Spectrum of hepatitis B and renal involvement.

Renal involvement in hepatitis B occurs in various spectrums and its knowledge is important for clinicians in management of patients. The renal diseases most commonly associated with hepatitis B virus (HBV) infection include membranous nephropathy, membranoproliferative glomerulonephritis and Polyarteritis nodosa. The widespread use of hepatitis B vaccination has decreased the incidence of HBV-related renal diseases. The incidence of HBV infection in dialysis patients has significantly decreased over the past few decades because of screening of blood products for hepatitis B surface antigen (HBsAg) and hepatitis B core antibody, implementation of infection control measures and hepatitis B vaccination. The definition of acute kidney injury has been recently modified in cirrhotic population, helping in prognosis and prediction of mortality. The most common etiologies of acute kidney injury in this cirrhotic population, which account for 80% to 90% of all cases, include volume depletion, acute tubular necrosis and hepatorenal syndrome. Treatment with oral nucleoside/tide analogues (NA) brought a new paradigm in the management of HBsAg positive glomerulonephritis, kidney transplant recipients and dialysis patients, resulting in effective viral suppression, reduced hepatic complications and improved patient survival, without compromising renal allograft outcome. NAs are cleared by the kidneys and therefore their dosage has to be adjusted in all patients with impaired renal function. This article reviews the recent knowledge of the pathogenesis and treatment of HBV-related glomerulonephritis and discusses the management of hepatitis B in patients on dialysis, kidney transplant recipients and cirrhotics, which is continuously evolving.

Development of predisposition, injury, response, organ failure model for predicting acute kidney injury in acute on chronic liver failure.

BACKGROUND AND AIM: There is limited data on predictors of acute kidney injury in acute on chronic liver failure. We developed a PIRO model (Predisposition, Injury, Response, Organ failure) for predicting acute kidney injury in a multicentric cohort of acute on chronic liver failure patients. PATIENTS AND METHODS: Data of 2360 patients from APASL-ACLF Research Consortium (AARC) was analysed. Multivariate logistic regression model (PIRO score) was developed from a derivation cohort (n=1363) which was validated in another prospective multicentric cohort of acute on chronic liver failure patients (n=997). RESULTS: Factors significant for P component were serum creatinine[(≥2 mg/dL)OR 4.52, 95% CI (3.67-5.30)], bilirubin [(<12 mg/dL,OR 1) vs (12-30 mg/dL,OR 1.45, 95% 1.1-2.63) vs (≥30 mg/dL,OR 2.6, 95% CI 1.3-5.2)], serum potassium [(<3 mmol/LOR-1) vs (3-4.9 mmol/L,OR 2.7, 95% CI 1.05-1.97) vs (≥5 mmol/L,OR 4.34, 95% CI 1.67-11.3)] and blood urea (OR 3.73, 95% CI 2.5-5.5); for I component nephrotoxic medications (OR-9.86, 95% CI 3.2-30.8); for R component,Systemic Inflammatory Response Syndrome,(OR-2.14, 95% CI 1.4-3.3); for O component, Circulatory failure (OR-3.5, 95% CI 2.2-5.5). The PIRO score predicted acute kidney injury with C-index of 0.95 and 0.96 in the derivation and validation cohort. The increasing PIRO score was also associated with mortality (P<.001) in both the derivation and validation cohorts. CONCLUSIONS: The PIRO model identifies and stratifies acute on chronic liver failure patients at risk of developing acute kidney injury. It reliably predicts mortality in these patients, underscoring the prognostic significance of acute kidney injury in patients with acute on chronic liver failure.

Systemic inflammatory response syndrome in acute-on-chronic liver failure: Relevance of 'golden window': A prospective study.

