Probiotics prevent hepatic encephalopathy in patients with cirrhosis: a randomized controlled trial.
OBJECTIVE
Hepatic encephalopathy (HE) is associated with a poor prognosis in patients with advanced liver disease. Probiotics alter the intestinal microbiota with non-urease-producing organisms that reduce production of ammonia. We investigated the efficacy of probiotics for the primary prophylaxis of HE.


METHODS
We conducted a prospective trial at a tertiary care referral institute in New Delhi, India, from January 2012 through March 2013, of patients with cirrhosis without overt HE (age, 48.6 ± 11.1 y; 96 men and 64 women); 25 were Child-Turcotte-Pugh (CTP) class A, 51 were CTP class B, and 84 were CTP class C. Subjects were assigned randomly to groups given probiotics (1 × 10(8) colony-forming units, 3 times daily; n = 86, 42 with minimal HE) or no test article (control, n = 74; 33 with minimal HE). All subjects underwent psychometric analyses, critical flicker fusion (CFF) threshold assessments, glucose hydrogen breath tests to identify small intestinal bacterial overgrowth (SIBO), and lactulose hydrogen breath tests to measure orocecal transit time (OCTT). The primary end point was the development of overt HE.


RESULTS
At baseline, subjects in each group had comparable CTP score, model for end-stage liver disease scores, CFF assessments, psychometric hepatic encephalopathy scores, and OCTT. After a mean follow-up period of 38.6 ± 8.80 weeks for patients given probiotics and 40.3 ± 9.8 weeks for controls, 6 patients given probiotics and 7 controls died (P = .81). Three months of probiotic administration significantly reduced levels of arterial ammonia, SIBO, and OCTT; increased psychometric hepatic encephalopathy scores; and increased CFF thresholds, compared with baseline. Seven subjects in the probiotic group and 14 controls developed overt HE (P < .05; hazard ratio for controls vs probiotic group, 2.1; 95% confidence interval, 1.31-6.53). Psychometric hepatic encephalopathy scores, CTP scores, and SIBO correlated with the development of overt HE.


CONCLUSIONS
In a prospective, randomized controlled trial, probiotics were found to be effective in preventing HE in patients with cirrhosis. Trial registration No: CTRI/2012/07/002807.
Department of Gastroenterology, G B Pant Hospital, New Delhi, India.
Manish Kumar
MK
Lunia
Department of Gastroenterology, G B Pant Hospital, New Delhi, India. Electronic address: drbcsharma@hotmail.com.
Barjesh Chander
BC
Sharma
Department of Gastroenterology, G B Pant Hospital, New Delhi, India.
Praveen
P
Sharma
Department of Gastroenterology, G B Pant Hospital, New Delhi, India.
Sanjeev
S
Sachdeva
Department of Gastroenterology, G B Pant Hospital, New Delhi, India.
Siddharth
S
Srivastava
D000293:Adolescent; D000328:Adult; D000368:Aged; D001944:Breath Tests; D005260:Female; D005947:Glucose / Q000032:analysis; D006501:Hepatic Encephalopathy / Q000473:pathology / Q000517:prevention & control*; D006801:Humans; D007194:India; D007792:Lactulose / Q000032:analysis; D008103:Liver Cirrhosis / Q000150:complications* / Q000473:pathology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D019936:Probiotics / Q000008:administration & dosage*; D011446:Prospective Studies; D011594:Psychometrics; D012720:Severity of Illness Index; D062606:Tertiary Care Centers; D016896:Treatment Outcome; D055815:Young Adult
D007792:Lactulose; D005947:Glucose
Clinical Trial; Cognitive and Motor Function; MHE; Therapy; Treatment