Observational Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Sep 14, 2017; 23(34): 6321-6329
Published online Sep 14, 2017. doi: 10.3748/wjg.v23.i34.6321
Natural history of covert hepatic encephalopathy: An observational study of 366 cirrhotic patients
An-Jiang Wang, A-Ping Peng, Bi-Min Li, Na Gan, Li Pei, Xue-Lian Zheng, Jun-Bo Hong, Hai-Ying Xiao, Jia-Wei Zhong, Xuan Zhu
An-Jiang Wang, A-Ping Peng, Bi-Min Li, Na Gan, Jun-Bo Hong, Hai-Ying Xiao, Jia-Wei Zhong, Xuan Zhu, Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
Li Pei, Department of Radiology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
Xue-Lian Zheng, Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
Author contributions: Wang AJ and Zhu X designed the research; Wang AJ, Li BM, Gan N, Pei L, Hong JB, Xiao HY and Zhong JW followed up with the patients and performed the research; Zheng XL analyzed the data; Wang AJ, Peng AP and Zhu X wrote the paper.
Supported by Science and Technology Planning Project of Health and Family Planning Commission of Jiangxi Province, No. 20171022; National Natural Science Fund of China, No. 81460122; Project in the Science and Technology Pillar Program of Jiangxi Provincial Department of Science and Technology, No. 20161BBG70166; Jiangxi Provincial Outstanding Young Talent Program, No. 20171BCB23085; and Natural Science Fund of Jiangxi Province For Young Scholars, No. 20171BAB215008.
Institutional review board statement: This study was approved by the Ethics Committee of The First Affiliated Hospital of Nanchang University.
Informed consent statement: Written informed consent was obtained from all enrolled patients.
Conflict-of-interest statement: None of the authors has declared any conflict of interest.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Xuan Zhu, MD, Professor, Chief, Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, 17 Yongwai Zheng Street, Nanchang 330006, Jiangxi Province, China. ndyfy0326@ncu.edu.cn
Telephone: +86-791-88692505 Fax: +86-791-88623153
Received: June 7, 2017
Peer-review started: June 8, 2017
First decision: July 13, 2017
Revised: July 27, 2017
Accepted: August 15, 2017
Article in press: August 15, 2017
Published online: September 14, 2017
Abstract
AIM

To explore the natural history of covert hepatic encephalopathy (CHE) in absence of medication intervention.

METHODS

Consecutive outpatient cirrhotic patients in a Chinese tertiary care hospital were enrolled and evaluated for CHE diagnosis. They were followed up for a mean of 11.2 ± 1.3 mo. Time to the first cirrhosis-related complications requiring hospitalization, including overt HE (OHE), resolution of CHE and death/transplantation, were compared between CHE and no-CHE patients. Predictors for complication(s) and death/transplantation were also analyzed.

RESULTS

A total of 366 patients (age: 47.2 ± 8.6 years, male: 73.0%) were enrolled. CHE was identified in 131 patients (35.8%). CHE patients had higher rates of death and incidence of complications requiring hospitalization, including OHE, compared to unimpaired patients. Moreover, 17.6% of CHE patients developed OHE, 42.0% suffered persistent CHE, and 19.8% of CHE spontaneously resolved. In CHE patients, serum albumin < 30 g/L (HR = 5.22, P = 0.03) was the sole predictor for developing OHE, and blood creatinine > 133 μmol/L (HR = 4.75, P = 0.036) predicted mortality. Child-Pugh B/C (HR = 0.084, P < 0.001) and OHE history (HR = 0.15, P = 0.014) were predictors of spontaneous resolution of CHE.

CONCLUSION

CHE exacerbates, persists or resolves without medication intervention in clinically stable cirrhosis. Triage of patients based on these predictors will allow for more cost-effect management of CHE.

Keywords: Covert hepatic encephalopathy, Overt hepatic encephalopathy, Natural history, Liver cirrhosis

Core tip: Covert hepatic encephalopathy (CHE) was prevalent in clinically-stable cirrhosis in the tertiary care hospital. A history of overt hepatic encephalopathy (OHE) was the only risk factor for CHE in patients with OHE history, while a high model for end-stage liver disease score was the only risk factor for those without OHE history. Natural history of CHE in the absence of medication intervention included development of complications, persistence or spontaneous resolution of CHE. Triage of patients based on predictors for exacerbation and resolution, rather than the degree of impairment in daily work productivity or quality of life, could make clinical management of CHE more cost-effective.