Performance of the hepatic encephalopathy scoring algorithm in a clinical trial of patients with cirrhosis and severe hepatic encephalopathy.
OBJECTIVE
The grading of hepatic encephalopathy (HE) is based on a combination of indicators that reflect the state of consciousness, intellectual function, changes in behavior, and neuromuscular alterations seen in patients with liver failure.


METHODS
We modified the traditional West Haven criteria (WHC) to provide an objective assessment of the cognitive parameters to complement the subjective clinical ratings for the performance of extracorporeal albumin dialysis (ECAD) using a molecular adsorption recirculating system in patients with cirrhosis and severe (grade III / IV) encephalopathy. The HE Scoring Algorithm (HESA) combined clinical indicators with those derived from simple neuropsychological tests,the latter more often used in milder grades of HE (I / II). The performance of each indicator was compared across grades and sites.


RESULTS
Results of HESA were also compared with the Glasgow Coma Scale. A total of 597 evaluations were performed in patients randomized to ECAD plus standard medical therapy or the latter only. Most parameters exhibited significant separation between grades; the most effective indicators were lack of verbal, eye, and motor response (grade IV), somnolence and disorientation to place (grade III), and lethargy and disorientation to time (grade II). Two clinical and four neuropsychological indicators were useful to classify patients as grade I. The Glasgow Coma Scale differed among the four stages of the WHC, but the differences between grades I and II were small and not clinically useful.


CONCLUSIONS
HESA extends the traditional WHC for grading HE. In the absence of a "gold" standard, the most useful indicators noted in this trial should be further validated.
Hassanein
Tarek
T
Department of Medicine, University of California-San Diego, 200 West Arbor Drive, San Diego, CA 92103-8423, USA. thassanein@ucsd.edu
Blei
Andres T
AT
Perry
William
W
Hilsabeck
Robin
R
Stange
Jan
J
Larsen
Fin S
FS
Brown
Robert S
RS
Caldwell
Stephen
S
McGuire
Brendan
B
Nevens
Frederik
F
Fontana
Robert
R
D000328:Adult; D000368:Aged; D000418:Albumins; D003071:Cognition / Q000502:physiology; D005060:Europe; D005260:Female; D005500:Follow-Up Studies; D015600:Glasgow Coma Scale; D006501:Hepatic Encephalopathy / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology; D006801:Humans; D008103:Liver Cirrhosis / Q000097:blood / Q000150:complications* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009043:Motor Activity / Q000502:physiology; D009483:Neuropsychological Tests; D011379:Prognosis; D006435:Renal Dialysis / Q000379:methods*; D012720:Severity of Illness Index; D014481:United States; D055815:Young Adult
D000418:Albumins