Randomized controlled trial of lactulose and lactulose with probiotic in the treatment of minimal hepatic encephalopathy in chronic liver disease

This was stratified randomized controlled trial. A total of 62 patients with MHE were analyzed. Child-Pugh Score was used to stratify the patients into three blocks of Child-Pugh Class (CPC) i


METHODOLOGY
The study was conducted as block stratified randomized controlled trial for the duration of 12 months from September 2015 to September 2016 in B P Koirala Institute of Health Sciences, Nepal after ethical approval was obtained from the institutional review committee.The diagnosis of cirrhosis was based on ultrasonography findings (irregular margins of liver parenchyma or portal vein diameter greater than 12 mm with or without enlarged spleen) and laboratory tests (platelet count less than 140000 or serum albumin less than 3.5 grams per deciliter or coagulopathy with INR greater than or equal to 1.5).All cirrhotic patients aged 18 years or more were included in the study.Patient who didn't give consent, overt hepatic encephalopathy or history of OHE during the past 2 weeks, recent (<2 weeks) use of drugs affecting psychometric performances like benzodiazepines, antiepileptic or psychotropic drugs, significant comorbidity such as congestive heart failure, pulmonary disease, uremia, neurological or psychiatric disorder etc. were excluded from the study.OHE was defined as a spectrum of neuropsychiatric abnormalities in patients with liver dysfunction, after exclusion of brain disease characterized by personality changes, intellectual impairment, and a depressed level of consciousness.8,9 All cirrhotic patients were allocated to different blocks of Child-Pugh class (CPC) according to Child-Pugh score and randomized by computer-generated table of random numbers.This study was an open-label study.Detailed neurological examination along with mini-mental state examination of the Nepalese version for gross neurological deficits was performed.This version of MMSE has been used by other study.10Patients without gross neurological deficits and mini-mental state examination score (MMSE) ≥ 24 were considered for psychometric tests.FCT-A and FCT-B were the psychometric tests used and tests was considered abnormal when the test score was more than the mean +2SD from age and education-matched controls.Patient was considered to be in MHE when both FCT-A and FCT-B were abnormal.Patients diagnosed as MHE were randomized and stratified according to CPC into the standard treatment group (lactulose) and standard treatment plus probiotic group (lactulose plus probiotic).The principle investigator enrolled and assigned participants to interventions. Figure 1.

Probiotic capsules contained Streptococcus faecalis T-110 30 million CFU plus clostridium butyricum TO-A 2 million CFU plus
Bacillus mesentericus TO-A 1 million CFU plus Lactobacillus sporogenes 50 million CFU.Commercially available probiotic capsules from one manufacturer available at the hospital pharmacy containing above flora were used.These capsules were given twice daily and patients were advised to conserve drug blisters.Compliance was confirmed by checking the drugfree blisters.All patients received usual medications for cirrhosis as per their disease status.Randomized patients were followed up at 1 month and assessed again with FCT A and B. The principal investigator was assessing the compliance as well as FCT A and B during follow-up visits at one month in medicine opd.
The response of treatment was based on the primary end point i.e.cognitive status interpreted by FCT-A and FCT-B scores in comparison to the baseline after one month of treatment.The secondary endpoints were the estimation of the prevalence of MHE in patients with chronic liver disease and to assess association of MHE and inflammatory markers.
Sample size was calculated by considering difference in proportion in two groups using following equation.
On the basis of results of three previous published studies, 1,2,7 we estimated an average improvement of 15% in MHE in the control group and an improvement of 60% in MHE in the treatment group with lactulose and p1 -probability of improvement in treatment group i.e; 0.6 p2 -probability of improvement in control group without treatment i.e; 0.15 Ā-(p1 + p2) /2 i.e.; 0.375 Zβ-1.28 at 90% power Zα/2-1.96 at 95% confidence interval Considering above equation sample size was calculated as at least 20 patients in each arm to detect a difference in improvement in MHE, that is, the proportion of patients with MHE at 1 month, with a 5% type 1 error and 90% power for a two-tailed log-rank test.

