Glutamine Challenge as Predictor of Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Glutamine Challenge as Predictor of Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Transjugular intrahepatic portosystemic shunt (TIPS) is the first-line therapy for patients
 with cirrhosis and refractory ascites. However, mental changes known as hepatic
 encephalopathy (HE) frequently occur after TIPS. There is no effective method to predict HE
 after TIPS. Oral glutamine challenge (OGC) and psychometric tests have been used to assess
 the risk for HE, but never in patients undergoing TIPS. Severe muscle loss may also
 predispose patients to HE. The aim of the present study is to assess if both the OGC and
 psychometric tests can accurately predict the development of overt HE after TIPS. Patients
 will be studied before TIPS and followed after TIPS for the development of HE. The role of
 muscle loss in favoring HE, as well as is possible reversibility after TIPS will also be
 investigated.
In cirrhosis, up to 10% of patients develop refractory ascites. TIPS (transjugular
 intrahepatic portosystemic shunt) is the first-line therapy for these patients. However, 30%
 will go on to develop hepatic encephalopathy (HE) as a consequence of TIPS, and there is no
 effective method to predict this outcome. Oral glutamine challenge (OGC) is used to
 functionally assess ammonia metabolism, and the severity of porto-systemic collateralization,
 and it has been used to predict overt HE. Psychometric tests (i.e. Psychometric Hepatic
 Encephalopathy Score [PHES] and inhibitory control test) allow the identification of covert
 forms of HE and can also predict overt HE. Severe sarcopenia may also predispose patients to
 HE. The aim of the present study is to assess if both the degree of impairment in ammonia
 metabolism as estimated with the OGC, and cognitive status as determined by psychometric
 tests, can accurately predict the development of overt HE after TIPS. Patients will be
 studied before TIPS and followed after TIPS for the development of overt HE. The role of
 sarcopenia in favoring HE, as well as is possible reversibility after TIPS will also be
 investigated.
Inclusion Criteria:

 -  Cirrhosis (any etiology)

 -  Refractory ascites or hepatic hydrothorax and plan for TIPS placement

 Exclusion Criteria:

 -  Well-documented overt hepatic encephalopathy, either persistent or at the time of
 screening

 -  Any contraindication for TIPS placement

 -  Except for coagulopathy and thrombocytopenia (decided on an individual basis)

 -  Uncontrolled depression/anxiety disorder or use of antipsychotic drugs

 -  Active use of alcohol or illicit drugs

 -  History of dementia

 -  TIPS planned for another indication.

 -  Active alcoholic liver disease.