Montagnese S, Balistreri E, Schiff S, De Rui M, Angeli P, Zanus G, Cillo U, Bombonato G, Bolognesi M, Sacerdoti D, Gatta A, Merkel C, Amodio P. Covert hepatic encephalopathy: Agreement and predictive validity of different indices. World J Gastroenterol 2014; 20(42): 15756-15762 [PMID: 25400460 DOI: 10.3748/wjg.v20.i42.15756]
Corresponding Author of This Article
Sara Montagnese, MD, Department of Medicine, University of Padova, Via Giustiniani 2, 35128 Padova, Italy. sara.montagnese@unipd.it
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Clinical Trials Study
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World J Gastroenterol. Nov 14, 2014; 20(42): 15756-15762 Published online Nov 14, 2014. doi: 10.3748/wjg.v20.i42.15756
Covert hepatic encephalopathy: Agreement and predictive validity of different indices
Sara Montagnese, Esmeralda Balistreri, Sami Schiff, Michele De Rui, Paolo Angeli, Giacomo Zanus, Umberto Cillo, Giancarlo Bombonato, Massimo Bolognesi, David Sacerdoti, Angelo Gatta, Carlo Merkel, Piero Amodio
Sara Montagnese, Esmeralda Balistreri, Sami Schiff, Michele De Rui, Paolo Angeli, Giancarlo Bombonato, Massimo Bolognesi, David Sacerdoti, Angelo Gatta, Carlo Merkel, Piero Amodio, Department of Medicine, University of Padova, 35128 Padova, Italy
Giacomo Zanus, Umberto Cillo, Department of Surgical, Oncological, and Gastroenterological Sciences, University of Padova, 35128 Padova, Italy
Author contributions: Montagnese S contributed to the study concept and design; acquisition, analysis and interpretation of data; drafting of the manuscript; Balistreri E contributed to the acquisition, analysis and interpretation of data; drafting of the manuscript; Schiff S contributed to the acquisition, analysis and interpretation of data; technical and material support; De Rui M contributed to the acquisition, analysis and interpretation of data; drafting of the manuscript; Angeli P, Zanus G, Cillo U and Bombonato G contributed to the acquisition of data; patient recruitment, technical and material support; Bolognesi M and Sacerdoti D contributed to the acquisition of data; technical and material support; Gatta A contributed to the study supervision; technical and material support; Merkel C contributed to the study concept and design; analysis and interpretation of data; Amodio P contributed to the study concept and design; analysis and interpretation of data; study supervision.
Supported by (in Part) Grant from the Italian Ministry of Health to Sara Montagnese (Giovani Ricercatori 2009); and Grants from the University of Padova to Piero Amodio; Publication fees were covered by the Foundation Lionello Forin Hepatos Onlus, Padova, Italy.
Correspondence to: Sara Montagnese, MD, Department of Medicine, University of Padova, Via Giustiniani 2, 35128 Padova, Italy. sara.montagnese@unipd.it
Telephone: +39-49-8218675 Fax: +39-49-8754179
Received: March 22, 2014 Revised: May 16, 2014 Accepted: June 14, 2014 Published online: November 14, 2014 Processing time: 239 Days and 17.7 Hours
Abstract
AIM: To investigate the agreement and prognostic value of different measures of covert hepatic encephalopathy (CHE).
METHODS: One-hundred-and-thirty-two cirrhotic outpatients underwent electroencephalography (EEG), paper-and-pencil psychometry (PHES) and critical flicker frequency, scored on the original/modified (CFFo/CFFm) thresholds. Eighty-four patients underwent Doppler-ultrasound to diagnose/exclude portal-systemic shunt. Seventy-nine were followed-up for 11 ± 7 mo in relation to the occurrence of hepatic encephalopathy (HE)-related hospitalisations.
RESULTS: On the day of study, 36% had grade I HE, 42% abnormal EEG, 33% abnormal PHES and 31/21% abnormal CFFo/CFFm. Significant associations were observed between combinations of test abnormalities; however, agreement was poor (Cohen’s κ < 0.4). The prevalence of EEG, PHES and CFFo/CFFm abnormalities was significantly higher in patients with grade I overt HE. The prevalence of EEG and CFFm abnormalities was higher in patients with shunt. The prevalence of EEG abnormalities was significantly higher in patients with a history of HE. During follow-up, 10 patients died, 10 were transplanted and 29 had HE-related hospitalisations. Grade I HE (P = 0.004), abnormal EEG (P = 0.008) and abnormal PHES (P = 0.04) at baseline all predicted the subsequent occurrence of HE; CFF did not.
CONCLUSION: CHE diagnosis probably requires a combination of clinical, neurophysiological and neuropsychological indices.
Core tip: Covert hepatic encephalopathy is a heterogeneous entity, which should probably be sought for by a combination of clinical, neurophysiological and neuropsychological indices. Grade I hepatic encephalopathy (HE), as diagnosed by an experienced clinician, holds prognostic relevance and is associated with a higher degree of hepatic failure. Thus, while its use as an outcome for clinical trials is not recommended, the abolition of Grade I HE seems premature.
