European Journal of Cardiovascular Medicine

The usual cause of mortality in hospital globally is cirrhosis of Liver as a consequence of hepatocellular damage which results in fibrosis and nodular regeneration throughout the liver.¹ In majority of the patients, HE occurs episodically in response to well-recognised precipitating factors, but patients may also have a chronically progressive or chronically persistent course, especially in the presence of extensive Porto-systemic shunting.² It is a life threatening complication that can occur in acute or chronic liver failure. About 30% patient of cirrhosis die due to hepatic coma.³ HE in patient of liver failure is an indication of poor prognosis. In a cirrhotic patient, HE develops due to one or more precipitating factor or due to fulminant liver failure or it could be a result of prolonged portal systemic shunting. Hepatic encephalopathy probably due to gut derived neurotoxin such as ammonia. Other key factors are astrocytes dysfunction, disturbed neurotransmitter regulation and oxidative stress developed in astrocytes.

There has been a decline in zinc concentrations in serum in patients suffering from liver cirrhosis resulting in portosystemic shunting which further augment the deficiency.⁴ Zinc functions as antioxidant and is an important trace element that enhances the effectiveness of urea cycle as well.⁵  Changes in personality include increased irritability, lack of restraint with poor risk assessment. Subtle but apparent intellectual decline. Inability to draw/construct and difficulty in writing are common. Reduced spontaneous movement, slowness, a fixed stare, loss of enthusiasm /interest and altered sleep pattern with increased day time sleepiness are early evidences of disturbed consciousness.⁶ Motor features include speech disorders, choreoathetoid movements, asterixis (flapping tremors), Babinski’s sign, hyporeflexia. Extrapyramidal features such as bradykinesia, limited expression of emotion, rigidity, slurred and monotonous speech and tremor are relatively common.⁶

The most common complications as consequence of live cirrhosis are ascites, portal hypertension, hepatic encephalopathy and varices. However, the possibility of zinc insufficiency should be taken into consideration which might be the concealed accelerating reason for the establishment of hepatic encephalopathy in later stages of the damage6 and thus it should be ruled out. Deficiency of zinc might be the reason for many systematic dysfunctions, including neurologic (may result in hepatic encephalopathy), hepatobiliary, reproductive, immune and skeletal systems. Conversely, the zinc supplementation considerably recovers neurologic signs in cirrhotic patients with refractory hepatic encephalopathy.^7,8

One of the Study done by Gusau KA et al⁹ discovered a significant decrease in the serum zinc levels of African cases when related to the controls. It is proposed that the deficiency of zinc in serum of liver cirrhosis patients, influence and potentiate the development of hepatic encephalopathy.⁸ The frequency of zinc insufficiency has been stated in alcoholic cirrhosis but there is a lack of these values in viral cirrhosis. This study was designed to assess and evaluate the zinc levels in serum of patients with viral cirrhosis.

The aim of the present study was to estimate serum zinc levels in different stages of hepatic encephalopathy.

The Observational study was conducted in the Department of Medicine, Sri Guru Ram das Institute of Medical Sciences, Vallah, Amritsar. Patients of age group between 18-65 years presenting in OPD/IPD of Medicine department with hepatic encephalopathy were recruited in current study after taking written and informed consent. The study period was from January 2023 to March 2024.

INCLUSION CRITERIA:

• All patients of age group 18-65 years presenting with hepatic encephalopathy.

EXCLUSION CRITERIA: -

• Primary Renal Disease
• Dementia
• Alcohol withdrawal state
• Hypertensive encephalopathy
• Toxication encephalopathy
• Encephalitis
• Meningitis
• Psychiatric illness
• Medications like psychiatric medicine or sedatives
• Severe malnutrition

METHODOLOGY:

All the patients of hepatic encephalopathy visiting OPD/indoor/emergency of SGRDIMSR, Vallah, Sri Amritsar were included in the current study after applying inclusion and exclusion criteria after taking informed and written consent. A detailed history about illness was obtained from the patient with special reference to some clinical points related to the disease (upper Gastro intestinal bleed, spontaneous bacterial peritonitis, ascites, hepatopulmonary syndrome, hepatic encephalopathy). These patients were then clinically evaluated for signs of Chronic Liver disease (Icterus, parotid swelling, temporal hollowing, gynaecomastia, hair loss, palmar erythema, dupuytren’s contracture, spider naevi, testicular atrophy) and its complications (Upper GI bleed, ascites, jaundice, spontaneous bacterial peritonitis, hepatic encephalopathy) and relevant laboratory investigations were done as per protocol.

