Stepwise diagnosis in covert hepatic encephalopathy: critical flicker frequency and MELD-score as a first-step approach

作者：Greinert R; Ripoll C; Hollenbach M; Zipprich A

来源：Alimentary Pharmacology and Therapeutics, 2016, 44(5): 514-521.

DOI：10.1111/apt.13721

<jats:title>Summary</jats:title><jats:sec><jats:title>Background</jats:title><jats:p>The diagnosis of covert hepatic encephalopathy (<jats:styled-content style="fixed-case">CHE</jats:styled-content>) by means of portosystemic encephalopathy syndrome (<jats:styled-content style="fixed-case">PSE</jats:styled-content>) test is costly and therefore infrequently performed.</jats:p></jats:sec><jats:sec><jats:title>Aim</jats:title><jats:p>To determine the ability of critical flicker frequency (<jats:styled-content style="fixed-case">CFF</jats:styled-content>) alone or in combination with laboratory findings, as an initial test to pre‐select which patients should undergo further testing for the diagnosis of covert hepatic encephalopathy.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>This single‐centre study included all patients with cirrhosis who underwent <jats:styled-content style="fixed-case">PSE</jats:styled-content> and <jats:styled-content style="fixed-case">CFF</jats:styled-content> in 2011. <jats:styled-content style="fixed-case">CHE</jats:styled-content> was defined by abnormal <jats:styled-content style="fixed-case">PSE</jats:styled-content> test. Logistic regression analysis was performed to identify predictors of <jats:styled-content style="fixed-case">CHE</jats:styled-content>. <jats:styled-content style="fixed-case">ROC</jats:styled-content> curves were used to identify cut‐offs of these independent predictors.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>One hundred and seventeen patients were included. Seventy (60%) had <jats:styled-content style="fixed-case">CHE</jats:styled-content> with a higher <jats:styled-content style="fixed-case">MELD</jats:styled-content> [16 (<jats:styled-content style="fixed-case">IQR</jats:styled-content> 13–21); <jats:italic>P</jats:italic> = 0.001] and lower <jats:styled-content style="fixed-case">CFF</jats:styled-content> [38 Hz (<jats:styled-content style="fixed-case">IQR</jats:styled-content> 36–41) <jats:italic>P</jats:italic> = 0.0011]. On multivariate analyses, <jats:styled-content style="fixed-case">CFF</jats:styled-content> [<jats:styled-content style="fixed-case">OR</jats:styled-content> 0.83 (95% <jats:styled-content style="fixed-case">CI</jats:styled-content> 0.74–0.94)] and <jats:styled-content style="fixed-case">MELD</jats:styled-content> [<jats:styled-content style="fixed-case">OR</jats:styled-content> 1.13 (95% <jats:styled-content style="fixed-case">CI</jats:styled-content> 1.04–1.22)] were identified as independent predictors of <jats:styled-content style="fixed-case">CHE</jats:styled-content>. Sensitivity and specificity of a <jats:styled-content style="fixed-case">CFF</jats:styled-content> cut‐off of 43 Hz was 93.5% and 42.9%, and for a <jats:styled-content style="fixed-case">MELD</jats:styled-content> cut‐off of 24, it was 97.5% and 32.8% respectively. Most patients with a <jats:styled-content style="fixed-case">MELD</jats:styled-content>‐Score &lt;24 and a <jats:styled-content style="fixed-case">CFF</jats:styled-content> &gt;43 Hz did not have <jats:styled-content style="fixed-case">CHE</jats:styled-content> (78%) and with a <jats:styled-content style="fixed-case">MELD</jats:styled-content>‐Score &gt;24 and <jats:styled-content style="fixed-case">CFF</jats:styled-content> &lt;43 Hz most patients had <jats:styled-content style="fixed-case">CHE</jats:styled-content> (85%). Therefore, 27% of patients could avoid further testing with a diagnostic accuracy of 81%.</jats:p></jats:sec><jats:sec><jats:title>Conclusion</jats:title><jats:p>The combination of <jats:styled-content style="fixed-case">MELD</jats:styled-content>‐score and critical flicker frequency may be used as a first diagnostic step to filter patients, in whom further covert hepatic encephalopathy testing could be avoided.</jats:p></jats:sec>

• 出版日期2016-9