BACKGROUND AND AIM: Systemic inflammatory response syndrome (SIRS) is an early marker of sepsis and ongoing inflammation and has been reported in large proportion of acute-on-chronic liver failure (ACLF) patients. Whether sepsis is the cause or the result of liver failure is unclear and is vital to know. To address this, the study investigated the course and outcome of ACLF patients without SIRS/sepsis. METHODS: Consecutive ACLF patients were monitored for the development of SIRS/sepsis and associated complications and followed till 90 days, liver transplant or death. RESULTS: Of 561 patients, 201 (35.8%) had no SIRS and 360 (64.2%) had SIRS with or without infection. New onset SIRS and sepsis developed in 74.6% and 8% respectively in a median of 7 (range 4-15) days, at a rate of 11% per day. The cumulative incidence of new SIRS was 29%, 92.8%, and 100% by days 4, 7, and 15. Liver failure, that is, bilirubin > 12 mg/dL (odds ratio [OR] = 2.5 [95% confidence interval {CI} = 1.05-6.19], P = 0.04) at days 0 and 4, and renal failure at day 4 (OR = 6.74 [95%CI = 1.50-13.29], P = 0.01), independently predicted new onset SIRS. Absence of SIRS in the first week was associated with reduced incidence of organ failure (20% vs 39.4%, P = 0.003), as was the 28-day (17.6% vs 36%, P = 0.02) and 90-day (27.5% vs 51%,P = 0.002) mortality. The 90-day mortality was 61.6% in the total cohort and that for those having no SIRS and SIRS at presentation were 42.8% and 65%, respectively (P < 0.001). CONCLUSION: Liver failure predicts the development of SIRS. New onset SIRS in the first week is an important determinant of early sepsis, organ failure, and survival. Prompt interventions in this 'golden window' before development of sepsis may improve the outcome of ACLF.

Metastatic Crohn's Disease.

Metastatic cutaneous involvement is a rare extraintestinal manifestation of Crohn's disease. Presence of cutaneous noncaseating granulomas that are anatomically noncontiguous in location with a fistula or the gastrointestinal tract is a diagnostic hallmark. We present a case of inflammatory bowel disease initially diagnosed as ulcerative colitis, but later manifesting as intra-abdominal abscesses and ulcerated cutaneous lesions that on biopsy proved to be metastatic Crohn's disease. The patient promptly responded to corticosteroid therapy.

Geographical patterns of the standing and active human gut microbiome in health and IBD.

OBJECTIVE: A global increase of IBD has been reported, especially in countries that previously had low incidence rates. Also, the knowledge of the human gut microbiome is steadily increasing, however, limited information regarding its variation on a global scale is available. In the light of the microbial involvement in IBDs, we aimed to (1) identify shared and distinct IBD-associated mucosal microbiota patterns from different geographical regions including Europe (Germany, Lithuania) and South Asia (India) and (2) determine whether profiling based on 16S rRNA transcripts provides additional resolution, both of which may hold important clinical relevance. DESIGN: In this study, we analyse a set of 89 mucosal biopsies sampled from individuals of German, Lithuanian and Indian origins, using bacterial community profiling of a roughly equal number of healthy controls, patients with Crohn's disease and UC from each location, and analyse 16S rDNA and rRNA as proxies for standing and active microbial community structure, respectively. RESULTS: We find pronounced population-specific as well as general disease patterns in the major phyla and patterns of diversity, which differ between the standing and active communities. The geographical origin of samples dominates the patterns of ß diversity with locally restricted disease clusters and more pronounced effects in the active microbial communities. However, two genera belonging to the Clostridium leptum subgroup, Faecalibacteria and Papillibacter, display consistent patterns with respect to disease status and may thus serve as reliable 'microbiomarkers'. CONCLUSIONS: These analyses reveal important interactions of patients' geographical origin and disease in the interpretation of disease-associated changes in microbial communities and highlight the added value of analysing communities on both the 16S rRNA gene (DNA) and transcript (RNA) level.

Immunoglobulin IgG4 and autoimmune hepatitis.

INTRODUCTION: IgG4 disease has been characterised by lymphoplasmacytic inflammation, rich in IgG4 plasma cells, elevated serum IgG4 and clinical improvement with steroid therapy. There is limited information about IgG4 plasma cells in autoimmune hepatitis (AIH). Aim of this study was to determine IgG4 plasma cells in autoimmune hepatitis and its impact on clinical course and treatment outcome. MATERIAL METHODS: Liver biopsies from 40 patients with AIH before therapy were subjected to IgG4 immunostaining. Clinical history, liver function tests and response to immunosuppressive therapy were recorded. Patients were monitored for 4 weeks. Liver biopsy from 23 non AIH patients served as control. Depending on the presence of IgG4 plasma cells on immunohistochemistry, patients of autoimmune hepatitis were grouped into IgG4 positive (group A) and IgG4 negative (group B). Both groups were compared before and after immunosuppressive therapy for clinicopathological features. RESULTS: Tissue IgG4 plasma cells > 5 per high power field (hpf) were seen in 10/40 (25%) and > 10 per hpf in 4/40 (10%) cases of AIH. None of the cases from control group (non AIH) were positive for IgG4 plasma cells. Group A patients were significantly younger than group B. (p < 0.05). There were no differences in histological severity but liver enzymes, serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were significantly higher in group A than group B. Post treatment biochemical improvement was similar in both groups. CONCLUSION: IgG4 positive AIH patients were younger with more abnormal liver enzymes. There was no difference in histology and response to treatment in both groups.

