RETROSPECTIVE EVALUATION OF THE EFFECT OF AMMONIA LEVELS ON MORTALITY IN PATIENTS WITH HEPATIC ENCEPHALOPATHY APPLYING TO THE EMERGENCY DEPARTMENT

Year 2021, , 453 - 461, 31.12.2021

İremgül Güngör , Ahmet Burak Erdem

https://doi.org/10.24938/kutfd.902008

Abstract

Objective: Hepatic encephalopathy is a cognitive, motor and behavioral disorder caused by the accumulation of liver metabolism products accompanying hepatic failure. The clinical picture of hepatic encephalopathy appears with the accumulation of metabolites such as ammonia and gamma aminobutyric acid. In our study, we aimed to investigate the effect of blood ammonia levels on mortality in patients diagnosed with hepatic encephalopathy.

Material and Methods: The records of patients who were admitted to the emergency department of our hospital with impaired consciousness, known chronic liver disease, and whose ammonia levels were studied between January 01 2015 and December 31 2018 were retrospectively analyzed. Liver function tests and coagulation tests of the patients were recorded. The patients were divided into two groups as with and without hepatic encephalopathy. The groups were divided into stages according to the West Haven classification. Liver function tests and coagulation tests of the two groups were compared according to ammonia level, disease stage and mortality.

Results: Four hundred and thirty-five of 883 patients whose ammonia levels were studied between 2015-2018 were included in the study. The age of the patients included in the study ranged from 18 to 95 years. One hundred and forty -four of them were female. When the relation of ammonia value with mortality was examined, there was no statistically significant difference (p=0.620). There was a statistically significant increase in the liver function test values and coagulation test values in the patients with hepatic encephalopathy who died.

Conclusion: While there is no correlation between ammonia level and mortality in hepatic encephalopathy patients, it is important in terms of mortality in chronic liver diseases.

Keywords

Ammonia, Hepatic Encephalopathy, Mortality

Supporting Institution

None

Project Number

None

Thanks

Thank Dr. Zübeyir Cebeci to supporting statistical analysis.

Acil Servise Başvuran Hepatik Ensefalopatili Hastaların Amonyak Düzeylerinin Mortaliteye Etkisinin Retrospektif Değerlendirilmesi

Abstract

Amaç: Hepatik ensefalopati, hepatik yetmezliğe eşlik eden karaciğer metabolizma ürünlerinin birikimi sonucu meydana gelen bilişsel, motor ve davranışsal bozukluktur. Hepatik ensefalopati klinik tablosu, amonyak ve gama aminobütirik asit gibi metabolitlerin birikimi ile karşımıza çıkmaktadır. Çalışmamızda hepatik ensefalopati tanısı konulan hastaların kan amonyak düzeyleri incelenerek mortalite üzerine etkisinin araştırılması amaçlanmıştır.

Gereç ve Yöntemler: Çalışmaya, hastanemiz acil servisine 01.01.2015-31.12.2018 tarihleri arasında bilinç bozukluğu ile başvuran, bilinen kronik karaciğer hastalığı olan, amonyak düzeyi bakılan hastaların kayıtları dahil edilmiştir. Hastaların karaciğer fonksiyon testleri ve koagülasyon testleri kaydedildi. Hastalar, hepatik ensefalopati olan ve olmayan olarak iki gruba ayrıldı. Gruplar, West Haven sınıflamasına göre evrelere ayrıldı. İki grubun karaciğer fonksiyon testleri ve koagülasyon testleri amonyak seviyesi, hastalık evresi ve mortaliteye göre karşılaştırıldı.

Bulgular: Acil servisimize 2015-2018 yılları arasında gelen ve amonyak düzeyi çalışılan 883 hastanın 435 tanesi çalışmaya dahil edilmiştir. Çalışmaya dahil edilen hastaların yaşı, 18-95 arasında dağılım göstermektedir. Hastaların 144’ü kadındı. Amonyak değerinin mortalite ile ilişkisine bakıldığında istatistiksel olarak bir fark yoktu (p=0,620). Karaciğer fonksiyon testlerinde ve koagülasyon testlerinde hepatik ensefalopatisi olan hastalardan ölenlerin değerlerinde istatistiksel olarak anlamlı bir yükselme vardı.

Sonuç: Hepatik ensefalopati hastalarında amonyak düzeyi ve mortalite arasında bir korelasyon yok iken kronik karaciğer hastalarında mortalite açısından önemlidir.

