1, 3, 19, 26 The current standard of care therefore relates to decreasing either the absorption of ammonia by using nonabsorbable disaccharides or either its production by reducing urease-producing bacteria by nonabsorbable antibiotics.26, 27 Recent innovations, such as rifaximin or liver

dialysis, are either not universally licensed for use or hampered because of lack of direct applicability.28-30 The ultimate solution remains liver transplantation but this implies relentless liver and renal insufficiency to become priorized in the current MELD era. Recently, large SPSSs were described to be highly prevalent Barasertib manufacturer (46%-71%) in patients with refractory HE. These latter might not only explain the refractoriness of HE but also serve as a therapeutic target.7-9, 12, 16, 31,

32 Nevertheless, the diagnosis of large SPSSs is often delayed and controversy still Epigenetics inhibitor prevails whether SPSSs might be therapeutically targeted for HE.11, 15 To elaborate further on these issues, we pooled the datasets of six different European liver units concerning 37 patients whose data were collated into a preset standardized case-report form. Our analysis not only confirms a delayed diagnosis, as in our series the diagnosis of SPSS was made on average 13 months after onset of HE, but more importantly substantiates the therapeutic effectiveness of embolization of the considered culprit SPSSs once the diagnosis is made. More specifically, almost 50% of the treated patients became HE-free during an average follow-up of more than 2 years. Considering secondary parameters of success, defined as either improved autonomy (objectively using mRS20), or decreased number of hospitalizations or severity of the worst HE episode after embolization, an improvement was observed in three-quarters of the patients. More specifically, autonomy was improved 3-fold and as such the hospitalization rate and in-hospital stays were similarly significantly reduced. Even more important, the need for liver transplantation

ifenprodil could theoretically be reduced in a large portion of these patients, as HE was the sole presenting symptom in a substantial proportion. It was impossible to retrospectively determine if all patients had been suitable for transplantation at the time of embolization. On the other hand, if eventually deemed necessary, as was the case in one patient, embolization did not technically compromise liver transplantation. If HE recurred nevertheless, it occurred either within days after index embolization (2-7 days, n = 15) or several months later (n = 4). Given angiographic confirmation of complete occlusion of the SPSS at the end of the procedure, the early occurrence presumably relates to insufficient remnant critical functional liver mass (cfr, the higher baseline MELD of nonresponders Fig.