Covert hepatic encephalopathy: agreement and predictive validity of different indices.
OBJECTIVE
To investigate the agreement and prognostic value of different measures of covert hepatic encephalopathy (CHE).


METHODS
One-hundred-and-thirty-two cirrhotic outpatients underwent electroencephalography (EEG), paper-and-pencil psychometry (PHES) and critical flicker frequency, scored on the original/modified (CFFo/CFFm) thresholds. Eighty-four patients underwent Doppler-ultrasound to diagnose/exclude portal-systemic shunt. Seventy-nine were followed-up for 11 ± 7 mo in relation to the occurrence of hepatic encephalopathy (HE)-related hospitalisations.


RESULTS
On the day of study, 36% had grade I HE, 42% abnormal EEG, 33% abnormal PHES and 31/21% abnormal CFFo/CFFm. Significant associations were observed between combinations of test abnormalities; however, agreement was poor (Cohen's κ < 0.4). The prevalence of EEG, PHES and CFFo/CFFm abnormalities was significantly higher in patients with grade I overt HE. The prevalence of EEG and CFFm abnormalities was higher in patients with shunt. The prevalence of EEG abnormalities was significantly higher in patients with a history of HE. During follow-up, 10 patients died, 10 were transplanted and 29 had HE-related hospitalisations. Grade I HE (P = 0.004), abnormal EEG (P = 0.008) and abnormal PHES (P = 0.04) at baseline all predicted the subsequent occurrence of HE; CFF did not.


CONCLUSIONS
CHE diagnosis probably requires a combination of clinical, neurophysiological and neuropsychological indices.
Sara Montagnese, Esmeralda Balistreri, Sami Schiff, Michele De Rui, Paolo Angeli, Giancarlo Bombonato, Massimo Bolognesi, David Sacerdoti, Angelo Gatta, Carlo Merkel, Piero Amodio, Department of Medicine, University of Padova, 35128 Padova, Italy.
Sara
S
Montagnese
Sara Montagnese, Esmeralda Balistreri, Sami Schiff, Michele De Rui, Paolo Angeli, Giancarlo Bombonato, Massimo Bolognesi, David Sacerdoti, Angelo Gatta, Carlo Merkel, Piero Amodio, Department of Medicine, University of Padova, 35128 Padova, Italy.
Esmeralda
E
Balistreri
Sara Montagnese, Esmeralda Balistreri, Sami Schiff, Michele De Rui, Paolo Angeli, Giancarlo Bombonato, Massimo Bolognesi, David Sacerdoti, Angelo Gatta, Carlo Merkel, Piero Amodio, Department of Medicine, University of Padova, 35128 Padova, Italy.
Sami
S
Schiff
Sara Montagnese, Esmeralda Balistreri, Sami Schiff, Michele De Rui, Paolo Angeli, Giancarlo Bombonato, Massimo Bolognesi, David Sacerdoti, Angelo Gatta, Carlo Merkel, Piero Amodio, Department of Medicine, University of Padova, 35128 Padova, Italy.
Michele
M
De Rui
Sara Montagnese, Esmeralda Balistreri, Sami Schiff, Michele De Rui, Paolo Angeli, Giancarlo Bombonato, Massimo Bolognesi, David Sacerdoti, Angelo Gatta, Carlo Merkel, Piero Amodio, Department of Medicine, University of Padova, 35128 Padova, Italy.
Paolo
P
Angeli
Sara Montagnese, Esmeralda Balistreri, Sami Schiff, Michele De Rui, Paolo Angeli, Giancarlo Bombonato, Massimo Bolognesi, David Sacerdoti, Angelo Gatta, Carlo Merkel, Piero Amodio, Department of Medicine, University of Padova, 35128 Padova, Italy.
Giacomo
G
Zanus
Sara Montagnese, Esmeralda Balistreri, Sami Schiff, Michele De Rui, Paolo Angeli, Giancarlo Bombonato, Massimo Bolognesi, David Sacerdoti, Angelo Gatta, Carlo Merkel, Piero Amodio, Department of Medicine, University of Padova, 35128 Padova, Italy.
Umberto
U
Cillo
Sara Montagnese, Esmeralda Balistreri, Sami Schiff, Michele De Rui, Paolo Angeli, Giancarlo Bombonato, Massimo Bolognesi, David Sacerdoti, Angelo Gatta, Carlo Merkel, Piero Amodio, Department of Medicine, University of Padova, 35128 Padova, Italy.
Giancarlo
G
Bombonato
Sara Montagnese, Esmeralda Balistreri, Sami Schiff, Michele De Rui, Paolo Angeli, Giancarlo Bombonato, Massimo Bolognesi, David Sacerdoti, Angelo Gatta, Carlo Merkel, Piero Amodio, Department of Medicine, University of Padova, 35128 Padova, Italy.
Massimo
M
Bolognesi
Sara Montagnese, Esmeralda Balistreri, Sami Schiff, Michele De Rui, Paolo Angeli, Giancarlo Bombonato, Massimo Bolognesi, David Sacerdoti, Angelo Gatta, Carlo Merkel, Piero Amodio, Department of Medicine, University of Padova, 35128 Padova, Italy.
David
D
Sacerdoti
Sara Montagnese, Esmeralda Balistreri, Sami Schiff, Michele De Rui, Paolo Angeli, Giancarlo Bombonato, Massimo Bolognesi, David Sacerdoti, Angelo Gatta, Carlo Merkel, Piero Amodio, Department of Medicine, University of Padova, 35128 Padova, Italy.
Angelo
A
Gatta
Sara Montagnese, Esmeralda Balistreri, Sami Schiff, Michele De Rui, Paolo Angeli, Giancarlo Bombonato, Massimo Bolognesi, David Sacerdoti, Angelo Gatta, Carlo Merkel, Piero Amodio, Department of Medicine, University of Padova, 35128 Padova, Italy.
Carlo
C
Merkel
Sara Montagnese, Esmeralda Balistreri, Sami Schiff, Michele De Rui, Paolo Angeli, Giancarlo Bombonato, Massimo Bolognesi, David Sacerdoti, Angelo Gatta, Carlo Merkel, Piero Amodio, Department of Medicine, University of Padova, 35128 Padova, Italy.
Piero
P
Amodio
D000368:Aged; D058070:Asymptomatic Diseases; D004569:Electroencephalography; D005260:Female; D006501:Hepatic Encephalopathy / Q000175:diagnosis* / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000523:psychology / Q000628:therapy; D006760:Hospitalization; D006801:Humans; D053208:Kaplan-Meier Estimate; D008103:Liver Cirrhosis / Q000150:complications* / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009483:Neuropsychological Tests; D015588:Observer Variation; D011237:Predictive Value of Tests; D011379:Prognosis; D011594:Psychometrics; D015203:Reproducibility of Results; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D018608:Ultrasonography, Doppler
Ammonia; Electroencephalography; Hepatic encephalopathy; Liver cirrhosis; Psychometry