Keywords

Amonyak, Hepatik Ensefalopati, Mortalite

Project Number

None

References

• 1. Wijdicks EF. Hepatic encephalopathy. NEJM. 2016;375(17):1660-70.
• 2. Shalimar, Sheikh MF, Mookerjee RP, Agarwal B, Acharya SK, Jalan R. Prognostic role of ammonia in patients with cirrhosis. Hepatology. 2019;70(3):982-94.
• 3. Cadranel JF, Lebiez E, Di Martino V, Bernard B, El Koury S, Tourbah A et al. Focal neurological signs in hepatic encephalopathy in cirrhotic patients: an underestimated entity? Am J Gastroenterol. 2001;96(2):515-8.
• 4. Kantar FU. Approach to elevated liver function tests. Klinik Tıp Bilimleri Dergisi. 2017;5(2):30-8.
• 5. Kramer L, Tribl B, Gendo A, Zauner C, Schneider B, Ferenci P et al. Partial pressure of ammonia versus ammonia in hepatic encephalopathy. Hepatology (Baltimore, Md). 2000;31(1):30-4.
• 6. Özatlı D, Haznedaroğlu İC, Büyükaşık Y, Şimşek H. Anemia in chronic liver disease. Türkiye Tıp Dergisi. 1999;6(4):238-45.
• 7. Ferenci P, Lockwood A, Mullen K, Tarter R, Weissenborn K, Blei AT. Hepatic encephalopathy definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 1998. Hepatology. 2002;35(3):716-21.
• 8. Maqsood S, Saleem A, Iqbal A, Butt JA. Precipitating factors of hepatic encephalopathy: experience at Pakistan Institute of Medical Sciences Islamabad. JAMC. 2006;18(4):58-62.
• 9. Vergara-Gomez M, Flavia-Olivella M, Gil-Prades M, Dalmau-Obrador B, Cordoba-Cardona J. Diagnosis and treatment of hepatic encephalopathy in Spain: results of a survey of hepatologists. Gastroenterol Hepatol. 2006;29(1):1-6.
• 10. Çadırcı K, Cerrah S. Evaluation of precipitating factors in our patients with hepatic encephalopathy. Fırat Med J. 2019;24(2):75-9.
• 11. Öztürk O, Tuncer İ, Doğanay L, Yorulmaz E, Çolak Y, Enç FY. Factors triggering hepatic encephalopathy in cirrhotic patients. Medeniyet Med J. 2010;25(4):164-8.
• 12. Saab S. Evaluation of the impact of rehospitalization in the management of hepatic encephalopathy. Int J Gen Med. 2015;5(8):165-73.
• 13. Pan C, Xu LJ, Zhou R, Zhou W, Huang JR. Multivariate analysis of hepatic encephalopathy occurrence in patients with liver failure. Chinese Journal of Hepatology. 2012;20(6):434-7.
• 14. Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL et al. A model to predict survival in patients with end-stage liver disease. Hepatol. 2001;33(2):464-70.
• 15. Djiambou-Nganjeu H. Hepatic encephalopathy in liver cirrhosis. J Transl Int Med. 2017;5(1):64-7.
• 16. Koch DG, Speiser JL, Durkalski V, Fontana RJ, Davern T, McGuire B et al. The natural history of severe acute liver ınjury. Am J Gastroenterol. 2017;112(9):1389-96.
• 17. Hu X-P, Gao J. International normalized ratio and Model for End-stage Liver Disease score predict short-term outcome in cirrhotic patients after the resolution of hepatic encephalopathy. World J Gastroenterol. 2019;25(26):3426-37.
• 18. Lee WM, Squires Jr RH, Nyberg SL, Doo E, Hoofnagle JH. Acute liver failure: summary of a workshop. Hepatology. 2008;47(4):1401-15.
• 19. Hu C, Huang K, Zhao L, Zhang F, Wu Z, Li L. Serum ammonia is a strong prognostic factor for patients with acute-on-chronic liver failure. Sci Rep. 2020;10(1):16970.
• 20. Li J, Li R, Gao Y, Jin X, Zhang J, Ren J et al. Increasing serum ammonia level is a risk factor for the prognosis of critically ill patients: A multicenter retrospective cohort study. J Crit Care. 2021;62:218-22.
• 21. Shawcross DL, Sharifi Y, Canavan JB, Yeoman AD, Abeles RD, Taylor NJ et al. Infection and systemic infammation, not ammonia, are associated with Grade 3/4 hepatic encephalopathy, but not mortality in cirrhosis. J Hepatol. 2011;54(4):640-9.