title: Predictors of nonresponse to lactulose in patients with cirrhosis and hepatic encephalopathy.
abstract: OBJECTIVE
  Lactulose is commonly used in the treatment of hepatic encephalopathy (HE). However, all patients do not respond to lactulose. We evaluated predictors of nonresponse to lactulose in patients with cirrhosis and HE.
  
  
  METHODS
  Consecutive cirrhotic patients with HE were enrolled. HE was diagnosed by West Haven criteria. Patients were treated with lactulose and correction of any associated precipitating factors. Nonresponse was defined if patient remained in HE even after 10 days of treatment or died while in HE.
  
  
  RESULTS
  Of 300 patients with cirrhosis and HE, 231 (77%) patients met the inclusion criteria. The majority (95%) of the patients had Grade 2 or 3 HE. Of 231 patients, 180 (78%) responded to lactulose. Fifty-one (22%) did not respond to lactulose, 34 (15%) died without any improvement in HE and HE did not improve in 17 (7%) patients after 10 days of therapy. On comparing baseline parameters between nonresponders versus responders there was significant difference between baseline age (42.0+/-11.9 vs. 46.6+/-12.7 year, P=0.02), total leukocyte count (median, 9300 vs. 7300 cells/mm3, P=0.001), serum sodium level (129.9+/-6.2 vs. 133.7+/-7.1 mmol/l, P=0.001), model for end stage liver disease (MELD) score (22.9+/-3.8 vs. 19.9+/-4.2, P=0.001), mean arterial pressure (MAP, 77.9+/-10.0 vs. 86.3+/-8.7 mmHg, P=0.001), serum AST (median, 114 vs. 76 IU/l, P=0.01), serum ALT (median, 84 vs. 48.5 IU/l, P=0.001), spontaneous bacterial peritonitis [18 (35%) vs. 37 (21%), P=0.02] and hepatocellular carcinoma [HCC, 17 (33%) vs. 14 (7%), P=0.001]. On multivariate analysis baseline total leukocyte count, MELD, MAP, and HCC were independent predictors of nonresponse to lactulose (P=0.001). Combination of low MAP, high MELD, and presence of HCC had diagnostic accuracy of 81% in predicting nonresponse to lactulose.
  
  
  CONCLUSIONS
  Of 78% patients with chronic liver disease with HE (majority with Grade 2 and 3) responded to lactulose. High baseline MELD, high total leukocyte count, low serum sodium, low MAP, and presence of hepatocellular carcinoma were predictors of nonresponse to lactulose.
authors.affiliation: Department of Gastroenterology, G B Pant Hospital, New Delhi, India.
authors.forename: Praveen
authors.initials: P
authors.lastname: Sharma
authors.forename: Barjesh Chander
authors.initials: BC
authors.lastname: Sharma
authors.forename: Shiv Kumar
authors.initials: SK
authors.lastname: Sarin
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000150:complications; D002908:Chronic Disease; D004351:Drug Resistance; D005260:Female; D005765:Gastrointestinal Agents / Q000627:therapeutic use*; D006501:Hepatic Encephalopathy / Q000188:drug therapy* / Q000209:etiology; D006801:Humans; D006975:Hypertension, Portal / Q000150:complications / Q000188:drug therapy; D007010:Hyponatremia / Q000150:complications; D007792:Lactulose / Q000627:therapeutic use*; D007958:Leukocyte Count; D008103:Liver Cirrhosis / Q000150:complications / Q000188:drug therapy*; D017093:Liver Failure / Q000188:drug therapy / Q000209:etiology; D008113:Liver Neoplasms / Q000150:complications; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D055815:Young Adult
chemical_list: D005765:Gastrointestinal Agents; D007792:Lactulose