title: Increased risk of cognitive impairment in cirrhotic patients with bacterial infections.
abstract: OBJECTIVE
  A causal relationship between infection, systemic inflammation, and hepatic encephalopathy (HE) has been suggested in cirrhosis. No study, however, has specifically examined, in cirrhotic patients with infection, the complete pattern of clinical and subclinical cognitive alterations and its reversibility after resolution. Our investigation was aimed at describing the characteristics of cognitive impairment in hospitalized cirrhotic patients, in comparison with patients without liver disease, with and without infection.
  
  
  METHODS
  One hundred and fifty cirrhotic patients were prospectively enrolled. Eighty-one patients without liver disease constituted the control group. Bacterial infections and sepsis were actively searched in all patients independently of their clinical evidence at entry. Neurological and psychometric assessment was performed at admission and in case of nosocomial infection. The patients were re-evaluated after the resolution of the infection and 3months later.
  
  
  RESULTS
  Cognitive impairment (overt or subclinical) was recorded in 42% of cirrhotics without infection, in 79% with infection without SIRS and in 90% with sepsis. The impairment was only subclinical in controls and occurred only in patients with sepsis (42%). Multivariate analysis selected infection as the only independent predictor of cognitive impairment (OR 9.5; 95% CI 3.5-26.2; p=0.00001) in cirrhosis. The subclinical alterations detected by psychometric tests were also strongly related to the infectious episode and reversible after its resolution.
  
  
  CONCLUSIONS
  Infections are associated with a worse cognitive impairment in cirrhotics compared to patients without liver disease. The search and treatment of infections are crucial to ameliorate both clinical and subclinical cognitive impairment of cirrhotic patients.
authors.affiliation: Gastroenterology, Department of Clinical Medicine, Sapienza University of Rome, Italy. manuela.merli@uniroma1.it
authors.forename: Manuela
authors.initials: M
authors.lastname: Merli
authors.forename: Cristina
authors.initials: C
authors.lastname: Lucidi
authors.forename: Ilaria
authors.initials: I
authors.lastname: Pentassuglio
authors.forename: Valerio
authors.initials: V
authors.lastname: Giannelli
authors.forename: Michela
authors.initials: M
authors.lastname: Giusto
authors.forename: Vincenza
authors.initials: V
authors.lastname: Di Gregorio
authors.forename: Chiara
authors.initials: C
authors.lastname: Pasquale
authors.forename: Silvia
authors.initials: S
authors.lastname: Nardelli
authors.forename: Barbara
authors.initials: B
authors.lastname: Lattanzi
authors.forename: Mario
authors.initials: M
authors.lastname: Venditti
authors.forename: Oliviero
authors.initials: O
authors.lastname: Riggio
mesh_terms: D000328:Adult; D000368:Aged; D001424:Bacterial Infections / Q000150:complications* / Q000523:psychology*; D016022:Case-Control Studies; D003072:Cognition Disorders / Q000209:etiology* / Q000523:psychology*; D005260:Female; D006501:Hepatic Encephalopathy / Q000209:etiology* / Q000523:psychology*; D006760:Hospitalization; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications* / Q000523:psychology*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011446:Prospective Studies; D011594:Psychometrics; D012307:Risk Factors; D018746:Systemic Inflammatory Response Syndrome / Q000150:complications / Q000523:psychology
keywords: C-reactive protein; CRP; DST; HE; Hepatic encephalopathy; Hyperammonemia; MHE; Minimal hepatic encephalopathy; Psycometric test; SIRS; Sepsis; Systemic inflammatory response syndrome (SIRS); TMT-A; TMT-B; digit-symbol test; hepatic encephalopathy; minimal hepatic encephalopathy; systemic inflammatory response syndrome; trail-making test A; trail-making test B