title: Clinical and Pathophysiological Characteristics of Cirrhotic Patients with Grade 1 and Minimal Hepatic Encephalopathy.
abstract: OBJECTIVE
  EASL/AASLD hepatic encephalopathy (HE) guidelines proposed the alternative use of the term 'Covert HE' combining minimal HE (mHE) and Grade 1 HE into a single entity. However, longitudinal data to indicate that these are indeed a single entity are lacking. The aims of this study were to determine whether the occurrence of complications of cirrhosis requiring hospital admission and mortality were similar in these sub-groups of patients.
  
  
  METHODS
  Clinically-stable cirrhotic patients (n = 106) with no previous history of 'Overt HE' were included over a 2-year period and classified as having no HE (n = 23), mHE (n = 39) or Grade 1 HE (n = 44). Standard biochemistry, venous ammonia, bacterial DNA and neutrophil function were measured at inclusion and the patients were followed for a mean of 230±95 days.
  
  
  RESULTS
  Patients with Grade 1 HE had significantly more complications requiring hospitalisation (infection 9/18/34%; HE 4/8/18%; other 13/10/11%; P = 0.02) and significantly greater mortality (4/5/20%; P = 0.04) compared to patients with no HE or mHE respectively. Patients with mHE and grade 1 HE had similar ammonia levels, but higher than the no HE group (P<0.001). MELD score was similar between groups but Grade 1 HE patients had increased frequency of bacterial translocation (P = 0.06) and neutrophil spontaneous respiratory burst (P = 0.02) compared to patients with mHE.
  
  
  CONCLUSIONS
  The results of this study show for the first time that 'Covert HE' is a heterogeneous entity with significantly greater hospitalisations and mortality in the Grade 1 HE patients compared with mHE. Further prospective longer-term studies are required before EASL/AASLD guidance is fully implemented.
authors.affiliation: Liver Failure Group, UCL Institute for Liver and Digestive Health, University College London Medical School, London, United Kingdom.
authors.forename: Karen Louise
authors.initials: KL
authors.lastname: Thomsen
authors.affiliation: Liver Failure Group, UCL Institute for Liver and Digestive Health, University College London Medical School, London, United Kingdom.
authors.forename: Jane
authors.initials: J
authors.lastname: Macnaughtan
authors.affiliation: Liver Failure Group, UCL Institute for Liver and Digestive Health, University College London Medical School, London, United Kingdom.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Tritto
authors.affiliation: Liver Failure Group, UCL Institute for Liver and Digestive Health, University College London Medical School, London, United Kingdom.
authors.forename: Rajeshwar P
authors.initials: RP
authors.lastname: Mookerjee
authors.affiliation: Liver Failure Group, UCL Institute for Liver and Digestive Health, University College London Medical School, London, United Kingdom.
authors.forename: Rajiv
authors.initials: R
authors.lastname: Jalan
mesh_terms: D000368:Aged; D000641:Ammonia / Q000097:blood; D016470:Bacteremia / Q000150:complications / Q000382:microbiology / Q000401:mortality / Q000473:pathology*; D018988:Bacterial Translocation; D004269:DNA, Bacterial / Q000097:blood; D005260:Female; D006501:Hepatic Encephalopathy / Q000150:complications / Q000382:microbiology / Q000401:mortality / Q000473:pathology*; D006760:Hospitalization; D006801:Humans; D008099:Liver / Q000378:metabolism / Q000382:microbiology / Q000473:pathology*; D008103:Liver Cirrhosis / Q000150:complications / Q000382:microbiology / Q000401:mortality / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D009504:Neutrophils / Q000473:pathology; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D016897:Respiratory Burst; D012720:Severity of Illness Index; D016019:Survival Analysis; D009626:Terminology as Topic
chemical_list: D004269:DNA, Bacterial; D000641:Ammonia