Differential impact of hyponatremia and hepatic encephalopathy on health-related quality of life and brain metabolite abnormalities in cirrhosis

• Published in: Journal of hepatology Vol. 59; no. 3; pp. 467 - 473
• Main Authors: Ahluwalia, Vishwadeep, Wade, James B, Thacker, Leroy, Kraft, Kenneth A, Sterling, Richard K, Stravitz, R. Todd, Fuchs, Michael, Bouneva, Iliana, Puri, Puneet, Luketic, Velimir, Sanyal, Arun J, Gilles, HoChong, Heuman, Douglas M, Bajaj, Jasmohan S
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier B.V 01.09.2013
• Subjects: Brain - metabolism; Cognition; Cognition Disorders - etiology; Cognition Disorders - metabolism; Cognition Disorders - psychology; Cognitive function; Diuretics - administration & dosage; Female; Gastroenterology and Hepatology; Glutamic Acid - metabolism; Glutamine - metabolism; Hepatic encephalopathy; Hepatic Encephalopathy - complications; Hepatic Encephalopathy - metabolism; Hepatic Encephalopathy - psychology; Humans; Hyponatremia; Hyponatremia - complications; Hyponatremia - metabolism; Hyponatremia - psychology; Inositol - metabolism; Liver Cirrhosis - complications; Liver Cirrhosis - metabolism; Liver Cirrhosis - psychology; Magnetic Resonance Spectroscopy; Male; Middle Aged; Quality of Life; Sickness Impact Profile; PHES; serial dotting test; HN; sickness impact profile; HE + HN; block design test; magnetic resonance spectroscopy; inhibitory control test; Cho; Cr; Glx; glutamate + glutamine; anterior cingulate cortex; right parietal white matter; TIPS; SDT; voxel of interest; Model for End-Stage Liver Disease; DST; health-related quality of life; occipital gray matter; PRESS; myoinositol; CHESS; VOI; RPWM; MELD; creatine; mini-mental status examination; HRQOL; SIP; Cognitive function; hepatic encephalopathy and hyponatremia; number connection tests A/B; magnetic resonance imaging; digit symbol test; MRI; point resolved spectroscopy; NCT-A/B; LTTt/e; line tracing test time/errors; N; MRS; choline; BDT; MMSE; hepatic encephalopathy; clinical hepatic encephalopathy staging scale; ACC; transjugular intra-hepatic porto-systemic shunting; OGM; psychometric hepatic encephalopathy score; hyponatremia; neither HE nor hyponatremia; ICT; mI; HE; HE+HN; Magnetic resonance spectroscopy; Hyponatremia; Sickness Impact Profile; Hepatic encephalopathy; glutamate+glutamine
• ISSN: 0168-8278; 1600-0641
• DOI: 10.1016/j.jhep.2013.04.023

Background & Aims Hyponatremia (HN) and hepatic encephalopathy (HE) together can impair health-related quality of life (HRQOL) and cognition in cirrhosis. We aimed at studying the effect of hyponatremia on cognition, HRQOL, and brain MR spectroscopy (MRS) independent of HE. Methods Four cirrhotic groups (no HE/HN, HE alone, HN alone (sodium <130 mEq/L), HE + HN) underwent cognitive testing, HRQOL using Sickness Impact Profile (SIP: higher score is worse; has psychosocial and physical sub-scores) and brain MRS (myoinositol (mI) and glutamate + glutamine (Glx)), which were compared across groups. A subset underwent HRQOL testing before/after diuretic withdrawal. Results 82 cirrhotics (30 no HE/HN, 25 HE, 17 HE + HN, and 10 HN, MELD 12, 63% hepatitis C) were included. Cirrhotics with HN alone and without HE/HN had better cognition compared to HE groups (median abnormal tests no-HE/HN: 3, HN: 3.5, HE: 6.5, HE + HN: 7, p = 0.008). Despite better cognition, HN only patients had worse HRQOL in total and psychosocial SIP while both HN groups (with/without HE) had a significantly worse physical SIP ( p <0.0001, all comparisons). Brain MRS showed the lowest Glx in HN and the highest in HE groups ( p <0.02). mI levels were comparably decreased in the three affected (HE, HE + HN, and HN) groups compared to no HE/HN and were associated with poor HRQOL. Six HE + HN cirrhotics underwent diuretic withdrawal which improved serum sodium and total/psychosocial SIP scores. Conclusions Hyponatremic cirrhotics without HE have poor HRQOL despite better cognition than those with concomitant HE. Glx levels were lowest in HN without HE but mI was similar across affected groups. HRQOL improved after diuretic withdrawal. Hyponatremia has a complex, non-linear relationship with brain Glx and mI, cognition and HRQOL.