Nutritional therapy for persistent cognitive impairment after resolution of overt hepatic encephalopathy in patients with cirrhosis: A double-blind randomized controlled trial.

Abstract

Minimal hepatic encephalopathy (MHE) reflects cognitive impairment in patients with liver cirrhosis and is associated with poor prognosis. We assessed the effects of nutritional therapy on cognitive functions, health-related quality of life (HRQOL), anthropometry, endotoxins, and inflammatory markers in cirrhotic patients with MHE. In a double-blind randomized controlled trial, cirrhotic patients with MHE were randomized to nutritional therapy (group I: 30-35kcal/kg/day and 1.0-1.5g of protein/kg/day) and no nutritional therapy (group II: diet as patients were taking before) for 6months. MHE was diagnosed based on psychometric hepatic encephalopathy score (PHES). Anthropometry, ammonia, endotoxins, inflammatory markers, myostatin, and HRQOL were assessed at baseline and after 6months. Primary endpoints were improvement or worsening in MHE and HRQOL. A total of 150 patients were randomized to group I (n=75, age 46.3±12.5years, 58 men) and group II (n=75, age 45.2±9.3years, 56 men). Baseline PHES (-8.16±1.42 vs -8.24±1.43; P=0.54) was comparable in both groups. Reversal of MHE was higher in group I (73.2% vs 21.4%; P=0.001) than group II. Improvement in PHES (Δ PHES 4.0±0.60 vs -4.18±0.40; P=0.001), HRQOL (Δ Sickness Impact Profile 3.24±3.63 vs 0.54±3.58; P=0.001), anthropometry, ammonia, endotoxins, cytokines, and myostatin levels was also significantly higher in group I than group II. Overt hepatic encephalopathy developed in 6 patients in group I and 13 in group II (P=0.04). Nutritional therapy is effective in treatment of MHE and associated with improvement in nutritional status, HRQOL, ammonia, endotoxins, inflammatory markers, and myostatin levels.