Impact of two-session fecal microbiota transplantation on minimal hepatic encephalopathy in cirrhosis

Table 1 Baseline characteristics of the patients

Characteristics	Overall population (n = 122)	FMT (n = 60)	Lactulose (n = 62)
Age (years)	44.3 ± 8.9	43.7 ± 9.1	44.8 ± 8.9
Sex (male)	118 (96.7)	57 (95.0)	61 (98.4)
BMI (kg/m2)	23.6 (21.9-25.8)	23.4 (21.2-25.9)	23.8 (22.1-25.8)
Education (formal education in years)	11.4 ± 3.4	11.3 ± 3.1	11.5 ± 3.7
Etiology
Alcohol	67 (54.9)	32 (53.3)	35 (56.4)
MASLD	22 (18.0)	9 (15.0)	13 (21.0)
Hepatitis B	25 (20.5)	15 (25.0)	10 (16.1)
Hepatitis C	8 (6.6)	4 (6.7)	4 (6.5)
Hemoglobin (g/dL)	11.1 (9.4-12.6)	11.5 (10.12-12.85)	10.8 (9.12-12.1)
TLC (mm3)	5500 (4400-7350)	6030 (5105-8655)	5290 (4090-6150)
Platelet count (× 103/mm3)	98 (66-128)	99 (68-137)	97 (65-118)
Total bilirubin (mg/dL)	2.0 (1.3-2.6)	2.1 (1.3-2.9)	1.7 (1.1-2.4)
AST (U/L)	64 (45-98)	66 (47-106)	64 (41-92)
ALT (U/L)	35 (25-49)	36 (24-51)	33 (26-45)
ALP (U/L)	139 (107-186)	140 (109-186)	139 (107-208)
Total protein (g/dL)	7.9 (7.4-8.2)	7.9 (7.3-8.2)	7.9 (7.5-8.3)
Albumin (g/dL)	3.5 ± 0.7	3.4 ± 0.7	3.6 ± 0.7
Urea (mg/dL)	22 (16-32)	25 (16-34)	20 (16-28)
Creatinine (mg/dL)	0.9 ± 0.2	0.9 ± 0.2	0.9 ± 0.2
Sodium (mEq/L)	136.0 ± 4.6	136.1 ± 4.2	135.9 ± 4.9
Potassium (mEq/L)	4.4 ± 0.5	4.3 ± 0.6	4.5 ± 0.5
INR	1.5 (1.3-1.8)	1.6 (1.3-1.8)	1.4 (1.3-1.8)
AFP	4.3 (2.7-5.8)	4.5 (2.7-5.8)	3.7 (2.68-6.0)
CTP class
A	39 (32.0)	15 (25.0)	24 (38.7)
B	65 (53.3)	33 (55.0)	32 (51.6)
C	18 (14.6)	12 (20.0)	6 (9.7)
ANT	12.4 ± 2.3	12.7 ± 2.2	12.0 ± 2.4
LSM (kPa)	40.1 (26.6-60.2)	37.3 (28.0-58.6)	43.3 (26.0-64.7)
CAP (dB/m)	224 (193-249)	223 (196-242)	226 (190-259)
Ammonia	86 (72-107)	87 (66-107)	84 (74-105)
CTP score	7.0 (6.0-9.0)	7.0 (6.5-9.0)	7.0 (6.0-9.0)
MELD	13 (10-17)	14 (11-17)	13 (10-16)
MELD-Na	15.4 ± 4.5	15.7 ± 4.5	15.2 ± 4.5

Note all data are presented as n (%), median or mean ± SD.

FMT: Fecal microbiota transplantation; BMI: Body mass index; MASLD: Metabolic dysfunction-associated liver disease; TLC: Total leucocyte count; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; ALP: Alkaline phosphatase; INR: International normalised ratio; AFP: Alpha-fetoprotein; CTP: Child-Turcotte-Pugh score; ANT: Animal naming test; LSM: Liver stiffness measurement; CAP: Controlled attenuation parameter; MELD: Model for end-stage liver disease.

Table 2 Effect of fecal microbiota transplantation and Lactulose on clinical outcomes and neuropsychological test results

