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Altered response to oral glutamine challenge as prognostic factor for overt episodes in patients with minimal hepatic
Manuel Romero-Gómez1, Lourdes Grande, Inés Camacho
1Unit of Hepatology, Hospital Universitario de Valme, Ctra Cádiz s/n. 41014 Seville, Spain. mromerog@supercable.es
Background/Aims:
We assessed the usefulness of oral glutamine challenge (OGC) and minimal hepatic encephalopathy in evaluating risk of overt hepatic encephalopathy in cirrhotic patients.
Methods:
Minimal hepatic encephalopathy (MHE) was inferred using neuro-psychological tests. Venous ammonia concentrations were measured pre- and post-60 min (NH(3)-60m) of a 10 g oral glutamine load. Receiver-operating-characteristic curve analysis indicated a pathological glutamine tolerance cut-off value of NH(3)-60m >128 microg/dl.
Results:
In healthy control subjects (n=10) ammonia concentrations remained unchanged but increased significantly in cirrhotic patients (from 70.41+/-45.2 to 127.43+/-78.6; P<0.001). In multiple logistic regression analysis, altered OGC was related to Child-Pugh (odds ratio, OR=7.69; 95% confidence interval, CI=1.72-33.3; P<0.01) and MHE (OR=5.45; 95% CI=1.17-25.4; P<0.05). In the follow-up 11 patients (15%) developed overt hepatic encephalopathy (HE). In multivariate analysis OGC (OR=14.5; 95% CI=1.26-126.3) and MHE (OR=1.56; 95% CI=1.02-21.9) were independently related with HE in the follow-up. Patients with MHE and altered OGC showed significantly higher risk of overt HE in the follow-up (60%) than patients without MHE and normal OGC (2.8%) (Log rank test=21.60; P<0.0001).
Conclusions:
A pathological OGC in patients with MHE appears to be a prognostic factor for the development of overt hepatic encephalopathy, whereas a normal OGC in patients without MHE could exclude risk of overt HE.
Insights
The oral glutamine challenge (OGC) combined with minimal hepatic encephalopathy (MHE) assessment effectively predicts overt hepatic encephalopathy in cirrhosis patients. Patients with MHE and an abnormal OGC face a significantly higher risk of developing overt HE.
Area of Science:
- Hepatology
- Gastroenterology
- Neurology
Background:
- Cirrhosis patients are at risk of overt hepatic encephalopathy (HE).
- Minimal hepatic encephalopathy (MHE) is a precursor to overt HE.
- Predictive markers for HE development are crucial for patient management.
Purpose of the Study:
- To evaluate the utility of oral glutamine challenge (OGC) and MHE in predicting overt HE in cirrhotic patients.
- To determine if combined OGC and MHE status improves risk stratification for HE development.
Main Methods:
- Minimal hepatic encephalopathy (MHE) diagnosed via neuropsychological tests.
- Oral glutamine challenge (OGC) involved a 10g glutamine load with ammonia level measurement at 60 minutes (NH(3)-60m).
- Receiver-operating-characteristic (ROC) analysis defined a pathological OGC cut-off at NH(3)-60m >128 microg/dl.
Main Results:
- In cirrhotic patients, ammonia levels significantly increased post-glutamine load (P<0.001), unlike in controls.
- Altered OGC and MHE were independently associated with overt HE development in follow-up (OR=14.5 and OR=1.56, respectively).
- Patients with both MHE and abnormal OGC had a 60% risk of overt HE, versus 2.8% for those without MHE and normal OGC (P<0.0001).
Conclusions:
- A pathological OGC in patients with MHE is a significant prognostic factor for overt HE.
- A normal OGC in patients without MHE can help exclude the risk of developing overt HE.
- Combined assessment of OGC and MHE offers valuable risk stratification for overt HE in cirrhosis.
