Abstract
Objectives: Hepatic encephalopathy (HE) is associated with hospital readmissions and mortality. We sought to determine whether cognitive testing and stool frequency at discharge predicted 30-day readmission or death in cirrhotic patients admitted with overt HE.
Methods: We approached consecutive inpatients with cirrhosis and overt HE when they were within 48 hours of discharge. Patients underwent cognitive tests, including Psychometric Hepatic Encephalopathy Score (PHES), and stool frequency was documented. Chart review identified Model for End-Stage Liver Disease-sodium (MELD-Na) and the presence of non-HE extrahepatic organ failures. Cox proportional hazards models were used to evaluate predictors of time to the primary
composite outcome of hospital readmission for HE or death within 30 days, censoring for liver transplantation.
Results: Of 51 patients consented and enrolled, 14 patients met the primary composite outcome. In unadjusted Cox models, 4 variables predicted HE readmission or death: MELD-Na (hazard ratio [HR] 1.10 [1.01–1.20], P = 0.03), respiratory failure (HR 4.26 [1.47–12.35], P = 0.008), total number of HE extrahepatic organ failures (HR 1.79 [1.12–2.88], P = 0.02), and score on a PHES subtest, Number Connection Test A (per 30 seconds; HR 1.25 [1.06–1.47], P = 0.01). PHES and 24-hour stool frequency did not predict the primary outcome. When controlling for MELD-Na, respiratory failure predicted the primary outcome (HR 3.67 [1.24–10.86], P = 0.02).
Conclusion: Cognitive testing and stool frequency at discharge did not predict poor outcomes in patients admitted with HE, while respiratory failure appeared to be a strong predictor.
This content is limited to qualifying members.
If you have an existing account please login now to access this article or view purchase options.
Create a free account, then purchase this article to download or access it online for 24 hours.
Create a free account, then purchase a subscription to get complete access to all articles for a full year.
References
1. Kim WR, Brown RS Jr, Terrault NA, et al. Burden of liver disease in the United States: summary of a workshop. Hepatology 2002;36:227–242.
2. Beste LA, Leipertz SL, Green PK, et al. Trends in burden of cirrhosis and hepatocellular carcinoma by underlying liver disease in US veterans, 2001–2013. Gastroenterology 2015;149:1471–1482.e5.
3. D'Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol 2006;44:217–231.
4. Bajaj JS, Reddy KR, Tandon P, et al. The 3-month readmission rate remains unacceptably high in a large North American cohort of patients with cirrhosis. Hepatology 2016;64:200–208.
5. Mokdad AA, Lopez AD, Shahraz S, et al. Liver cirrhosis mortality in 18 countries between 1980 and 2010: a systematic analysis. BMC Med 2014;12:145.
6. Volk ML, Tocco RS, Bazick J, et al. Hospital readmissions among patients with decompensated cirrhosis. Am J Gastroenterol 2012;107:247–252.
7. Bajaj JS, O'Leary JG, Tandon P, et al. Hepatic encephalopathy is associated
with mortality in patients with cirrhosis independent of other extrahepatic
organ failures. Clin Gastroenterol Hepatol 2017;15:565–574.e4.
8. Kamath PS, Kim WR, Advanced Liver Disease Study Group. The model for
end-stage liver disease (MELD). Hepatology 2007;45:797–805.
9. Seraj SM, Campbell EJ, Argyropoulos SK, et al. Hospital readmissions in decompensated cirrhotics: factors pointing toward a prevention strategy. World J Gastroenterol 2017;23:6868–6876.
10. Tapper EB, Halbert B, Mellinger J. Rates of and reasons for hospital readmissions in patients with cirrhosis: a multistate population-based cohort study. Clin Gastroenterol Hepatol 2016;14:1181–1188.e2.
11. Stepanova M, Mishra A, Venkatesan C, et al. In-hospital mortality and economic burden associated with hepatic encephalopathy in the United States from 2005 to 2009. Clin Gastroenterol Hepatol 2012;10:1034–41.e1.