HLA - DQ genotyping in celiac disease in western India.

BACKGROUND AND AIMS: Very few human leukocyte antigen (HLA) studies have been carried out in celiac disease patients in India. The aim was to study the HLA DQ antigens in diagnosed celiac disease patients. METHODS: The cross sectional study analysed non-consecutive 34 celiac patients diagnosed as per modified ESPGHAN criteria at tertiary centre and compared with 25 controls. The HLA-DQ typing was carried out using Histo Spot SSO HLA DQ celiac disease kit by tissue typing department. RESULTS: Out of 34 celiac disease patients (26 females, age ± SD 38.79 ± 15.84 years), 59% presented with typical diarrheal disease. Anemia (76%) was most common extra intestinal manifestation followed by bone pain (53%), neurological (12%) and infertility (3%). All 34 patients were IgA antiendomysial antibody positive out of which 32 patients (94%) were HLA-DQ positive (31 patients were HLA-DQ 2 and 1 was HLA-DQ 8 positive).Among HLA positive patients 13, 9 and 10 patients had modified Marsh stage 1, 2 and 3 respectively. HLA DQ 2 and DQ8 positivity among celiac patients (94%) was statistically significant as compared to controls (12%) (P< 0.0001). HLA DQ 2.5 (DQA1*0501 :DQB1*0201 haplotype) and DQ 2 (DQB1*02) haplotypes were common accounting for 70% of patients followed by DQ X.5, DQ8 and DQ 2.2. CONCLUSION: Celiac disease in Indian patients is predominantly associated with HLA DQ 2 and DQ 8 genotype and has high positive predictive value for diagnosis when combined with serology in symptomatic patients.

Management of Chronic Hepatitis B Infection in India.

Chronic hepatitis B (CHB) infection is a substantial global health problem with highest prevalence observed in the sub-Saharan Africa and East Asia. India lies in the intermediate endemicity zone with prevalence ranging from 0.1% to 11.7%. The predominant route of transmission is horizontal and the most commonly occurring genotypes are A and D. The high mortality and morbidity associated with CHB constitutes significant health and economic burden in developing countries like India. Antiviral agents decrease HBV DNA load and prevent disease progression. Several regional and country expert associations have developed treatment guidelines for appropriate management of CHB; however, various factors like prevalence, disease awareness, immunization status, cost implications, availability of resources, type of transmission and emerging significance of HBV genotypes have influenced the management of CHB in a country. This article focuses on expert's recommendations on CHB management including initiation, monitoring and termination of treatment with emphasis on borderline cases. The article also throws light on the challenges to optimum management and provides preferred therapeutic approaches in Indian perspective.

A Case of Tuberculous Colitis with Associated Takayasu's Arteritis.

Intestinal tuberculosis and Crohn's disease (CD) are two different granulomatous diseases affecting the intestinal tract with similarities in clinical presentation but different therapeutic strategies. Takayasu's arteritis (TA) is a graulomatous disease of aorta and its major branches. TA is associated with tuberculosis as well as CD. We present a case of Granulomatous colitis in a young female who was detected to have TA. She was initially diagnosed as a case of CD elsewhere four years previously and has been on immunosuppressive treatment. Repeat evaluation at our centre using endoscopic, radiological and histological criteria suggested a diagnosis of intestinal tuberculosis which was confirmed both by molecular biology techniques as well as by tissue cultures for mycobacterium tuberculosis. Herein we discuss the diagnostic challenge of distinguishing intestinal tuberculosis and CD in a tuberculous endemic country like India. Recent studies have analysed the immunological mechanisms explaining the association of TA and tuberculosis. These studies are important as they may give a clue for better targeted therapies and out come in TA.

Re-evaluating transarterial chemoembolization for the treatment of hepatocellular carcinoma: Consensus recommendations and review by an International Expert Panel.

