Natural history of covert hepatic encephalopathy: An observational study of 366 cirrhotic patients

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.

Effects of Low-dose and High-dose Rifaximin in the Treatment of Covert Hepatic Encephalopathy

Background and Aims:Rifaximin is effective in prevent-ing and treating hepatic encephalopathy(HE).This study aimed to investigate the efficacy and safety of different dosages of rifaximin in the treatment of cirrhotic patients with covert HE(CHE).Methods:In this single-center,ran-domized,controlled,open-label study,CHE was diagnosed using a combination of the psychometric HE score and the EncephalApp Stroop test.Cirrhotic patients with CHE were recruited and randomly assigned to low-dose rifaximin 800 mg/day,high-dose rifaximin(1,200 mg/day),and control groups,and were treated for 8 weeks.The sickness impact profile(SIP)scale was used to evaluate the health-relat-ed quality of life(HRQOL)of patients.Forty patients were included in the study,12 were assigned to the low-dose group,14 to the high-dose group,and 14 patients to the control group.Results:The percentage of patients with CHE reversal was significantly higher in both the low-dose(41.67%,5/12)and high-dose(57.14%,8/14)groups than in the control group(7.14%,1/14)at 8 weeks(p=0.037 and p=0.005,respectively).In addition,both doses of ri-faximin resulted in significant improvement of the total SIP score compared with the control group.There were no sig-nificant differences in the CHE reversal rate,total SIP score improvement,and incidence of adverse event between the low-dose and high-dose groups(p>0.05).Conclusions:Low-dose rifaximin reverses CHE and improves HRQOL in cirrhotic patients with comparable effects and safety to high-dose rifaximin.