A retrospective study of 201 hepatic encephalopathy (HE) patients at a Pakistani tertiary care hospital revealed a 28.4% in-hospital mortality rate, with high Model for End-Stage Liver Disease (MELD) scores and elevated ammonia levels emerging as key predictors of poor outcomes. Non-survivors showed significantly higher MELD scores (29.3 vs. 24.9, p<0.001), ammonia levels (136.2 vs. 103.1 µmol/L, p<0.001), and prevalence of renal dysfunction (64.9% vs. 28.9%, p<0.001), with high-grade HE (West Haven Grade III/IV) present in 73.7% of fatal cases. Multivariate analysis identified MELD ≥28, ammonia ≥120 µmol/L, hyponatremia (<130 mEq/L), renal impairment, and severe HE as independent mortality predictors, with MELD demonstrating the strongest predictive value (AUC=0.78). These findings underscore the need for early intensive care and transplant evaluation in high-risk patients presenting with these clinical markers.
The research, conducted at Punjab Rangers Teaching Hospital from 2023-2025, analyzed electronic records of adults admitted with HE, using West Haven criteria for diagnosis. Striking differences emerged between survivors and non-survivors: 57.9% of deceased patients had hyponatremia versus 29.6% of survivors (p=0.002), while cerebral edema and multi-organ failure were frequent terminal complications. The study highlights HE’s dual role as both a neuropsychiatric manifestation and harbinger of systemic deterioration in liver disease, with mortality often resulting from secondary complications like sepsis or aspiration pneumonia rather than encephalopathy alone. These insights challenge the adequacy of current prognostic tools, suggesting ammonia levels and sodium status should be incorporated into risk stratification protocols.
Clinical implications are particularly relevant for resource-limited settings where late presentation is common. The 28.4% mortality rate exceeds many global benchmarks, possibly reflecting advanced disease at admission in the study population. Researchers emphasize that while MELD scores effectively prioritize transplant candidates, HE-specific mortality predictors like hyperammonemia and neurological grade warrant greater consideration in clinical decision-making. The findings align with growing evidence that HE pathophysiology extends beyond ammonia toxicity to include blood-brain barrier disruption and systemic inflammation—factors that may explain why some patients deteriorate despite ammonia-lowering therapies.
This study strengthens calls for modified prognostic models integrating both liver function metrics (MELD) and HE-specific markers. As hepatic encephalopathy remains a major driver of mortality in cirrhosis—with 40-50% of decompensated patients developing HE within 5 years—the identified predictors could guide timely transitions to palliative care when appropriate or expedite life-saving interventions. Future directions include validating these parameters in prospective cohorts and developing targeted management protocols for high-risk subgroups, particularly in regions with limited access to transplantation.