Multiple Concomitant Precipitating Factors of Hepatic Encephalopathy Are Associated With a Poor Prognosis in Patients With Cirrhosis Admitted to Intensive Care Unit.

Introduction: Management of hepatic encephalopathy relies on the identification and control of precipitating factors (PF). The prognostic value of a PF is unknown, which we aimed to explore.

Patients and methods: Single-center retrospective study of cirrhotic patients included in a prospective cohort admitted to an intensive care unit (ICU) between 2019 and 2022.

Inclusion criteria: cirrhosis; overt hepatic encephalopathy; ammonemia ≥ 50 μmol/L. PF considered: gastrointestinal bleeding, infection, acute renal injury (AKI), hyponatremia, constipation, non-adherence to ammonia-lowering therapy, TIPS, drugs precipitating overt hepatic encephalopathy. The primary endpoint was 1-year transplant-free survival (TFS). Secondary endpoint was recurrence of hepatic encephalopathy.

Results: 179/497 patients were included (men 72%, age 59, cause of cirrhosis alcohol (ALD)/metALD/MASLD/other in 41/21/6/32%, Child-Pugh A/B/C in 1/18/81%, West Haven grade 2/3/4 in 63/15/22%, MELD score 23). Reasons for admission were: gastrointestinal bleeding (31%), acute encephalopathy (28%), worsening liver function/jaundice (25%), infection (8%), and AKI (8%). All patients (100%) had at least one PF of hepatic encephalopathy (infection [64%], AKI [63%], drugs [41%], bleeding [36%], hyponatremia [22%], TIPS [12%], and constipation [1%]), and 82% had multiple concomitant PF. In-hospital mortality was 50%, and median TFS was 0.8 months. In multivariate analysis, factors associated with death or liver transplantation were the number of PF, MELD and Child-Pugh scores, ACLF, AKI and infection. Hepatic encephalopathy reoccurred in 42% (median delay of 30 months).

Conclusion: All patients had precipitating factor of hepatic encephalopathy, 82% of them having multiple concomitant precipitating factors. Concomitant multiple precipitating factors were associated with death or liver transplantation. A systematic screening for all precipitating factors of hepatic encephalopathy should be proposed for cirrhotics admitted to intensive care unit.