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60 j 275281
Pembimbing Dipresentasikan
: dr. Putut Bayu Purnama, Sp. PD KGEH : dr. Meldy Muzada Elfa
Latar belakang
Hepatic encephalopathy (HE) is a common complication of cirrhosis [1,2] Recently, acute-on-chronic liver failure (ACLF) was defined by the Canonic Study 1. acute decompensation of cirrhosis (ascites, HE, gastrointestinal hemorrhage, bacterial infections or any combination of these) 2. at least 1 organ failure 3. belong to a subgroup with high short-term (28 day) mortality rate (>15%). Organ failure was defined based on a modified SOFA score adapted for patients with cirrhosis (CLIF-SOFA score)
The goals of the study were to assess the characteristics of cirrhotics that develop HE, describe the characteristics of HE in relation to the underlying liver disease (isolated decompensated cirrhosis or ACLF), identify risk factors for HE, and assess short-, mid- and long-term survival in relation to the presence or absence of HE and ACLF.
The presence of HE was diagnosed as an impairment of cognition, consciousness, or motor function. Severity of HE was assessed according to the West Haven scale and grouped in 2 levels (mild: grade I or II; severe: grade III or IV).
Distribution of patients included in the study in relation to the presence of HE (left side) or ACLF (right side).
Hasil
Patients with HE (n = 460) did not differ significantly from those without HE (n = 888) in relation to the causes: Cirrhosis alcohol Hepatitis C Hepatitis C plus alcohol Previous comorbidities: arterial hypertension, diabetes mellitus requiring treatment Gender Age
Hasil
Patients with HE, there was a more frequent clinical history
of previous decompensations, ascites and overt HE HE also exhibited a higher proportion of hospitalizations in the previous 3 months, which was mainly due to higher number of hospitalizations related to HE and bacterial infections There were no differences between patients with and without HE in the proportion of hospitalization during the previous 3 months for ascites or GI bleeding
Hasil
Role of HE as an isolated decompensation
Patients without ACLF and with HE (n = 286) were
slightly older than those without HE. HE patients had a higher prevalence of previous ascites and HE
Among precipitating events, differences were only found for
the use of diuretics, which was higher in patients with HE, and in the prevalence of gastrointestinal bleeding, which was lower in patients with HE.
Hasil
Role of HE as part of ACLF
Patients with ACLF and HE had no statistical
differences in age to those without HE. HE showed higher prevalence of previous HE and ascites. The frequency of respiratory failure at enrollment was significantly higher in HE but affected less patients
Hasil
HE as an isolated decompensation or as part of ACLF
Patients with HE not associated with ACLF had
significantly higher age, had less frequently alcoholic cirrhosis, and had more frequently prior decompensations. There were marked differences in the prevalence of precipitating events between non-ACLF (higher
prevalence of diuretics) and ACLF (higher prevalence of bacterial infections, active alcoholism, and hyponatremia). Patients with ACLF had more deteriorated bilirubin, INR, and creatinine. In addition, ACLF patients show more abnormal inflammatory markers (leukocyte count and Creactive protein), AST and less sodium.
Hasil
Risk factors for HE and survival
Multivariate analysis assessing independent risk factors
for HE in the whole series of patients and in those without ACLF found prior HE and diuretic use within the prior 3 months to be associated with the development of HE. In patients with ACLF, only prior HE was significantly associated with current HE.
Hasil
Risk factors for HE and survival (Cont.)
The mortality probability was significantly higher in
patients with HE compared to those without HE, it increased significantly as the HE grade worsened. The mortality probability of patients with ACLF was much higher than that of patients without ACLF, independently of the presence or absence of HE
Hasil
Risk factors for HE and survival (Cont.)
In each subgroup (with and without ACLF) the mortality
probability was significantly higher in patients with HE. The independent risk factors of mortality at 28 days, 90 days and 1 year in patients with HE at enrollment were age, bilirubin, INR, sodium, and creatinine
Risk factors for short, mid and long-term mortality in patients with HE.
Hasil
Risk factors for HE and survival (Cont.)
The main causes of death in patients with and without
HE were multiorgan failure (36.7% vs. 34.2%), septic shock (23.5% vs. 20.4%), and hypovolemic shock (5.1% and 5%); a variety of other causes were present. In 20.4% of patients with HE and in 21.5% of patients without HE the cause of death could not be established
Diskusi
Episodic HE is one of the most frequent complications of cirrhosis Traditionally HE has been considered the effect on brain function of a combination of factors that include extrahepatic(infection, gastrointestinal bleeding, hyponatremia, renal failure, etc.) and intrahepatic mechanisms (worsening liver function, acute liver damage, etc.), which lead to an increase in circulating toxins that impact the brain
Diskusi
1. The most outstanding finding is the observation that previous HE is the most important risk factor for the development of HE These data indicate that even in the most severe cases of cirrhosis, development of HE is highly determined by the history prior to this complication. 2. A second important finding is the poor relationship between the traditional precipitating factors and the development of HE. 3. This analysis indicates that the increase in HE with the use of diuretics was not explained by differences in the severity of liver failure. We could not detect specific abnormalities caused by diuretic treatment
Diskusi
From the results of our study we propose the existence of two presentations of HE: 1. Isolated HE: occurs in older cirrhotics, inactive drinkers (hepatitis C cirrhosis or alcoholic cirrhotics who stopped drinking). 2. HE associated with ACLF: occurs in young cirrhotics, more frequently alcoholics as a consequence of impairment in liver function and bacterial infections, active alcoholism or dilutional hyponatremia.
Kesimpulan
1. The relation of HE with prior history of HE supports the view that this is a highly recurrent disorder 2. HE is not a homogeneous disorder 3. HE as a manifestation of ACLF, characterized by severe liver failure, acute inflammatory reaction and organ failure(s) 4. A better characterization of the patient that develops HE will allow improvements in diagnosis and therapy of this severe complication.
Kriteria Banevo V
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