Prognostic significance of hepatic encephalopathy in patients with cirrhosis

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Abstract

Background: There are numerous studies concerning the natural history and prognostic factors in cirrhosis, the results of which are useful in selecting liver transplant candidates. However, little attention has been paid to the prognostic significance of hepatic encephalopathy despite the high frequency of this complication.

Methods: We reviewed the charts of 111 cirrhotic patients who developed a first episode of acute hepatic encephalopathy to determine their survival probability and to identify prognostic factors.

Results: During follow-up (12±17 months), 82 (74%) patients died. The survival probability was 42% at 1 year of follow-up and 23% at 3 years. With univariate analyses followed by a multivariate analysis, 7 out of 30 clinical and standard laboratory variables were significantly associated with poor prognosis: male sex, increased serum bilirubin, alkaline phosphatase, potassium and blood urea nitrogen, and decreased serum albumin and prothrombin activity. Patients were classified into two groups according to a prognostic index calculated from these 7 variables. Survival probability at 1 and 3 years was 73% and 38%, respectively, in patients with a low prognostic index, and 10% and 3% in patients with a high prognostic index.

Conclusion: Hepatic encephalopathy is associated with short survival in cirrhotic patients. Although these patients can be classified into several groups with a different prognosis, the survival probability in every group is lower than that currently expected after liver transplantation. Therefore, cirrhotic patients developing a first episode of acute hepatic encephalopathy should be considered as potential candidates for this therapeutic procedure.

Section snippets

Patients and Methods

The medical records from all cirrhotic patients consecutively admitted to our Liver Unit between January 1990 and December 1993 were retrospectively reviewed. One hundred and eleven of these patients had their first episode of acute HE either at the time of hospital admission or during hospitalization, and were included in the study. The diagnosis and grade of HE were established on the basis of classical neuropsychiatric signs (10). No patient with proven or highly suspected hepatocellular

Characteristics of patients

There were 71 male and 40 female patients with ages of 60±12 years. The diagnosis of cirrhosis was made by histological data in 53 cases and by clinical and laboratory data in the remaining 58 cases. The etiology of cirrhosis was alcoholic in 41 patients, HCV infection in 18, HBV infection in six (associated with HDV infection in one case), primary biliary cirrhosis in two, autoimmune in one, combined factors in 23 (HCV infection and alcohol in 12, HBV infection and alcohol in six, HCV and HBV

Discussion

The results of the present study indicate that the development of HE in cirrhotic patients is a sign associated with short life expectancy. In our investigation the cumulative survival at 1 and 3 years after the presentation of the first episode of acute HE was only 42% and 23%, respectively (Fig. 1). These data are in agreement with the results previously reported by other authors 21., 22. and suggest that the prognosis in cirrhotic patients developing HE has not substantially changed during

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