Outcomes	FMT baseline (n = 60)	FMT 3 months (n = 60)	P valuea,1	Lactulose baseline (n = 62)	Lactulose 3-month (n = 62)	P value2	Intergroup difference3 (adjusted mean difference ± standard error) [adjusted risk difference (95% confidence interval)]	P value4
Primary outcome
Resolution of MHE	-	41 (68.3%)	-	-	41 (66.1%)	-	2.2% (-14.4% to 18.9%)	0.800
Secondary outcomes
Overt HE	-	2 (3.3%)	-	-	1 (1.6%)	-	-1.7% (-7.2% to 3.8%)	1.000
MELD-Na score	15.7 ± 4.5	14.9 ± 4.3	0.18	15.2 ± 4.5	13.7 ± 4.3	0.06	-0.89 ± 0.35	0.250
CTP score	7.9 ± 1.5	7.2 ± 1.5	< 0.001	7.4 ± 1.4	7.2 ± 1.5	0.22	0.32 ± 0.22	0.150
Ammonia	89 ± 30	85 ± 27	0.351	89 ± 26	82 ± 22	0.109	-0.9 ± 12.5	0.950
PHES score	-6.1 ± 1.2	-3.3 ± 1.8	< 0.001	-6.1 ± 1.2	-3.2 ± 1.5	< 0.001a	-0.12 ± 0.31	0.710
PHES individual components
NCT-A	89.6 ± 25.4	78.0 ± 17.1	0.065	93.4 ± 28.3	80.1 ± 20.0	0.009a	-2.08 ± 3.61	0.570
FCT	79.2 ± 20.7	62.4 ± 15.8	< 0.001	79.2 ± 20.7	58.4 ± 15.7	< 0.001a	3.76 ± 2.99	0.210
SDT	61.0 ± 10.5	50.9 ± 7.8	< 0.001	61.0 ± 10.5	50.6 ± 9.4	< 0.001a	0.34 ± 1.66	0.840
DST	17.4 ± 4.3	22.3 ± 7.8	< 0.001	17.4 ± 4.3	20.2 ± 5.0	0.044a	-2.52 ± 1.24	0.044a
LTT	97.7 ± 20.7	76.9 ± 16.9	< 0.001	97.7 ± 20.7	78.3 ± 22.4	< 0.001a	-0.60 ± 3.73	0.870
Health-related Quality of Life (SF-36) domains
Physical functioning	657 ± 183	783 ± 145	0.001	637 ± 193	798 ± 136	< 0.001a	15.07 ± 27.69	0.590
Role limitation physical health	193 ± 140	290 ± 134	0.005	161 ± 130	302 ± 124	< 0.001a	7.36 ± 25.69	0.780
Role limitation and mental health	237 ± 84	280 ± 46	0.007	242 ± 82	260 ± 78	0.250	-19.64 ± 12.85	0.130
Energy/fatigue	188 ± 40	217 ± 42	0.002	185 ± 39	206 ± 42	0.005a	-11.23 ± 8.27	0.180
Emotional well-being	345 ± 33	363 ± 25	0.003	338 ± 38	359 ± 31	0.004a	-4.76 ± 5.62	0.400
Social functioning	164 ± 33	186 ± 23	0.001	166 ± 33	179 ± 25	0.018a	-7.58 ± 4.76	0.120
Pain	150 ± 29	183 ± 22	< 0.001	148 ± 24	175 ± 25	< 0.001a	-8.86 ± 4.64	0.059
General health	241 ± 47	276 ± 41	0.001	229 ± 39	284 ± 36	< 0.001a	7.84 ± 7.72	0.312

^aP < 0.05.

¹Difference between pre and post fecal microbiota transplantation scores at baseline and 3 months, respectively.

²Difference between pre and post lactulose scores at baseline and 3 months respectively.

³Final observation at 3 months is compared between the two treatment groups adjusted for respective baseline parameters. minimal hepatic encephalopathy is given as an adjusted risk difference. Positive values indicate a higher value in the lactulose group and vice versa.

⁴Intergroup difference adjusted for baseline.

FMT: Fecal microbiota transplantation; MHE: Minimal hepatic encephalopathy; HE: Hepatic encephalopathy; MELD: Model for end-stage liver disease; CTP: Child-Turcotte-Pugh score; PHES: Psychometric hepatic encephalopathy score; NCT-A: Number connection test; FCT: Figure connection test; SDT: Serial-dotting test; DST: Digit symbol test; LTT: Line-tracing test; SF-36: The 36-item short form survey.

Table 3 Adverse events over 3 months follow-up, n (%)

	Overall (n = 122)	FMT (n = 60)	Lactulose (n = 62)	P value
Any adverse events1	58 (47.5)	32 (53.3)	26 (41.9)	0.21
Bloating	18 (14.8)	3 (5.0)	15 (24.2)	< 0.01
Abdominal pain	16 (13.1)	7 (11.7)	9 (14.5)	0.64
Diarrhoea	11 (9.0)	6 (10.0)	5 (8.1)	0.71
Vomiting	4 (3.3)	3 (5.0)	1 (1.6)	0.36
Malaise	9 (7.4)	7 (11.7)	2 (3.2)	0.09
Fever	17 (13.9)	12 (20.0)	5 (8.1)	0.06
Cough	3 (2.5)	3 (5.0)	0	0.12
Constipation	7 (5.7)	7 (11.7)	0	< 0.01
Altered taste	1 (0.8)	1 (1.7)	0	0.49
Death	3 (2.5)	2 (3.3)	1 (1.6)	0.62
Overt HE	3 (2.5)	2 (3.3)	1 (1.6)	1.00
Sepsis	7 (5.7)	5 (8.3)	2 (3.2)	0.13
Pneumonia	2 (1.6)	2 (3.3)	0
Urosepsis	2 (1.6)	1 (1.7)	1 (1.6)
Cellulitis	1 (0.8)	0	1 (1.6)
Gastrointestinal	2 (1.6)	2 (3.3)	0

¹Total number of adverse events may not be additive, as a single patient may experience more than one event.

FMT: Fecal microbiota transplantation; HE: Hepatic encephalopathy.