Prognosis and Survivability in Hepatic Encephalopathy
The overall survival rate after an episode of overt hepatic encephalopathy is poor, with only 42% survival at 1 year and 23% at 3 years, making liver transplantation a critical consideration for patients with severe or recurrent hepatic encephalopathy. 1
Prognostic Factors Affecting Survival
- Patients with hepatic encephalopathy (HE) who are not expected to survive hospitalization should be excluded from treatment trials, indicating their extremely poor prognosis 1
- The presence of multiple concomitant precipitating factors significantly worsens prognosis, with a recent study showing median transplant-free survival of only 0.8 months in patients with multiple precipitating factors 2
- Acute-on-chronic liver failure (ACLF) with HE carries a particularly poor prognosis, with survival being the most important endpoint and hepatic transplantation often the only definitive treatment 1
- The severity of HE is directly associated with overall prognosis, with higher grades (West Haven criteria grade ≥3) requiring intensive care monitoring due to inability to protect airways 1, 3
Survival Rates and Mortality
- In-hospital mortality for cirrhotic patients with HE admitted to intensive care can be as high as 50% 2
- Recurrence of HE occurs in 50-70% of patients within 1 year of the first episode, necessitating secondary prevention 1
- HE recurrence was observed in 42% of patients with a median delay of 30 months in a recent study 2
- HE is a prognostically relevant neuropsychiatric syndrome and one of the most serious complications of decompensated liver cirrhosis, alongside ascites and variceal bleeding 4
Factors That Improve Survival
Identification and management of precipitating factors is crucial for improving outcomes, including:
- Infections, gastrointestinal bleeding, electrolyte disturbances (particularly hyponatremia)
- Medication non-compliance, constipation, and inappropriate use of proton pump inhibitors 3
Pharmacological interventions that improve survival:
- Lactulose as first-line therapy (25 ml syrup every 12 hours, titrated to achieve 2-3 soft stools per day) 3
- Addition of rifaximin (550 mg twice daily) when lactulose alone is insufficient or for prevention after a second HE episode 3
- Guideline-recommended prophylaxis with lactulose or secondary prophylaxis with rifaximin plus lactulose decreases hospital admissions and mortality rates 5
Liver Transplantation Considerations
Liver transplantation is indicated in patients with:
Liver transplantation can reverse even major incapacitating neurological features, including Parkinsonian features and spastic paraparesis associated with hepatic myelopathy 1
Special Considerations for Different Patient Groups
Patients with stable, persistent cognitive/motor abnormalities (acquired non-Wilsonian hepato-cerebral degeneration) are difficult to manage with conventional treatment but may benefit from liver transplantation 1
For patients with ACLF and HE:
- Improving HE may favor bridge time to transplantation
- May improve health-related quality of life
- Might shorten ICU stay and overall hospitalization length 1
Monitoring and Follow-up
Monitoring neurological manifestations is necessary to:
- Adjust treatment appropriately
- Investigate presence and degree of covert HE or signs of recurring HE
- Evaluate gait and walking to consider fall risk 3
Treatment endpoints should focus on two key aspects:
- Cognitive performance
- Daily life autonomy 3
Pitfalls and Caveats
- Benzodiazepines are contraindicated in decompensated liver cirrhosis and can worsen HE 3
- Weight loss with sarcopenia may worsen HE, making nutritional support critical 3
- Flumazenil might temporarily improve consciousness in severe HE but does not improve survival and is not recommended as first-line treatment 1
- The presence of dysfunction in another organ (e.g., kidney) in addition to the liver indicates ACLF and significantly worsens prognosis 1