liver transplantation as a treatment improves the quality of life of patients with end-stage liver disease. It is considered in some patients with advanced chronic liver disease of different etiolo-gies and in patients with severe acute liver failure that is not reversible with conventional treatment measures. The main pa-thologies that are the reason for liver transplantation are: liver cirrhosis of various etiologies (59% of transplant patients), liver tumors (21%), cholestatic conditions (5%) and severe acute liver failure (3%)2.For all of the above, the Technical Nutrition Unit of the Carlos Andrade Marin Specialty Hospital has seen the need to carry out the following protocol in order to standardize adequate nu-tritional management for the prevention, treatment and complications of patients in the terminal cirrhotic stage who re-quire a liver transplant.
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Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Encefalopatía Hepática , Estado Nutricional , Trasplante de Hígado , Dislipidemias , Cirrosis Hepática , Pruebas de Función Hepática , EcuadorRESUMEN
Decompensated chronic liver disease, is a histopathologically defined condition with a variety of clinical symptoms and complications, some of which are associated with an increased risk of in-hospital mortality. Cirrhosis is predicted to affect 100 (range 25-400) per 100,000 people worldwide, with a male-to-female ratio of one. Patients with ethanol-related cirrhosis have a 5-year death rate ranging from 60-85%. One of the leading causes of cirrhosis is alcoholism. However, it can also be caused by non-alcoholic steatohepatitis (NASH), autoimmune disorders, and viral hepatitis. The decompensated chronic liver disease carries a 9.7 times greater chance of mortality. Cirrhosis is a histologic diagnosis, but a combination of clinical, laboratory, and imaging characteristics can help confirm a cirrhosis diagnosis. For evaluating liver cirrhosis, a liver biopsy continues to be the gold standard. A non-invasive approach to assessing liver cirrhosis is transient elastography (FibroScan). Patients with severe cirrhosis may experience several significant sequelae that complicate their clinical path. These include portal hypertension and related side effects, such as gastroesophageal varices, splenomegaly, ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatopulmonary syndrome, and hepatocellular carcinoma. In decompensated chronic liver disease, treatment focuses on underlying liver disease, dietary changes, and long-term medical management to control underlying problems. For patients who do not react to other medications, liver transplantation can be an effective long-term therapy option.
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Abstract Hepatic encephalopathy (HE) is a potentially reversible neuropsychiatric syndrome. Often, HE causes cognitive and motor dysfunctions due to an acute or chronic insufficiency of the liver or a shunting between the hepatic portal vein and systemic vasculature. Liver damage induces peripheral changes, such as in the metabolism and peripheral inflammatory responses that trigger exacerbated neuroinflammation. In experimental models, anti-inflammatory strategies have demonstrated neuroprotective effects, leading to a reduction in HE-related cognitive and motor impairments. In this scenario, a growing body of evidence has shown that peripheral and central nervous system inflammation are promising preclinical targets. In this review, we performed an overview of FDA-approved drugs and natural compounds which are used in the treatment of other neurological and nonneurological diseases that have played a neuroprotective role in experimental HE, at least in part, through anti-inflammatory mechanisms. Despite the exciting results from animal models, the available data should be critically interpreted, highlighting the importance of translating the findings for clinical essays.
Resumo A encefalopatia hepática (EH) é uma síndrome neuropsiquiátrica potencialmente reversível. Muitas vezes a EH causa disfunções cognitivas e motoras devido à insuficiência do fígado ou por um desvio entre a veia porta hepática e a vasculatura sistêmica. O dano no fígado provoca alterações periféricas, como no metabolismo e nas respostas inflamatórias periféricas, que desencadeiam uma neuroinflamação exacerbada. Em modelos experimentais, estratégias anti-inflamatórias têm demonstrado efeitos neuroprotetores, levando a uma redução dos prejuízos cognitivos e motores relacionados à EH. Neste cenário, evidências crescentes têm mostrado a inflamação periférica e no sistema nervoso central como um promissor alvo pré-clínico. Nesta revisão, abordamos uma visão geral de drogas e compostos naturais aprovados pelo FDA para o uso no tratamento de outras doenças neurológicas e não neurológicas, que tiveram papel neuroprotetor na EH experimental, pelo menos em parte, através de mecanismos anti-inflamatórios. Apesar dos resultados empolgantes em modelos animais, os dados avaliados devem ser criticamente interpretados, destacando a importância da tradução dos achados para ensaios clínicos.
