The aims of optimal cirrhosis care are to manage and prevent complications to preserve or extend quality of life. These aims are supported by tools enabling the prediction of hepatic encephalopathy (HE). Understanding a patient’s risk of HE changes management in multiple ways including how we counsel patients, the nutritional guidance we offer, and the use of HE-directed therapies. The dominant paradigm of overt HE risk prediction is the determination of baseline covert HE through psychometric testing. As we have reviewed elsewhere, this strategy has shortcomings. Psychometrics are under-utilized, have not been studied in those who comprise the average contemporary patient (alcohol-related disease, multiple comorbidities, polypharmacy), and as many patients without abnormal psychometrics develop incident HE, it offers incomplete risk stratification.(1) Our lab aims to democratize risk assessment tools for the prediction of HE, maximizing ease of use, access, and by providing the ability to choose tools suited to many contexts. To date, we have developed the BABS (bilirubin-albumin-beta blocker-statin) score and the MASQ-HE.(2, 3) The MASQ-HE leverages factors – impact on activity, quality of life, and chair-stands – that are each impacted by cognitive dysfunction and possibly covert HE.
As such we agree with Soni et al and thank them for their letter and interest. We agree on nearly all their points. Similarly, we agree with their observations that most patients had abnormal SIP scores and Inhibitory Control Tests. Tests that are abnormal in the majority of a prospective samples of ambulatory patients cannot discriminate risk, failed in comparison to the MASQ-HE (and BABS) and offer little value to clinicians. Finally, the authors wish to see our score validated in an external cohort. We would love to collaborate. Our only question is: when can we start?
Funding:
Elliot Tapper receives funding from the National Institutes of Health through NIDDK (1K23DK117055).
Footnotes
Conflicts of interest: Elliot Tapper has served as a consultant to Norvartis, Axcella, and Allergan, has served on advisory boards for Mallinckrodt, Bausch Health, Kaleido, Takea, Novo Nordisk, and has received unrestricted research grants from Gilead and Valeant.
References
- 1.Tapper EB. Predicting Overt Hepatic Encephalopathy for the Population With Cirrhosis. Hepatology. 2019. [DOI] [PMC free article] [PubMed] [Google Scholar]
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- 3.Tapper EB, Zhao L, Nikirk S, Baki J, Parikh ND, Lok AS, Waljee AK. Incidence and Bedside Predictors of the First Episode of Overt Hepatic Encephalopathy in Patients With Cirrhosis. Official journal of the American College of Gastroenterology| ACG. 2020. [DOI] [PMC free article] [PubMed] [Google Scholar]