Minimal Hepatic Encephalopathy among Cirrhotics; A Cross Sectional, Clinico- Epidemiological, Multi-Centre Registry in Patients of Pakistan. The PREEMPT Registry

Abstract Background: Minimal hepatic encephalopathy (MHE) is a common yet underrecognized complication of liver cirrhosis, associated with cognitive decline and reduced health-related quality of life (HRQoL). Early detection is essential, particularly in low-resource settings like Pakistan, where the burden of chronic liver disease is high. This study aimed to determine the prevalence and clinical features of MHE, identify associated risk factors, and assess its impact on HRQoL using the SF-36 tool. Methods: This multicenter, cross-sectional survey included adults aged 18–65 years with liver cirrhosis and no overt hepatic encephalopathy, recruited from primary care and gastroenterology clinics across Pakistan. Participants with Mini-Mental State Examination (MMSE) scores ≥24 were assessed for MHE using the Psychometric Hepatic Encephalopathy Score (PHES), with a cutoff of ≤−5. HRQoL was evaluated using the SF-36 questionnaire. Statistical analyses included chi-square tests, unpaired t-tests, and multivariable logistic regression. Results: Of 1,096 participants, 602 (54.9%) met criteria for MHE. These patients had significantly lower SF-36 scores: physical component score (41.4 ± 8.2 vs. 43.2 ± 8.1) and mental component score (41.3 ± 10.6 vs. 46.9 ± 11.0; p < 0.001). Hepatitis C was the most common etiology (71.4%), though it was inversely associated with MHE (OR 0.42, 95% CI 0.32–0.55). Independent risk factors included age (OR 1.01), NASH/NAFLD (OR 4.59), hepatitis B (OR 2.20), low sodium (OR 1.03), and tobacco chewing (OR 2.88). Commonly prescribed medications included lactulose, omeprazole, and carvedilol. Conclusion: MHE is highly prevalent among cirrhotic patients in Pakistan and significantly impairs both physical and mental well-being. Routine cognitive screening and integration of tools like MMSE and SF-36 into standard cirrhosis care may improve early detection and patient outcomes in high-burden, resource-limited settings.