12. Bajaj JS, Wade JB, Gibson DP, et al. The multi-dimensional burden of cirrhosis and hepatic encephalopathy on patients and caregivers. Am J Gastroenterol 2011;106:1646–1653.
13. Tapper EB. Predicting overt hepatic encephalopathy for the population with
cirrhosis. Hepatology 2019;70:403–409.
14. Bajaj JS, Sanyal AJ, Bell D, et al. Predictors of the recurrence of hepatic encephalopathy in lactulose-treated patients. Aliment Pharmacol Ther 2010;31:1012–1017.
15. Kruger AJ, Aberra F, Black SM, et al. A validated risk model for prediction of early readmission in patients with hepatic encephalopathy. Ann Hepatol 2019;18:310–317.
16. Tapper EB, Finkelstein D, Mittleman MA, et al. A quality improvement initiative reduces 30-day rate of readmission for patients with cirrhosis. Clin Gastroenterol Hepatol 2016;14:753–759.
17. Morando F, Maresio G, Piano S, et al. How to improve care in outpatients with cirrhosis and ascites: a new model of care coordination by consultant hepatologists. J Hepatol 2013;59:257–264.
18. Vilstrup H, Amodio P, Bajaj J, et al. Hepatic encephalopathy in chronic liver disease: 2014 practice guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology 2014;60:715–735.
19. Acharya C, Wade JB, Fagan A, et al. Overt hepatic encephalopathy impairs learning on the EncephalApp stroop which is reversible after liver transplantation. Liver Transpl 2017;23:1396–1403.
20. Allampati S, Duarte-Rojo A, Thacker LR, et al. Diagnosis of minimal hepatic encephalopathy using stroop EncephalApp: a multicenter US-based, norm-based study. Am J Gastroenterol 2016;111:78–86.
21. Bajaj JS, Thacker LR, Heuman DM, et al. Cognitive performance as a predictor of hepatic encephalopathy in pretransplant patients with cirrhosis receiving psychoactive medications: a prospective study. Liver Transpl 2012;18:1179–1187.
22. Wuensch T, Ruether DF, Zollner C, et al. Performance characterization of a novel electronic number connection test to detect minimal hepatic encephalopathy in cirrhotic patients. Eur J Gastroenterol Hepatol 2017;29:456–463.
23. Ney M, Tangri N, Dobbs B, et al. Predicting hepatic encephalopathy-related hospitalizations using a composite assessment of cognitive impairment and frailty in 355 patients with cirrhosis. Am J Gastroenterol 2018;113:1506–1515.
24. Nasreddine ZS, Phillips NA, Bedirian V, et al. The montreal cognitive assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 2005;53:695–699.
25. Lai JC, Covinsky KE, McCulloch CE, et al. The liver frailty index improves mortality prediction of the subjective clinician assessment in patients with cirrhosis. Am J Gastroenterol 2018;113:235–242.
26. Lai JC, Sonnenday CJ, Tapper EB, et al. Frailty in liver transplantation: an expert opinion statement from the American Society of Transplantation Liver and Intestinal Community of Practice. Am J Transplant 2019;19:1896–1906.
27. Garrido M, Turco M, Formentin C, et al. An educational tool for the prophylaxis of hepatic encephalopathy. BMJ Open Gastroenterol 2017;4:e000161.
28. O'Leary JG, Reddy KR, Garcia-Tsao G, et al. NACSELD acute-on-chronic liver failure (NACSELD-ACLF) score predicts 30-day survival in hospitalized patients with cirrhosis. Hepatology 2018;67:2367–2374.
29. Austin PC, Lee DS, Fine JP. Introduction to the analysis of survival data in the presence of competing risks. Circulation 2016;133:601–609.
30. Bajaj JS, O'Leary JG, Tandon P, et al. Targets to improve quality of care for patients with hepatic encephalopathy: data from a multi-centre cohort. Aliment Pharmacol Ther 2019;49:1518–1527.