Patients with unresectable hepatocellular carcinoma (HCC) usually receive transarterial chemoembolization (TACE) or systemic therapies with intermediate and advanced-stage disease. However, intermediate-stage HCC patients often have unsatisfactory clinical outcomes with repeated TACE and there is considerable uncertainty surrounding the criteria for repeating or stopping TACE treatment. In July 2012, an Expert Panel Opinion on Interventions in Hepatocellular Carcinoma (EPOIHCC) was re-convened in Shanghai in an attempt to provide a consensus on the practice of TACE, particularly in regard to evaluating TACE 'failure'. To that end, current clinical practice throughout Asia was reviewed in detail including safety and efficacy data on TACE alone as well as in combination with targeted systemic therapies for intermediate HCC. This review summarizes the evidence discussed at the meeting and provides expert recommendations regarding the use of TACE for unresectable intermediate-stage HCC. A key consensus of the Expert Panel was that the current definitions of TACE failure are not useful in differentiating between situations where TACE is no longer effective in controlling disease locally vs. systemically. By redefining these concepts, it may be possible to provide a clearer indication of when TACE should be repeated and more importantly, when TACE should be discontinued.

Association of IL28B single nucleotide polymorphism rs8099917 with response to treatment in genotype 3 HCV-infected patients from India.

BACKGROUND AND AIM: IL28B gene polymorphisms have been associated with treatment-response (sustained virological response, SVR) in genotype 1 hepatitis C virus (HCV)-infected patients, but only with early phase of viral decline (rapid virological response, RVR) with genotype 3 HCV-infected patients. Association between IL28B variants and SVR in genotype 3 HCV- infected patients is unclear. Our study aimed to replicate the association of IL28Bsingle nucleotide polymorphism (SNP) rs8099917 with SVR and to validate its association with RVR in genotype 3 HCV-infected patients. METHODS: 72 patients receiving combination therapy (interferon-alpha and ribavirin) at different Indian centers were retrospectively recruited and their genotype atrs8099917 was determined. The association with RVR and SVR was tested taking in to account the variation in relevant covariates such as age, gender, baseline HCV RNA copy number and liver enzymes. RESULTS: The minor allele frequency (MAF) in the pooled samples was 0.17 at rs8099917 (G allele). 68% had TT, 29% had GT and 3% had the GG genotype. SVR was achieved in 71% of patients. A significant association ofrs8099917 with both RVR (p = 0.026) and SVR (p = 0.016) was observed with none of the covariates showing any significant association. The relapse rate was high (20%) but no association of rs8099917 was observed with relapse (p = 0.420). CONCLUSION: An IL28B SNP associates with both early phase of viral decline and sustained response in a cohort of genotype 3 HCV-infected patients from India.

Consensus recommendations and review by an International Expert Panel on Interventions in Hepatocellular Carcinoma (EPOIHCC).

Hepatocellular carcinoma (HCC) presents with a high burden of disease in East Asian countries. Intermediate-stage HCC as defined by the Barcelona Clinic Liver Cancer (BCLC) staging system poses a clinical challenge as it includes a heterogeneous population of patients that can vary widely in terms of tumour burden, liver function and disease aetiology. Intermediate HCC patients often have unsatisfactory clinical outcomes with repeated transarterial chemoembolization (TACE, due to non-response of the target tumour or the development of further metastasis indicating progressive disease. In September 2011, an Expert Panel Opinion on Interventions in Hepatocellular Carcinoma (EPOIHCC) was convened in HK in an attempt to provide a consensus on the practice of TACE. To that end, current clinical practice throughout Asia was reviewed in detail including safety and efficacy data on TACE alone as well as in combination with targeted systemic therapies. This review summarises the evidence discussed at the meeting and provides expert recommendation regarding the available therapeutic options for unresectable intermediate stage HCC. A key consensus of the Expert Panel was that in order to improve patient outcomes and long-term survival, the possibility of using TACE in combination with targeted agents given systemically should be explored. While the currently available clinical data is promising, the expected completion of several pivotal phase II and III RCTs will provide further evidence in support of the rationale for combination therapy regimens.

Association of N-acetyltransferase 2 and cytochrome P450 2E1 gene polymorphisms with antituberculosis drug-induced hepatotoxicity in Western India.

