Glutamine Challenge as Predictor of Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt (TIPS)

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.