Hepatic encephalopathy in patients with liver cirrhosis: Is there a role of malnutrition?

To The ediTorThe pathogenesis of hepatic encephalopathy (HE), a common complication of liver cirrhosis, remains incompletely understood but it is probably multifactorial in most cases [1] .Malnutrition is also commonly encountered in patients with cirrhosis and it has been reported to have an effect on health related quality of life [2] .Although experimental studies suggest that low energy intake and poor nutritional status may facilitate the development of HE [3] , there are scarce data on the potential role of malnutrition in HE in patients with liver cirrhosis.Recently Soros et al [4] performed a study investigating the potential role of malnutrition and hypermetabolism in HE in which 223 patients with non-alcoholic cirrhosis were enrolled.They were evaluated for the presence of HE according to the West Haven criteria and for malnutrition by means of body mass index (BMI), anthropometric measurements, and bioelectrical impedance analysis.Energy metabolism was also assessed by means of indirect calorimetry.Eighty-five (38%) out of 223 patients had no clinically evident HE, 123/223 (55%) had HE grade 1 and 15/223 (7%) had HE grade 2 or 3. Neither metabolic variables or BMI nor fat free mass or muscle mass differed significantly in patients with HE grade 1-3 from those without HE.In multivariate analysis none of these parameters was found to be independently related to HE.The authors concluded that malnutrition or catabolism does not seem to be independent risk factors for the presence of HE in patients with liver cirrhosis [4] .Recently, we performed a prospective study evaluating HE in 128 patients with liver cirrhosis of various etiologies [5] .HE was evaluated by means of the West Haven criteria and two psychometric tests (number connection test A and B).HE was defined as overt HE according to the West Haven criteria and/or number connection test A and/or B > 3 standard deviations of the general population.Nutritional status was evaluated with BMI and anthropometric measurement as well as estimation of recent weight change.Malnutrition was defined as anthropometric measurement below the 5th