Abstract
Minimal hepatic encephalopathy (MHE) is characterized by disturbance of mental state and neuromuscular function. To assess the clinical efficacy of acetyl-l-carnitine (ALC) in the treatment of MHE, we performed a randomized, double-blind, placebo-controlled study administering ALC in cirrhotic patients with this disease and evaluating their cognitive functions. One hundred and twenty-five cirrhotic patients, of whom 21 were infected by hepatitis B virus, 75 by hepatitis C virus and 29 with cryptogenic cirrhosis, were enrolled in our study. Patients were randomly divided into two groups, and using double-blind administration, group A was treated with ALC and group B with placebo for 90 days. The two groups were similar in demographic characteristics, aetiology of cirrhosis, duration and Child-Pugh grade. Minimal hepatic encephalopathy was diagnosed with the Trail Making Test (TMT), Symbol Digit Modalities Test (SDMT) and Auditory Verbal Learning Test (AVL) and cognitive function with the Mini Mental State Examination (MMSE). After 90 days in group A treated with ALC, we observed a significant decrease in prothrombin time (P < 0.001), bilirubin serum levels (P < 0.01), AST (P < 0.001), fasting NH4 serum levels (P < 0.001), Trail Making Test-A (P < 0.001) and Trail Making Test-B (P < 0.001), and a significant increase in albumin serum levels (P < 0.005), MMSE test (P < 0.001), Symbol Digit Modalities Test (P < 0.001), BDT (P < 0.001), AVL long-term test (P < 0.001) and AVL total test (P < 0.001). No significant differences were observed in EEG in either group of patients treated with ALC or placebo. The benefits of ALC in comparison with placebo are demonstrated in greater reductions in serum ammonia levels, as well as in improvements of neuropsychological functioning.
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References
Ferenci P, Lockwood A, Mullen K, Tarter R, Weissenborn K, Blei AT (2002) Hepatic encephalopathy: definition, nomenclature, diagnosis, and quantification: final report of the Working Party at the 11th World Congresses of Gastroenterology, Vienna,1998. Hepatology 35:716–721. doi:10.1053/jhep.2002.31250
Blei AT (2000) Diagnosis and treatment of hepatic encephalopathy. Baillieres Best Pract Res Clin Gastroenterol 14:959–974. doi:10.1053/bega.2000.0141
Quero JC, Hartmann IJ, Meulstee J, Hop WC, Schalm SW (1996) The diagnosis of subclinical hepatic encephalopathy in patients with cirrhosis using neuropsychological tests and automated electroencephalogram analysis. Hepatology 24:556–560. doi:10.1002/hep.510240316
Malaguarnera M, Greco F, Barone G, Gargante MP, Malaguarnera M, Toscano MA (2007) Bifidobacterium longum with fructo-oligosaccharide (FOS) treatment in minimal hepatic encephalopathy: a randomized, double-blind, placebo-controlled study. Dig Dis Sci 52:3259–3265. doi:10.1007/s10620-006-9687-y
Siliprandi N, Siliprandi D, Ciman M (1965) Stimulation of oxidation of mitochondrial fatty acids and of acetate by acetylcarnitine. Biochem J 96:777–780
Dolezal V, Tucek S (1981) Utilization of citrate, acetylcarnitine, acetate, pyruvate and glucose for the synthesis of acetylcholine in rat brain slices. J Neurochem 36:1323–1330. doi:10.1111/j.1471-4159.1981.tb00569.x
Spagnoli A, Lucca U, Menasce G, Bandera L, Cizza G, Forloni G, Tettamanti M, Frattura L, Tiraboschi P, Pomelli M et al (1991) Long term acetyl-l-carnitine treatment in Alzheimer’s disease. Neurology 41:1726–1732
Virmani A, Gaetani F, Binienda Z, Xu A, Duhart H, Ali SF (2004) Role of mitochondrial dysfunction in neurotoxicity of MPP+: partial protection of PC12 cells by acetyl-L-carnitine. Ann N Y Acad Sci 1025:267–273. doi:10.1196/annals.1316.033
Cheng AY, Leiter LA (2006) Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Curr Opin Cardiol 21:400–404. doi:10.1097/01.hco.0000231412.15049.fb
McCrea M, Cordoba J, Vessey J, Blei AT, Randolph C (1996) Neuropsychological characterization and detection of subclinical hepatic encephalopathy. Arch Neurol 53:758–763