RESULTS
Out of 150 chronic liver disease patients screened for MHE, 62 were included in the study, with a prevalence of 41.3%.Patients were stratified into three groups according to Child-Pugh scores.Patients in each group were randomized to receive lactulose or lactulose with probiotics (Figure 1).The etiology of cirrhosis was alcohol consumption (n=58), chronic hepatitis B (n=2) and chronic hepatitis C (n=2).Baseline characteristics of the patients in each group were similar except Child-Pugh Score in CPC-B (Tables 1, 2 and 3).All the baseline variables in each randomised group were similar except Child-Pugh Score between groups in CPC-B.Among CPC-B, Child-Pugh Score was either 8 or 9 in lactulose group while four patients in lactulose with probiotic group had Child-Pugh Score of 7 (p=0.02)(Table 2).
There was no significant difference in FCT A and FCT B between the two groups in CPC-A (Table 4).Two patients failed to normalize the FCT A (one in each group), were older (mean age 53.50 vs. 47.28,p= 0.290) and of higher baseline FCT A (mean value 123.5 vs. 97.22,p= 0.297).Total leukocyte count was higher in those two patients who didn't improve (9000 vs. 6455.56,p= 0.005).
One patient failed to have normal FCT B after treatment, was older (62 vs. 47, p= 0.058).Total leukocyte count was higher in the patient who didn't improve (9100 vs. 6584.21,p= 0.058).Sex, education status, Child-Pugh score and Model for end stage liver disease score (MELD) were not found to be significantly different in those with and without improvement (Table 4).
There was no significant difference in FCT A and FCT B between the two groups in CPC-B (     This study showed that probiotics in addition to standard treatment with lactulose does not have added advantage in treatment of MHE.Liu et al 11 showed that modulation of gut micro ecology and acidification of gut lumen in patients with liver cirrhosis and MHE by treatment with synbiotics (probiotics and prebiotic) resulted in increased faecal content of non-urease producing Lactobacillus species whereas the number of urease producing pathogenic Escherichia coli and Staphylococcal species decreased.This effect persisted for 14 days after cessation of supplementation.It was associated with significant reduction in blood ammonia and endotoxin levels and MHE reversal in 50% of the patients.Malaguarnera et al. 12 studied bifidobacterium longum with fructooligosaccharide treatment in MHE patients and showed improvement in blood ammonia levels and psychometric scores in synbiotic treated group.A possible explanation for the similar efficacy between lactulose and lactulose plus probiotic might be because of the lactulose cathartic effect causing probiotic clearance in feces. 13Also lactulose causes acidification of gut lumen that can interfere with the probiotic effect.Zhao et al. 14 demonstrated varying degrees of imbalance of intestinal flora among cirrhotic compared to normal healthy controls; there was an increase in the counts of aerobes and anaerobes and a decrease in the count of Bifidobacterium.The severity of imbalance in gut flora matched the degree of liver dysfunction, with the most serious imbalance observed in patients in CPC-C.This may be the reason for the decreased frequency of improvement seen in CPC-C patients compared with CPC-A and B in this study (CPC-A vs. B vs. C: 90% vs. 45-55% vs. 30-40%) (Figure 2).
After screening 150 patients with chronic liver disease, we found 62 patients had MHE, a prevalence of 41.33%.Studies have shown that markers of inflammation are higher in patients with MHE than those without it. 15Our, this study with similar findings further emphasizes that inflammation has a role in the maintenance of MHE.The FCT A and B failed to normalize in all Child-Pugh classes with higher total leukocyte count.
The major limitations of this study are non-blinding of study participants and the lack of a placebo in the lactulose group.We conclude that lactulose alone and the addition of probiotics to lactulose, both are equally effective for the treatment of MHE.Improvement in FCT score was less with treatment with higher baseline FCT values.The improvement was also correlated with baseline inflammatory state as improvement in FCT scores was significantly less with increased total leukocyte count.

CONCLUSION
There was no difference in cognitive status between lactulose alone and lactulose with probiotics in treatment for chronic liver disease patients with MHE.High baseline FCT scores and TLC had poor recovery.The prevalence of MHE was 41.33%.

LIMITATIONS OF THE STUDY
We couldn't compare FCT A and FCT B with other modalities DISCUSSION

Figure 1 .
Figure 1.Flowchart of screening and randomization of study subjects

Fig 2 :
Fig 2: Comparison of FCT A and FCT B between different Child-Pugh classes

Table 4 )
. Five patients in the lactulose group and six patients in the lactulose plus probiotic group failed to show improvement in MHE.The mean age of the patients who didn't improve was lower (46.38 vs. 49, p= 0.43).Baseline mean FCT A and FCT B was higher in those who didn't improve, (mean value 164.55 vs. 115.18and 272.18 vs. 206.73with p= 0.007).Total leucocyte count was also higher in those who didn't normalized FCT (mean 8318.18 vs. 5198.18,p= 0.00).No significant difference was found with haemoglobin, platelet, albumin, bilirubin, AST, ALT, INR, creatinine and MELD scores.(

Table 4 )
There was no significant difference in FCT A and FCT B between two groups in CPC-C (Table4).Thirteen patients (six in lactulose and seven in lactulose with probiotic) failed FCT normalization.Age was higher in those without FCT normalization (mean age 55.08 vs. 44, p= 0.001).Baseline FCT A and FCT B was higher in

Table 1 :
Baseline characteristics of the group CPC-A

Table 3 :
Baseline characteristics of the group CPC-C ¶ : mean ± standard deviation º: frequency

Table 4 :
Response of treatment in the study groups

Table 5 :
Association of Response of treatment and total leukocyte count