Prior overt hepatic encephalopathy and hyponatremia are more strongly linked to recent driving accidents than measures of minimal hepatic encephalopathy.

Abstract

Background: Cognitive impairment in cirrhosis is driven by multiple influencers. Those with cognitive impairment have greater traffic accidents and violations. While the presence of minimal hepatic encephalopathy has been associated with poor driving skills, studies show conflicting results and variable associations with regard to accidents.

Methods: In a prospective study of stable outpatients with cirrhosis without a recent history of overt hepatic encephalopathy (OHE) (<3 months), we assessed, the overall practice of driving, recent (<1 month) self-reported accidents, and factors associated with driving accidents.

Results: Of 433 patients, 147 (33.9%) [age, 55 (46-61) years, 97.9% males, 29.9% alcohol-related, 13.6% prior OHE, MELD 11 (10-16), lactulose use 45.5%, rifaximin use 23.1%] reported recent driving (≤1 month), of whom 22 (14.9%) had recent driving accidents. Those with reported accidents had a higher history of prior OHE (31.8 vs. 10.5%, P < 0.05) and lower sodium [131 (129-134) vs. 134 (132-138), P < 0.05]. Psychometric hepatic encephalopathy score (PHES) [-5.5 (-4 to -9), vs. -4 (-3 to -7), P = 0.10], alcohol as an etiology (22.7 vs. 31.2%, P = 0.68), MELD [12.5 (10-17) vs. 11 (9.7-16), P = 0.36], animal naming test [18 (16-23) vs. 18 (15-22), P = 0.35], outpatient fasting ammonia [93 (63.7-121.5) vs. 81 (67.2-96.2), P = 0.43] were similar. On univariate analysis, prior OHE, sodium levels and PHES [odds ratio (OR): 0.87 (0.75-1.0), P = 0.09], and animal naming test [OR: 0.89 (0.76-1.04), P = 0.10)] showed a trend of association, while on multivariable analysis only prior OHE [adjusted OR: 3.48 (1.07-10.74), P = 0.03] and sodium levels [adjusted OR: 0.89 (0.79-0.99), P = 0.03] were associated with recent driving accidents [model AUC (prior OHE + Na≤130), 0.70 (0.62-0.77)].

Conclusion: In stable outpatients with cirrhosis, a remote history of OHE and hyponatremia are most strongly associated with recent driving accidents.