Hepatic encephalopathy was diagnosed by clinical examination and PHES and grading was done according to the west heaven criteria. Patients with symptoms and signs of hepatic encephalopathy were recruited in study.

Blood samples were collected and sent to laboratory for measurement of serum zinc levels and then its correlation with stage of hepatic encephalopathy was established.

LABORATORY INVESTIGATIONS:

7 ml of peripheral venous blood was withdrawn from each individual and divided into three aliquots; 2 ml of whole blood was collected in EDTA tube for measurement of ammonia, another 2 ml of whole blood was collected in sodium citrate tube for prothrombin time determination. The remaining part was collected in serum separator tube, centrifuged at 3000 rpm for 10 min. Serum was divided into two portions; first one for measurements of liver function tests [(alanine transaminases (ALT), aspartate transaminase (AST), albumin (Alb), total bilirubin (T. Bil), alkaline phosphatase (ALP)] and serum Creatinine, the second part of serum was stored at 2-8 °C for serum zinc detection. Liver function tests and serum creatinine was done using spectrophotometry (Siemens). Prothrombin time measurements was performed on a diagnostic full automated coagulation analyzer. Serum sodium was done by Spectrophotometry (siemens). Serum zinc levels were assayed with the zinc kit using colorimetric method.

STATISTICAL METHODS:

The recorded data was compiled and entered in a spreadsheet computer program (Microsoft Excel 2010) and then exported to the editor page of SPSS version 22. (SPSS Inc., Chicago, Illinois, USA). Descriptive statistics included computations of percentages, means and standard deviations were calculated. Statistical test applied for the analysis were Pearson chi-square test, student t-test, One-way ANOVA and Pearson correlation coefficient. The level of confidence interval and p-value were set at 95% and 5%.

Table 1: Baseline characteristics

33% of the patients had age of 58-65 years followed by 27.5% (38-48 years), 21.1% (48-58 years), 14.7% (28-38 years), and 3.7% (18-28 years). Mean age of the patients was 50.055±12.12194 years. 89% were males and 11% were females. Mean BMI was 26.8365±2.95112. Majority of the patients (66.1%) had BMI 25-29.9 followed by 23-24.9 (16.5%), more than 29.9 (9.2%), and 18.5-22.9 (8.3%).

Table 2: Distribution of findings on examination

74.3% had temporal hollowing, 71.5% had parotid enlargement, 57.7% had palmar erythema, 53.2% had asterixis, 52.3% had pallor, 50.5% had icterus, 45% had Dupuytren's Contracture, 35.7% had Spider Naevi, 32.1% had Divarication of Recti, 28.4% had axillary hair loss, 25.7% had pedal edema, 17.4% had Gynaecomastia, 14.6% were disoriented, 12.8% had Myoclonic Jerks, and 5.5% had stupor/ coma.

Table 3: Distribution of encephalopathy grades (according to west haven criteria)

34.9% patients had MHE grade I followed by grade II (33.9%), grade III (13.8%), MHE (11.9%), and grade IV (5.5%).

Table 4: Distribution of zinc levels (mcg/dL)

32.1% patients had Zn levels 40-49 followed by 30.3% (30-39), 16.5% (50-59), 11% (>60), and 10.1% (<30). Mean Zn levels were 43.6330±11.87018.

Table 5: Association between encephalopathy grades and mean zinc levels (mcg/dl)

Association between Encephalopathy grades and mean Zinc levels was found statistically significant as mean Zn levels were reducing with increase in encephalopathy grades.

Table 6: Distribution of serum zinc level in various WHC Grade

Association of serum zinc level in various WHC grades was also found statistically significant.

