Patients with cirrhosis commonly experience hepatic encephalopathy (HE), a condition associated with alterations in behavior, cognitive function, consciousness, and neuromuscular function of varying severity. HE occurring before liver transplant can have a substantial negative impact on posttransplant outcomes, and preoperative history of HE may be a predictor of posttransplant neurologic complications. Even with resolution of previous episodes of overt or minimal HE, some patients continue to experience cognitive deficits after transplant. Because HE is one of the most frequent pretransplant complications, improving patient HE status before transplant may improve outcomes. Current pharmacologic therapies for HE, whether for the treatment of minimal or overt HE or for prevention of HE relapse, are primarily directed at reducing cerebral exposure to systemic levels of gut-derived toxins (e.g., ammonia). The current mainstays of HE therapy are nonabsorbable disaccharides and antibiotics. The various impacts of adverse effects (such as diarrhea, abdominal distention, and dehydration) on patient's health and nutritional status should be taken into consideration when deciding the most appropriate HE management strategy in patients awaiting liver transplant. This paper reviews the potential consequences of pretransplant HE on posttransplant outcomes and therapeutic strategies for the pretransplant management of HE. 1. Introduction Cirrhosis of the liver—the only cure for which is liver transplant—is associated with several serious complications, including ascites, spontaneous bacterial peritonitis, variceal bleeding, and hepatic encephalopathy (HE) [1]. Guidelines established by the American Association for the Study of Liver Diseases currently recommend referring patients with cirrhosis for liver transplant when their model for end-stage liver disease (MELD) score is ≥10 and their Child-Turcotte-Pugh (CTP) score is ≥7 or when they experience their first major complication (e.g., HE, ascites, or variceal bleeding) [2]. However, the current United Network for Organ Sharing allocation system only uses the MELD score for prioritizing adults for liver transplant [3]. The MELD scoring system evaluates a patient’s short-term prognosis based on 3 common laboratory test results: serum bilirubin, international normalized ratio, and serum creatinine levels. However, this scoring system does not take into account several serious complications of cirrhosis, such as HE, when prioritizing patients for liver transplant [4]. This may have negative ramifications for patient
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