BACKGROUND AND AIM: Tuberculosis (TB) is a major public health problem in India. Despite the treatment availability and monitoring, drug-induced hepatotoxicity (DIH) is a serious concern and can lead to discontinuation of treatment. Anti-TB DIH is well known and can aggravate because of pharmacokinetic and pharmacodynamic interactions. Genetic polymorphism in the drug-metabolizing enzyme genes is an important factor that predisposes certain fraction of the population to drug-induced toxicity. The purpose of this study was to assess the association of N-acetyltransferase 2 (NAT2) and cytochrome P450 2E1 (CYP2E1) gene polymorphism with anti-TB DIH in Western Indian population. METHODS: A prospective cohort study of 215 patients taking treatment against TB was performed. The NAT2 and CYP2E1 genotypes were determined using polymerase chain reaction and restriction fragment length polymorphism methods. Logistic regression model was used to calculate odds ratio at 95% confidence interval and their respective P values. RESULTS: The risk of anti-TB DIH was significantly higher in slow acetylator (SA) than in intermediate and rapid acetylator of NAT2 genotypes (odds ratio: 2.3, P = 0.01). We also observed the homozygous point mutation at position 481, associated with higher risk of hepatotoxicity (P < 0.01). The major haplotype NAT2*4 seems to provide protection in DIH compared with non-DIH TB patients (P = 0.04). However, we did not find a significant association between CYP2E1 genotypes and anti-TB DIH. CONCLUSION: Increased susceptibility to isoniazid (INH)-induced hepatotoxicity due to presence of NAT2 SA polymorphism was demonstrated in Western Indian population. NAT2 genotyping can therefore serve as an important tool for identifying patients predisposed to anti-TB DIH.

Serum aminotransferase levels in healthy population from western India.

BACKGROUND & OBJECTIVES: Serum alanine aminotransferase (ALT) level is most commonly used as a marker for the assessment of various liver diseases. Currently upper limits of normal for aspartate aminotransferase (AST) or ALT levels used are based on the western literature. This study was conducted to determine the ALT and AST levels in healthy blood donors from western India and to determine the relation with body mass index (BMI) and waist-to-hip ratio (WHR). METHODS: A total of 5077 voluntary blood donors were selected with strict routine inclusion and exclusion criteria. Weight, height, BMI and WHR were determined along with AST and ALT levels. BMI and WHR were correlated with liver enzymes. RESULTS: Of the 5077 donors, 160 were excluded due to positive serological results. In the remaining 4917 individuals, 4643 (94.4%) were males and 274 (5.6%) were females. Majority 3024 (61.5%) showed BMI more than 23 kg/m2. WHR > 0.85 and 0.80 was found in 4046 (87.0%) males and 250 (91.2%) females. Mean AST and ALT levels in males were 23.4 ± 9.9 IU/l and 27.0 ± 17.3 IU/l and in females 19.1 ± 9.8 IU/l and 17.7 ± 11.2 IU/l, respectively. With increase in BMI, there was a significant increase in AST and ALT levels. Similar increase was also seen with WHR. INTERPRETATION & CONCLUSIONS: Majority of voluntary blood donors showed high BMI and WHR which was directly related to AST and ALT levels. This study highlights the magnitude of obesity in general healthy population of western India and a need to revise the current normal limits of serum ALT.

Association of GST null genotypes with anti-tuberculosis drug induced hepatotoxicity in Western Indian population.

BACKGROUND: The first line anti-tubercular (anti-TB) treatment normally involves isoniazid, rifampicin, pyrazinamide, and ethambutol. Clearance of these drugs depends on the activity of several enzymes such as N-acetyl transferase 2, cytochrome P450 oxidase and glutathione S-transferase (GST). Some of these enzymes are highly polymorphic leading to significant inter-individual variation in their activity thereby increasing the risk of drug induced hepatotoxicity (DIH). AIM: To investigate the possible association of anti-TB DIH with genetic polymorphism of GST genes in Western Indian population. MATERIAL AND METHODS: A prospective case-control study was undertaken on patients who received anti-TB treatment. Cases (n = 50) were distinguished from controls (n = 246) based on occurrence of DIH during anti-tubercular treatment. A multiplex polymerase chain reaction was employed to identify homozygous null mutation at GSTM1 and GSTT1 loci. Results. Homozygous null mutation in GSTM1 gene alone or in both GSTM1 and T1 genes was found to be significantly associated with anti-TB DIH at p < 0.02 and p < 0.007, respectively, in our study population. CONCLUSIONS: This is the first study to report GSTM1 null and combined GSTM1 and T1 null genotypes to be risk factors of anti-TB DIH in Western Indian population. Screening of patients for these genotypes prior to anti-TB regimen would provide better control of hepatotoxicity.

