Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.
World J Hepatol. Apr 27, 2026; 18(4): 116153
Published online Apr 27, 2026. doi: 10.4254/wjh.v18.i4.116153
Published online Apr 27, 2026. doi: 10.4254/wjh.v18.i4.116153
Impact of two-session fecal microbiota transplantation on minimal hepatic encephalopathy in cirrhosis
Ankit Agarwal, Samagra Agrawal, Sagnik Biswas, Shekhar Swaroop, Rithvik Golla, Arnav Aggarwal, Hem C Singh, Ayush Agarwal, Mridul Mahajan, Bipin Tiwari, Baibaswata Nayak, Shalimar, Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
Daizee Talukdar, Manjeet Kaur, Bharti Kandiyal, Pradipta Jana, Subhash Tanwar, Bhabatosh Das, Center for Microbial Research, BRIC-Translational Health Science and Technology Institute, Faridabad 121001, Haryāna, India
Amit Goel, Department of Hepatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
Co-first authors: Ankit Agarwal and Samagra Agrawal.
Co-corresponding authors: Bhabatosh Das and Shalimar.
Author contributions: Agarwal A and Agarwal S contributed to study concept and design and they contributed equally to this manuscript and are co-first authors; Agarwal A, Biswas S, Swaroop S, Golla R, Aggarwal A, Singh HC, Agarwal A, Mahajan M, Tiwari B, Nayak B, Das B, and Shalimar contributed to analysis and interpretation of data; Agarwal A, Agarwal S, Talukdar D, Biswas S, Das B, and Shalimar contributed to drafting of the manuscript; Das B and Shalimar contributed to critical revision of the manuscript for important intellectual content, obtained funding, and they contributed equally to this manuscript and are co-corresponding authors; administrative, technical, or material support; Agarwal A, Agarwal S, Talukdar D, and Goel A contributed to statistical analysis; Shalimar contributed to study supervision.
Supported by the Department of Biotechnology, Government of India, No. BT/PR30159/MED/15/188/2018; Blockchain For Impact, No. 2025; and the Science and Engineering Research Board, India, No. SPR/2020/000315.
Institutional review board statement: This work was approved by the Institutional Ethics Committee, No. IEC-753/02.09.2022, RP-37/2022.
Clinical trial registration statement: This study was registrated in the Clinical Trials Registry of India, No. CTRI/2023/02/050008.
Informed consent statement: Informed consent has been obtained for this study.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
CONSORT 2010 statement: The authors have read the CONSORT 2010 Statement, and the manuscript was prepared and revised according to the CONSORT 2010 Statement.
Data sharing statement: The raw 16S rRNA gene sequencing data generated in the present study have been submitted to the Indian Nucleotide Data Archive. The 16S rRNA gene sequences will be available in the Indian Biological Data Center, study accession: No. INRP000315, and International Nucleotide Sequence Database Collaboration, study accession: No. ERP171343. The datasets used and analysed are available from the corresponding author on reasonable request.
Corresponding author: Shalimar, Professor, Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, Delhi, India. drshalimar@gmail.com
Received: November 4, 2025
Revised: December 8, 2025
Accepted: February 6, 2026
Published online: April 27, 2026
Processing time: 168 Days and 19.2 Hours
Revised: December 8, 2025
Accepted: February 6, 2026
Published online: April 27, 2026
Processing time: 168 Days and 19.2 Hours
Core Tip
Core Tip: Minimal hepatic encephalopathy (MHE) is common in cirrhosis. Gut dysbiosis is a key pathogenic player of MHE. Lactulose has been demonstrated to reverse MHE and prevent progression to overt hepatic encephalopathy. This randomised trial compared two endoscopic fecal microbiota transplantations (1 month apart) with daily lactulose over 3 months for MHE reversal. We found fecal microbiota transplantation and lactulose to have similar efficacy in improving MHE, supporting microbiota-targeted therapy as a viable alternative to standard care for MHE. These findings justify larger trials to assess long-term outcomes and optimal microbiota-based strategies.