Abstract
Hepatic encephalopathy (HE), a subtype of delirium, is common in cirrhosis and associated with poor outcomes. Yet, objective bedside screening tools for HE are lacking. We examined the relationship between an established screening tool for delirium, Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and short-term outcomes while comparing its performance with previously established measures of cognitive function such as West Haven criteria (WHC). Prospectively enrolled adults with cirrhosis who completed the CAM-ICU from 6/2014–6/2018 were followed for 90 days. Blinded provider-assigned West Haven Criteria (WHC) and other measures of cognitive function were collected. Logistic regression was used to test associations between CAM-ICU status and outcomes. Mortality prediction by CAM-ICU status was assessed using Area under the Receiver Operating Characteristics curves (AUROC). Of 469 participants, 11% were CAM-ICU( +), 55% were male and 94% were White. Most patients were Childs-Pugh class C (59%). CAM-ICU had excellent agreement with WHC (Kappa = 0.79). CAM-ICU( +) participants had similar demographic features to those CAM-ICU(-), but had higher MELD (25 vs. 19, p < 0.0001), were more often admitted to the ICU (28% vs. 7%, p < 0.0001), and were more likely to be admitted for HE and infection. CAM-ICU( +) participants had higher mortality (inpatient:37% vs. 3%, 30-day:51% vs. 11%, 90-day:63% vs. 23%, p < 0.001). CAM-ICU status predicted mortality with AUROC of 0.85, 0.82 and 0.77 for inpatient, 30-day and 90-day mortality, respectively. CAM-ICU easily screens for delirium/HE, has excellent agreement with WHC, and identifies a hospitalized cirrhosis cohort with high short-term mortality.
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The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.
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Funding
APD is funded by National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under award number K23DK123408. ESO is funded by National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under award number K23DK109202. The funder was not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
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Study Concept and Design: Archita Desai, MD; Eric S. Orman, MD, MS.
Data Analysis: Devika Gandhi, MD; Chenjia Xu, PhD; Archita Desai, MD; Eric S. Orman, MD, MS.
Manuscript Preparation: Devika Gandhi, MD; Archita Desai, MD.
Critical Manuscript Review: All authors.
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The authors declare that they have no conflict of interests which are directly relevant to this work. For full disclosure, relationships unrelated to this work are listed. Dr. Naga Chalasani served as a paid consultant to Abbvie, Madrigal, Zydus, Galectin, Boehringer-Ingelheim, Lilly, and Altimmune. He has research funding from NIH, Galectin, DSM, and Exact Sciences. Dr. Chalasani has equity in RestUp, Inc, a start-up specializing in health care staff placement. Dr. Boustani receives consulting fees and honoria from Lilly, Eisa, BioGen, Genetech, ACADIA, Merck. Additionally, he has patents pending for the “ABC Took Kit” and Agile Processes and has stock options in PPHM, RestUP and BlueAgillis.Ethics approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Indiana University Institutional Review Board. (Last Date of Approval July 20, 2022/No 1402496491).
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Desai, A.P., Gandhi, D., Xu, C. et al. Confusion assessment method accurately screens for hepatic encephalopathy and predicts short-term mortality in hospitalized patients with cirrhosis. Metab Brain Dis 38, 1749–1758 (2023). https://doi.org/10.1007/s11011-022-01149-4
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DOI: https://doi.org/10.1007/s11011-022-01149-4