Studies in acute liver failure show correlation between evidence of a systemic inflammatory response syndrome (SIRS) and progression of hepatic encephalopathy (HE). We tested the hypothesis that SIRS mediators, such as nitric oxide and proinflammatory cytokines, may exacerbate the neuropsychological effects of hyperammonemia in cirrhosis.
Ten patients with cirrhosis were studied, 24–36 h after admission with clinical evidence of infection, and following its resolution. Hyperammonemia was induced by oral administration of an amino-acid (aa) solution mimicking hemoglobin composition. Inflammatory mediators, nitrate/nitrite, ammonia, aa profiles and a battery of neuropsychological tests were measured.
The hyperammonemia generated in response to the aa solution was similar prior to, and after resolution, of the inflammation (P=0.77). With treatment of the infection there were significant reductions in white blood cell count (WBC), C-reactive protein (CRP), nitrate/nitrite, interleukin-6, interleukin-1β and tumour necrosis factor α. Induced hyperammonemia resulted in significant worsening of the neuropsychological scores when patients showed evidence of SIRS but not after its resolution.
The significant deterioration of neuropsychological test scores following induced hyperammonemia during the inflammatory state, but not after its resolution, suggests that the inflammation and its mediators may be important in modulating the cerebral effect of ammonia in liver disease.
Abbreviations:aa (amino acid), BBB (blood–brain barrier), CNS (central nervous system), HE (hepatic encephalopathy), IL-6 (interleukin 6), IL-1β (interleukin 1 β), NO (nitric oxide), TNF-α (tumour necrosis factor α), SIRS (systemic inflammatory response syndrome), UGIB (upper gastrointestinal bleed)
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Accepted: October 22, 2003
Received in revised form: October 22, 2003
Received: May 8, 2003See Editorial, pages 327–330
☆This paper was presented in part as an abstract at the British Society of Gastroenterology Annual Meeting in Birmingham, UK, 23–26 March 2003.
© 2003 European Association for the Study of the Liver. Published by Elsevier Inc. All rights reserved.