Richmond, Virginia.
Dallas, Texas.
Aliment Pharmacol Ther. 2019 Jun;49(12):1518-1527. doi: 10.1111/apt.15265. Epub 2019 Apr 29.
Hepatic encephalopathy (HE) can adversely affect outcomes in both in-patients and out-patients with cirrhosis.
To define targets for improving quality of care in HE management in the multi-centre North American Consortium for End-Stage Liver Disease (NACSELD) cohort.
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.
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).
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.
肝性脑病（HE）可对住院和门诊肝硬化患者的预后产生不利影响。
在北美终末期肝病联盟（NACSELD）多中心队列中确定改善 HE 管理质量的目标。
对 NACSELD 住院患者队列进行分析，包括（a）药物相关诱因，（b）吸入性肺炎的发生，（c）HE 药物的变化，以及（d）90 天 HE 复发/再入院。比较无治疗、乳果糖仅、利福昔明仅或两者均有的患者。90 天 HE 再入院分析调整了 MELD 评分。
共纳入 2810 例患者（无治疗 1102 例，乳果糖 659 例，利福昔明 154 例，两者均有 859 例）。与无治疗或利福昔明仅治疗相比，仅用乳果糖或联合治疗的患者入院时和住院期间的 HE 发生率更高（均 P<0.001）。药物是最常见的诱因（32%；21%乳果糖使用不当，5%苯二氮䓬类药物，4%阿片类药物，1%利福昔明使用不当，1%催眠药）。与其他诱因相比，有药物相关诱因的患者预后更好。共有 23%（n=217）达到 3/4 级 HE，其中 16%发生与 HE 相关的吸入性肺炎。2420 例患者在未进行肝移植的情况下出院（无治疗 790 例，乳果糖 639 例，利福昔明 136 例，两者均有 855 例）；12.5%（n=99）无治疗患者未接受出院后 HE 治疗更新。90 天内与 HE 相关的再入院率为 16%（无治疗 9%，利福昔明仅 9%，仅用乳果糖 18%，联合治疗 21%，<0.001），即使调整了 MELD 评分，这一比例仍持续存在（P=0.009）。
在一组大型住院肝硬化患者中确定了改善 HE 管理的几个目标。需要减少药物诱发的 HE、预防吸入性肺炎和优化 HE 药物治疗。