Encephalopathy is a complication of acute and chronic liver failure. The pathogenesis of hepatic encephalopathy is still poorly understood. The most popular theories focus on the role of ammonia, an imbalance between cyclic and branched chain amino acids, or GABA.¹⁰ All three factors are presumed to influence neurotransmission in the central nervous system. Zinc is a major trace element in the human body and is found in several enzymes.¹¹ Encephalopathy due to zinc deficiency in patients with an underlying liver disease may be attributable to further disturbance of the metabolism of specific toxins. Indeed, in healthy volunteers zinc deficiency caused an increase in plasma ammonia levels¹² and patients with liver cirrhosis exhibited a stimulated synthesis of urea during zinc therapy.¹³

In the present study, mean age of the patients was 50.055±12.12194 years. In study conducted by Hiwarkar SR et al¹⁴ the mean age at presentation was 45.67 ± 8.73 years. In our study, 89% were males and 11% were females. In study conducted by Hiwarkar SR et al¹⁵ there was male preponderance, 60/66 (90.91%); only 6 cases were female with a M: F ratio of 10:1. On examination, 74.3% had temporal hollowing, 71.5% had parotid enlargement, 57.7% had palmar erythema, 53.2% had asterixis, 52.3% had pallor, and 50.5% had icterus. Other common findings were Dupuytren's Contracture, Spider Naevi, Divarication of Recti, axillary hair loss, pedal edema, gynecomastia, disoriented, Myoclonic Jerks, and stupor/ coma in present study.  In study conducted by Deep V et al¹⁶, all (100%) patients had icterus/yellow discoloration of the eyes, followed by ascites (80%) and black stools (64%), with 10 (10%) patients being in a coma at the time of presentation. In similar study conducted by Meena RK et al¹⁷ common findings were ascites (81.3%), pedal oedema (65.3%), and coma (5.3%). In study conducted by Hiwarkar SR et al¹⁴ the most common presenting symptom was ascites (100%) and the next common were constipation (84.85%), pedal edema (78.79%), vomiting (71.2%), and GI bleeding (66.67%).

In present study, 34.9% patients had grade I followed by grade II (33.9%), grade III (13.8%), MHE (11.9%), and grade IV (5.5%). Association between Encephalopathy grades and mean Zinc levels was found statistically significant as mean Zn levels were reducing with increase in encephalopathy grades. In study done by Deep V et al¹⁶ Serum zinc level was significantly lower in patients with higher grades of hepatic encephalopathy, implying an association of low serum zinc level with increased severity of hepatic encephalopathy. There have been three good quality meta-analyses evaluating the benefit of zinc supplementation in patients with HE. Chavez-Tapia NC et al¹⁸ looked at a total of four randomized controlled trials incorporating 233 patients. These trials compared the benefit of oral zinc supplementation with no intervention, placebo or other management for HE. They reported a significant improvement in the number connection test results across three of their studies. Their other outcome of interest was the recurrence rate of HE: two studies reported a trend towards lower recurrence rate in the zinc group; however, given the small overall sample size, this did not reach statistical significance.

Reding et al¹⁹ in a double-blind, randomized placebo-controlled trial reported that short-term (for seven days) oral zinc supplementation improved the hepatic encephalopathy state in 22 patients with cirrhosis. Similarly, Katayama et al²⁰ in a preliminary randomized controlled trial showed that daily supplementation with zinc acetate for three months in patients with liver cirrhosis was an effective and safe therapy for managing hyperammonaemia. Similarly, a recent systematic review and meta-analysis assessing the effect of zinc treatment on clinical outcomes in patients with cirrhosis found that zinc supplementation is not associated with reduced mortality in patients with cirrhosis. However, findings may have been limited by the small number of included studies and significant heterogeneity among the studies.²¹

It can be concluded that Serum zinc level was significantly lower among patients with higher grades of hepatic encephalopathy, implying that low zinc level may be a precipitating factor for hepatic encephalopathy. Furthermore, supplementation with zinc may possibly reduce the clinical worsening in such patients. Hence, all patients of cirrhosis liver with hypoalbuminemia and HE should be evaluated for low serum zinc levels.

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