Impact of compensated cirrhosis on survival in patients with acute-on-chronic liver failure.

BACKGROUND AND AIMS: Acute-on-chronic liver failure (ACLF) is considered a main prognostic event in patients with chronic liver disease (CLD). We analyzed the 28-day and 90-day mortality in ACLF patients with or without underlying cirrhosis enrolled in the ACLF Research Consortium (AARC) database. METHODS: A total of 1,621 patients were prospectively enrolled and 637 (39.3%) of these patients had cirrhosis. Baseline characteristics, complications and mortality were compared between patients with and without cirrhosis. RESULTS: Alcohol consumption was more common in cirrhosis than non-cirrhosis (66.4% vs. 44.2%, p < 0.0001), while non-alcoholic fatty liver disease/cryptogenic CLD (10.9% vs 5.8%, p < 0.0001) and chronic HBV reactivation (18.8% vs 11.8%, p < 0.0001) were more common in non-cirrhosis. Only 0.8% of patients underwent liver transplantation. Overall, 28-day and 90-day mortality rates were 39.3% and 49.9%, respectively. Patients with cirrhosis had a greater chance of survival compared to those without cirrhosis both at 28-day (HR = 0.48; 95% CI 0.36-0.63, p < 0.0001) and 90-day (HR = 0.56; 95% CI 0.43-0.72, p < 0.0001), respectively. In alcohol CLD, non-cirrhosis patients had a higher 28-day (49.9% vs. 23.6%, p < 0.001) and 90-day (58.4% vs. 35.2%, p < 0.001) mortality rate than cirrhosis patients. ACLF patients with cirrhosis had longer mean survival than non-cirrhosis patients (25.5 vs. 18.8 days at 28-day and 65.2 vs. 41.2 days at 90-day). Exaggerated systemic inflammation might be the reason why non-cirrhosis patients had a poorer prognosis than those with cirrhosis after ACLF had occurred. CONCLUSIONS: The 28-day and 90-day mortality rates of ACLF patients without cirrhosis were significantly higher than those with cirrhosis in alcoholic CLD. The presence of cirrhosis and its stage should be evaluated at baseline to guide for management. Thai Clinical Trials Registry, TCTR20191226002.

A systematic review of hepatitis C virus epidemiology in Asia, Australia and Egypt.

BACKGROUND: The hepatitis C pandemic has been systematically studied and characterized in North America and Europe, but this important public health problem has not received equivalent attention in other regions. AIM: The objective of this systematic review was to characterize hepatitis C virus (HCV) epidemiology in selected countries of Asia, Australia and Egypt, i.e. in a geographical area inhabited by over 40% of the global population. METHODOLOGY: Data references were identified through indexed journals and non-indexed sources. In this work, 7770 articles were reviewed and 690 were selected based on their relevance. RESULTS: We estimated that 49.3-64.0 million adults in Asia, Australia and Egypt are anti-HCV positive. China alone has more HCV infections than all of Europe or the Americas. While most countries had prevalence rates from 1 to 2% we documented several with relatively high prevalence rates, including Egypt (15%), Pakistan (4.7%) and Taiwan (4.4%). Nosocomial infection, blood transfusion (before screening) and injection drug use were identified as common risk factors in the region. Genotype 1 was common in Australia, China, Taiwan and other countries in North Asia, while genotype 6 was found in Vietnam and other Southeast Asian countries. In India and Pakistan genotype 3 was predominant, while genotype 4 was found in Middle Eastern countries such as Egypt, Saudi Arabia and Syria. CONCLUSION: We recommend implementation of surveillance systems to guide effective public health policy that may lead to the eventual curtailment of the spread of this pandemic infection.

Minimal hepatic encephalopathy: consensus statement of a working party of the Indian National Association for Study of the Liver.

Hepatic encephalopathy (HE) is a major complication that develops in some form and at some stage in a majority of patients with liver cirrhosis. Overt HE occurs in approximately 30-45% of cirrhotic patients. Minimal HE (MHE), the mildest form of HE, is characterized by subtle motor and cognitive deficits and impairs health-related quality of life. The Indian National Association for Study of the Liver (INASL) set up a Working Party on MHE in 2008 with a mandate to develop consensus guidelines on various aspects of MHE relevant to clinical practice. Questions related to the definition of MHE, its prevalence, diagnosis, clinical characteristics, pathogenesis, natural history and treatment were addressed by the members of the Working Party.