Targets to improve quality of care for patients with hepatic encephalopathy: data from a multi‐centre cohort

Abstract

Background: Hepatic encephalopathy (HE) can adversely affect outcomes in bothin-patients and out-patients with cirrhosis.Aim: To define targets for improving quality of care in HE management in the multicentre North American Consortium for End-Stage Liver Disease (NACSELD) cohort.Method: NACSELD in-patient cohort was analysed for (a) medication-associated precipitants, (b) aspiration pneumonia development, (c) HE medication changes, and (d) 90-day HE recurrence/readmissions. Comparisons were made between patients on no-therapy, lactulose only, rifaximin only or both. Ninety-day HE-readmission analysis was adjusted for MELD score.Results: Two thousand eight hundred and ten patients (1102 no-therapy, 659 lactulose, 154 rifaximin, 859 both) were included. HE on admission, and HE rates during hospitalisation were highest in those on lactulose only or dual therapy compared to no-therapy or rifaximin only (P < 0.001). Medications were the most prevalent precipitants (32%; 21% lactulose over/underuse, 5% benzodiazepines, 4% opioids, 1% rifaximin underuse, 1% hypnotics). Patients with medication-associated precipitants had a better prognosis compared to other precipitants. A total of 23% (n = 217) reached grade 3/4 HE, of which 16% developed HE-related aspiration pneumonia. Two thousand four hundred and twenty patients were discharged alive without liver transplant (790 no-therapy, 639 lactulose, 136 rifaximin, 855 both); 12.5% (n = 99) of no-therapy patients did not receive a discharge HE therapy renewal. Ninety-day HE-related readmissions were seen in 16% of patients (9% no-therapy, 9% rifaximin only, lactulose only 18%, dual 21%, <0.001), which persisted despite MELD adjustment (P = 0.009).Conclusion: Several targets to improve HE management were identified in a large cohort of hospitalised cirrhotic patients. Interventions to decrease medication-precipitated HE, prevention of aspiration pneumonia, and optimisation of HE medications are warranted. | 1519BAJAJ et Al. SUPPORTING INFORMATIONAdditional supporting information will be found online in the Supporting Information section at the end of the article.How to cite this article: 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

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“…75 Concomitant medications can modulate the cognitive function and course of HE as well. [76][77][78][79] The mechanisms underlying the increased risk of HE in these populations is not clear, but likely result from worsening cerebrovascular disease, systemic inflammation, the effect of senescence and oxidative stress. 80 Further elucidation of the relevant pathogenic pathways would enable the development of new therapeutic strategies to prevent HE in these patients.…”

Safe use of medication in patients with cirrhosis: pharmacokinetic and pharmacodynamic considerations

“…confusion, HE) with certain medicines. A recent work by Bajaj and colleagues demonstrated the significant role of medicines in precipitating HE [74]. Among 2810 patients with cirrhosis, 5% of the 913 HE episodes were related to benzodiazepines, 4% to opioids and 1% to hypnotics.…”

Cost‐effectiveness of integrating gut microbiota analysis into hospitalisation prediction in cirrhosis

“…7,9 Cirrhosis is associated with altered gut microbiota composition and function, which can affect the development and propagation of several complications such as hepatic encephalopathy (HE), infections such as spontaneous bacterial peritonitis (SBP) and renal dysfunction. [10][11][12][13] Infections and HE are also one of the leading causes of admissions in cirrhosis. 7,[13][14][15][16][17][18] Therefore, recent studies in cirrhosis have used microbial composition analysis to predict inpatient and outpatient outcomes.…”

“…[10][11][12][13] Infections and HE are also one of the leading causes of admissions in cirrhosis. 7,[13][14][15][16][17][18] Therefore, recent studies in cirrhosis have used microbial composition analysis to predict inpatient and outpatient outcomes. 12,19,20 These analyses included testing of faecal and salivary microbiota to predict 90-day hospitalisations, inpatient deaths as well as admissions and readmissions.…”