Hepatic encephalopathy laboratory findings

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

Overview

An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].

OR

Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].

OR

[Test] is usually normal among patients with [disease name].

OR

Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].

OR

There are no diagnostic laboratory findings associated with [disease name].

Laboratory Findings

The normal plasma level of ammonia is 12 - 48 μmol/L.[1] A study in 2019 found that elevated plasma ammonia (≥79.5 µmol/L) predicted HE grade 3 or more[2].

Venous ammonia and level of encephalopathy.[3]
Number (%) of patients.
NH3 level Grade 0
(no encephalopathy)
Grade 1 Grade 2 Grade 3 Grade 4
> 50 10 (33%) 18 (67%) 14 (52%) 25 (89%) 12 (92%)
25-20 12 (40%) 9 (33%) 5 (19%) 3 (11%) 0
< 25 8 (27%) 0 (0%) 4 (15%) 0 (0)%) 1* (8%)
Total
patients
30 (100%) 27 (100%) 2 (100%)3 28 (100%) 13 (100%)
*This patient's ammonia level was approximately 20 μmol/L.

The ammonia level can help diagnose encephalopathy[3][4][5] although its ability is less clear in chronic liver disease[6].

Accuracy of the venous ammonia[3]
Venous ammonia levels Sensitivity Specificity
> 50 μmol/L 76% 67%
> 25 μmol/L 93% 27%

Ammonia levels over 123 are likely to improve with lactulose therapy.[7]

An ammonia level more than 200 strongly suggests hepatic encephalopathy.[3]

Other important laboratory findings in hepatic encephalopathy may include:

References

  1. Kratz A, Lewandrowski KB (1998). "Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Normal reference laboratory values". N Engl J Med. 339 (15): 1063. doi:10.1056/NEJM199810083391508.
  2. Sheikh MF, Mookerjee RP, Agarwal B, Acharya SK, Jalan R (2019). "Prognostic Role of Ammonia in Cirrhotic Patients". Hepatology. doi:10.1002/hep.30534. PMID 30703853.
  3. 3.0 3.1 3.2 3.3 Ong JP, Aggarwal A, Krieger D; et al. (2003). "Correlation between ammonia levels and the severity of hepatic encephalopathy". The American journal of medicine. 114 (3): 188–93. PMID 12637132. Unknown parameter |month= ignored (help)
  4. Stahl J (1963). "Studies of the blood ammonia in liver disease. Its diagnostic, prognostic, and therapeutic significance". Annals of internal medicine. 58: 1–24. PMID 13978712. Unknown parameter |month= ignored (help)
  5. Nicolao F, Efrati C, Masini A, Merli M, Attili AF, Riggio O (2003). "Role of determination of partial pressure of ammonia in cirrhotic patients with and without hepatic encephalopathy". Journal of hepatology. 38 (4): 441–6. PMID 12663235. Unknown parameter |month= ignored (help)
  6. Ge PS, Runyon BA (2014). "Serum ammonia level for the evaluation of hepatic encephalopathy". JAMA. 312 (6): 643–4. doi:10.1001/jama.2014.2398. PMID 25117134.
  7. Sharma P, Sharma BC, Sarin SK (2009). "Predictors of nonresponse to lactulose for minimal hepatic encephalopathy in patients with cirrhosis". Liver Int. 29 (9): 1365–71. doi:10.1111/j.1478-3231.2009.02067.x. PMID 19555401.
  8. Yun BC, Kim WR (2009). "Hyponatremia in hepatic encephalopathy: an accomplice or innocent bystander?". Am J Gastroenterol. 104 (6): 1390–1. doi:10.1038/ajg.2009.287. PMID 19455127.
  9. Gaduputi V, Chandrala C, Abbas N, Tariq H, Chilimuri S, Balar B (2014). "Prognostic significance of hypokalemia in hepatic encephalopathy". Hepatogastroenterology. 61 (133): 1170–4. PMID 25436277.
  10. Kalaitzakis E, Josefsson A, Castedal M, Henfridsson P, Bengtsson M, Andersson B; et al. (2013). "Hepatic encephalopathy is related to anemia and fat-free mass depletion in liver transplant candidates with cirrhosis". Scand J Gastroenterol. 48 (5): 577–84. doi:10.3109/00365521.2013.777468. PMID 23452072.
  11. Djiambou-Nganjeu H (2017). "Hepatic Encephalopathy in Liver Cirrhosis". J Transl Int Med. 5 (1): 64–67. doi:10.1515/jtim-2017-0013. PMC 5490964. PMID 28680841.
  12. Hartleb M, Gutkowski K (2012). "Kidneys in chronic liver diseases". World J Gastroenterol. 18 (24): 3035–49. doi:10.3748/wjg.v18.i24.3035. PMC 3386317. PMID 22791939.

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