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Introduction: Albumin is administered 20% as a part of treatment in various indications associated with decompensated liver disease. Methods: The study was conducted on patients over six months. Data were collected from 50 patients including males and females who are administered 20% albumin for liver cirrhosis. Disease severity before and after albumin infusion was calculated using prognostic tools like Child-Pugh and MELD-Na scoring system. Results: Among 50 patients, a major percent of patients were found to be HRS (28%) for albumin infusion and few extended indications were noticed; Decompensated liver cirrhosis without any other complications (18%), HE (18%), Hyponatremia (16%). After albumin infusion for six months, prognostic tools (CPT and MELD-Na scores) and laboratory parameters (serum creatinine, serum sodium, serum albumin) were significantly improved with P-value less than 0.05. Conclusion: Albumin usage has increased in some extended indications like decompensated liver cirrhosis without any other complications, hyponatremia, hepatic encephalopathy. Doses used in the present study were significantly less (when compared to standard doses as per the clinical guidelines) to minimize the adverse effects of albumin primarily pulmonary edema due to volume overload. Our study was consistent with the ANSWER trial where 20% albumin was used for the long term in decompensated liver cirrhosis.
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Sarcopenia is one of the manifestations of malnutrition in patients with liver cirrhosis. Most studies have shown that sarcopenia is associated with overt hepatic encephalopathy (OHE), leading to an increased risk of events such as reduced quality of life, poor clinical prognosis, and even death in patients with liver cirrhosis, but there are few studies on the association between sarcopenia and minimal hepatic encephalopathy (MHE). This article reviews the research advances in sarcopenia and hepatic encephalopathy to provide a reliable basis for clinical treatment, and it is pointed out that the nutritional status of patients can be improved to prevent MHE and even reduce the onset of OHE, thereby improving patient prognosis, increasing quality of life, and reducing the risk of death.
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Objective To investigate the value of serum markers in the early diagnosis of liver cirrhosis with minimal hepatic encephalopathy (MHE). Methods A prospective analysis was performed for 81 patients who were hospitalized and treated in General Hospital of Ningxia Medical University from April 2020 to February 2022, and all these patients were diagnosed with hepatitis B cirrhosis based on clinical manifestation, laboratory examination, and radiological examination or liver biopsy. According to digital connection test A (NCT-A) and digital symbol test (DST), these patients were divided into simple cirrhosis group with 45 patients and MHE group with 36 patients. Related indices were measured, including liver function [alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transpeptidase (GGT), alkaline phosphatase (ALP), and total bilirubin (TBil)], albumin, blood ammonia, cholinesterase, and prothrombin time. The independent samples t -test was used for comparison of normally distributed continuous data between two groups; the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups, and the Kruskal-Wallis H test was used for comparison between multiple groups; the chi-square test was used for comparison of categorical data between groups. The logistic regression analysis and the area under the ROC curve (AUC) were used to investigate the predictive factors for MHE. Results Compared with the simple cirrhosis group, the MHE group had a significant increase in NCT-A score ( Z =-7.110, P < 0.001) and a significant reduction in DST score ( t =12.223, P < 0.001). The univariate analysis showed that there were significant changes in AST, albumin, prothrombin time, cholinesterase, and blood ammonia in the patients with MHE ( Z =-2.319, -2.643, -1.982, -6.594, and -5.331, all P < 0.05), while the multivariate analysis showed that only cholinesterase and blood ammonia were significant predictive factors (all P < 0.05) and were correlated with Child-Pugh score (all P < 0.05). Cholinesterase, blood ammonia, and their combination had an AUC of 0.925, 0.845, and 0.941, respectively, in the diagnosis of MHE, with an optimal cut-off value of 2966, 60, and 0.513, respectively. Conclusion Blood ammonia, cholinesterase, and their combined measurement have a potential clinical value in the early diagnosis of liver cirrhosis with MHE.
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Hepatic encephalopathy is a serious complication of liver cirrhosis and can cause neuropsychiatric symptoms such as cognitive impairment and motor impairment. More than 30% of patients with liver cirrhosis may develop hepatic encephalopathy， posing a huge economic burden to the health of patients and bringing many challenges to clinical diagnosis and treatment. Therefore， early identification， diagnosis， and treatment are the key to improving patient prognosis. Based on the clinical experience of our center， this article elaborates on hepatic encephalopathy from the aspects of pathogenesis， time dimension， minimal hepatic encephalopathy， and non-organic brain lesions， in order to provide new ideas or strategies for the diagnosis and treatment of hepatic encephalopathy in liver cirrhosis.
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Hepatic encephalopathy (HE) is a common complication and an independent risk factor for death in patients with liver cirrhosis. Brain lactate level is associated with the progression and severity of HE, and research on brain lactate level may help to further explain the pathogenesis of HE. This article summarizes the metabolic process of brain lactate, the association between brain lactate level and HE, and the potential therapeutic targets for HE and provides a reference for clinicians to further systematically evaluate the progression, treatment outcome, and prognosis of patients with HE, in order to reduce the medical burden of patients and improve the prognosis of patients with HE.