Risk Factors of Mortality in Children with Hepatic Encephalopathy

Abstract

Background: Hepatic encephalopathy is a serious but potentially reversible complication in children with liver disease. The aim of this study is to evaluate the risk factors of mortality in children with hepatic encephalopathy.

Method: Totally 42 patients including 22 boys and 20 girls with clinical diagnosis of hepatic encephalopathy who admitted to Pediatric Intensive Care Unit at Nemazee Hospital affiliated to Shiraz University of Medical Sciences, during 5 years period were enrolled in this study. Demographic features, cause of hepatic failure, grade of hepatic encephalopathy, predisposing factors, concurrent clinical manifestations and laboratory data, as possible prognostic factors were evaluated. The survival states of the patients (survivors or non-survivors) as final outcome were also documented.

Results: The most common underlying liver diseases were cryptogenic (57.2%), hepatitis A (23.8%), Wilson disease (7.1%), and autoimmune hepatitis (7.1%). The total mortality rate was 54%. There was no statistically significant difference in age, weight and hospital stay between survivors or nonsurvivors groups. Only gastrointestinal bleeding had significant association with mortality (37% vs 92%; p=0.001). The most common predisposing factor was infection (52.5%). Patients with higher international normalized ratio and partial thromboplastin time and lower serum sodium and bicarbonate on admission and those with higher bilirubin, international normalized ratio, partial thromboplastin time, aspartate aminotransferase and lower platelets and serum bicarbonate level on last day were more likely to die.

Conclusion: Poor prognostic factors for hepatic encephalopathy were included gastrointestinal bleeding, higher international normalized ratio, partial thromboplastin time, bilirubin, and aspartate aminotransferase, and lower serum sodium and bicarbonate levels and platelet counts. 

Keywords

• Hepatic encephalopathy
• Mortality
• Risk factors

References

1. Ferenci P, Lockwood A, Mullen K, Tarter R, Weissenborn K, Blei AT. Hepatic encephalopathydefinition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 19 Hepatology 2002; 35 (3): 716-721.
2. Poordad FF. Review article: the burden of hepatic encephalopathy. Aliment Pharmacol Ther 2007; 25 Suppl 1: 3-9.
3. Lehner S, Stemmler HJ, Mück A, Braess J, Parhofer KG. Prognostic Parameters and Risk Stratification in Intensive Care Patients with Severe Liver Diseases. J Gastrointestin Liver Dis 2010; 19 (4): 399-404.
4. Carithers RL Jr. Liver transplantation. American Association for the Study of Liver Diseases. Liver Transpl 2000; 6 (1): 122-135.
5. Rivera-Penera T, Moreno J, Skaff C, McDiarmid S, Vargas J, Ament ME. Delayed encephalopathy in fulminant hepatic failure in the pediatric population and the role of liver transplantation. J Pediatr Gastroenterol Nutr 1997; 24 (2): 128-134.
6. Munoz SJ. Hepatic encephalopathy. Medical Clinics of North America 2008; 92 (4): 795-812.
7. Bass NM, Mullen KD, Sanyal A, Poordad F, Neff G, Leevy CB, et al. Rifaximin treatment in hepatic encephalopathy. N Engl J Med 2010; 362 (12): 107110
8. D'Agostino D, Diaz S, Sanchez MC, Boldrini G. Management and prognosis of acute liver failure in children. Curr Gastroenterol Rep 2012; 14 (3): 2622

9. Samanta T, Ganguly S. Aetiology, clinical profile and prognostic indicators for children with acute liver failure admitted in a teaching hospital in Kolkata. Trop Gastroenterol 2007; 28 (3): 135-139.
10. Sanchez MC, D'Agostino DE. Pediatric end-stage liver disease score in acute liver failure to assess poor prognosis. J Pediatr Gastroenterol Nutr 2012; 54 (2): 193-1
11. Latif N, Mehmood K. Risk factors for fulminant hepatic failure and their relation with outcome in children. J Pak Med Assoc 2010; 60 (3): 175-178.
12. Blei AT, Córdoba J. Practice Parameters Committee of the American College of Gastroenterology. Hepatic Encephalopathy. Am J Gastroenterol 2001; 96 (7): 1968-1976.
13. O'Grady JG, Alexander GJ, Hayllar KM, Williams R. Early indicators of prognosis in fulminant hepatic failure. Gastroenterology 1989; 97 (2): 439-445.
14. Bernal W, Hall C, Karvellas CJ, Auzinger G, Sizer E, Wendon J. Arterial ammonia and clinical risk factors for encephalopathy and intracranial hypertension in acute liver failure. Hepatology 2007; 46 (6): 1844-1852.
15. Miyake Y, Sakaguchi K, Iwasaki Y, Ikeda H, Makino Y, Kobashi H, et al. New prognostic scoring model for liver transplantation in patients with nonacetaminophen-related fulminant hepatic failure. Transplantation 2005; 80 (7): 930-936.
16. Guevara M, Baccaro ME, Torre A, Gómez-Ansón B, Ríos J, Torres F, et al. Hyponatremia is a risk factor of hepatic encephalopathy in patients with cirrhosis: a prospective study with time-dependent analysis. Am J Gastroenterol 2009; 104 (6): 138213
17. Guevara M, Baccaro ME, Ríos J, Martín-Llahí M, Uriz J, Ruiz del Arbol L, et al. Risk factors for hepatic encephalopathy in patients with cirrhosis and refractory ascites: relevance of serum sodium concentration. Liver Int 2010; 30 (8): 1137-1142.
18. Godbole G, Shanmugam N, Dhawan A, Verma A. Infectious complications in pediatric acute liver failure. J Pediatr Gastroenterol Nutr 2011; 53 (3): 320-3
19. Kaur S, Kumar P, Kumar V, Sarin SK, Kumar A. Etiology and Prognostic Factors of Acute Liver Failure in Children. Indian Pediatr 2012 doi:pii: S097475591200142.