Manuel Romero-Gómez, MD, PhD; María Jover, PhD; José A. Del Campo, PhD; José L. Royo, PhD; Elena Hoyas, MD; José J. Galán, PhD; Carmina Montoliu, PhD; Eugenia Baccaro, MD; Mónica Guevara, MD, PhD; Juan Córdoba, MD, PhD; Germán Soriano, MD, PhD; José M. Navarro, MD; Carmen Martínez-Sierra, MD, PhD; Lourdes Grande, MD, PhD; Antonio Galindo, MD, PhD; Emilia Mira, PhD; Santos Mañes, PhD; and Agustín Ruiz, MD, PhD. Annals of Int Med, September 7, 2010, vol. 153 no. 5 281-288
Background: Hepatic encephalopathy is a major complication of cirrhosis and is associated with a poor prognosis.
Objective: To identify mutations in the gene sequence for glutaminase in humans that could be responsible for the development of hepatic encephalopathy in patients with cirrhosis.
Design: Cohort study.
Setting: Outpatient clinics in 6 Spanish hospitals.
Patients: 109 consecutive patients with cirrhosis in the estimation cohort, 177 patients in the validation cohort, and 107 healthy control participants.
Measurements: Patients were followed every 3 or 6 months until the development of hepatic encephalopathy or liver transplantation, death, or the end of the study.
Results: The genetic analyses showed that glutaminase TACC and CACC haplotypes were linked to the risk for overt hepatic encephalopathy. Mutation scanning of the glutaminase gene identified a section in the promoter region where base pairs were repeated (a microsatellite). Over a mean follow-up of 29.6 months, hepatic encephalopathy occurred in 28 patients (25.7%) in the estimation cohort. Multivariable Cox models were used to determine the following independent predictors: Child–Turcotte–Pugh stage (hazard ratio [HR], 1.6 [95% CI, 1.29 to 1.98]; P = 0.001), minimal hepatic encephalopathy (HR, 3.17 [CI, 1.42 to 7.09]; P = 0.006), and having 2 long alleles of the microsatellite (HR, 3.12 [CI, 1.39 to 7.02]; P = 0.006). The association between 2 long alleles of the microsatellite and overt hepatic encephalopathy was confirmed in a validation cohort (HR, 2.1 [CI, 1.17 to 3.79]; P = 0.012). Functional studies showed higher luciferase activity in cells transfected with the long form of the microsatellite, which suggests that the long microsatellite enhances glutaminase transcriptional activity.
Limitation: Other genes and allelic variants might be involved in the clinical expression of hepatic encephalopathy.
Conclusion: This study identifies a genetic factor that is associated with development of hepatic encephalopathy in patients with cirrhosis.
Primary Funding Source: Instituto de Salud Carlos III, Spanish Ministry of Health.
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