Reitan RM, Wolfson D (1993) The Halstead-Reitan: neuropsychological test battery: theory and clinical interpretation. Neuropsychology Press, Tucson, AZ
Wechsler D (1981) Wechsler Adult Intelligence Scale—Revised. Psychological Corp, New York
Kharbanda PS, Saraswat VA, Dhiman RK (2003) Minimal hepatic encephalopathy: diagnosis by neuropsychological and neurophysiologic methods. Indian J Gastroenterol 22:S37–S41
Smith A (1982) Symbol Digit Modalities Test (SDMT): manual (revised). Western Psychological Services, Los Angeles, CA
Folstein MF, Folstein SE, McHugh PR (1975) “Mini Mental State”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:189–198. doi:10.1016/0022-3956(75)90026-6
Schmidt M (1996) Rey Auditory and Verbal Learning Test. Instruction manual. Western Psychological Services, Los Angeles, CA
Malaguarnera M, Pistone G, Trovato BA, Scuderi M, Vinci M, Romano M, Marletta F (1996) Electrophysiological alterations in hepatic encephalopathy detected by brain mapping. Panminerva Med 38:84–88
Pugh RN, Murray-Lyon IM, Dawson JL, Petroni MC, Williams R (1973) Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 60:646–649. doi:10.1002/bjs.1800600817
Da Fonseca-Wollheim F (1973) Direkte plasmaammoniakbestimmung ohne Enteiweissung. Z Klin Chem Biochem 11:426–431
World Medical Association Declaration of Helsinki (1997) Recommendations guiding physicians in biomedical research involving human subjects. Cardiovasc Res 35:2–3. doi:10.1016/S0008-6363(97)00109-0
Montgomery SA, Thal LJ, Amrein R (2003) Meta-analysis of double blind randomized controlled clinical trials of acetyl-l-carnitine versus placebo in the treatment of mild cognitive impairment and mild Alzheimer’s disease. Int Clin Psychopharmacol 18:61–71. doi:10.1097/00004850-200303000-00001
Malaguarnera M, Pistone G, Astuto M, Dell’Arte S, Finocchiaro G, Lo Giudice E, Pennisi G (2003) L-Carnitine in the treatment of mild or moderate hepatic encephalopathy. Dig Dis 21:271–275. doi:10.1159/000073347
Mullen KD, Gacad R (1994) Pathogenetic mechanism of acute hepatic encephalopathy. New Horiz 2:505–511
Casas H, Murtra B, Casas M, Ibanez J, Ventura JL, Ricart A, Rodriguez F, Viscor G, Palacios L, Pages T, Rama R (2001) Increased blood ammonia in hypoxia during exercise in humans. J Physiol Biochem 57:303–312
Therrien G, Rose C, Butterworth J, Butterworth RF (1997) Protective effect of L-carnitine in ammonia-precipitated encephalopathy in the portacaval shunted rat. Hepatology 25:551–556. doi:10.1002/hep.510250310
Davanzo WJ, Ullian ME (2002) L-Carnitine administration reverses acute mental status changes in a chronic haemodialysis patient with hepatitis C infection. Clin Nephrol 57:402–405
Pettegrew JW, Levine J, McClure RJ (2000) Acetyl-L-carnitine physical-chemical, metabolic, and therapeutic properties: relevance for its mode of action in Alzheimer’s disease and geriatric depression. Mol Psychiatry 5:616–632. doi:10.1038/sj.mp.4000805
Malaguarnera M, Pistone G, Rampello E, Leotta C, Scarpello L, Rampello L (2005) Effects of L-carnitine in patients with hepatic encephalopathy. World J Gastroenterol 11:7197–7202
Malaguarnera M, Pistone G, Astuto M, Vecchio I, Raffaele R, Lo Giudice E, Rampello L (2006) Effects of L-acetylcarnitine on cirrhotic patients with hepatic coma: randomized double-blind, placebo-controlled trial. Dig Dis Sci 51:2242–2247. doi:10.1007/s10620-006-9187-0
Ortiz M, Cordoba J, Jacas C, Montserrat F, Esteban R, Guardia J (2006) Neuropsychological abnormalities in include learning impairment. J Hepatol 44:104–110. doi:10.1016/j.jhep.2005.06.013
Virmani A, Binienda Z (2004) Role of carnitine esters in brain 351 neuropathology. Mol Aspects Med 25:533–549. doi:10.1016/j.mam.2004.06.003
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Malaguarnera, M., Gargante, M.P., Cristaldi, E. et al. Acetyl-l-Carnitine Treatment in Minimal Hepatic Encephalopathy. Dig Dis Sci 53, 3018–3025 (2008). https://doi.org/10.1007/s10620-008-0238-6
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DOI: https://doi.org/10.1007/s10620-008-0238-6