Sixty patients with liver disease and 34 controls were enrolled after written consent. Inclusion mTOR inhibitor criteria comprised the following: Patients were recruited between March 2007 and April 2010 from the outpatient clinics at Hospital Clinico Universitario and Hospital Arnau de Vilanova, in Valencia, Spain, and were included if they had clinical, biochemical, and histological evidence of liver cirrhosis. For controls, liver disease was discarded

by clinical, analytical, and serologic analysis. All subjects were volunteers. Patients were excluded if they had clinical evidence of overt HE, as measured by the West Haven criteria,27 decompensate diabetes, renal dysfunction, hyponatremia, neurological disease, severe cardiovascular

disease, or antibiotic use. Patients had to be abstinent from alcohol for 6 months before the study. Patients were not on any specific therapy for HE. The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki28 and was approved by the ethical committee of the hospital. After performing the psychometric tests, patients were classified as without MHE or with MHE (see below). The study included, therefore, three groups: (1) control subjects; (2) patients without MHE; and (3) patients with MHE. Composition of the groups, age, and etiology of the disease are given in Tables 1A and 1B. Table 2 shows the analytical data. 1B To assess whether MMN changes in parallel with MHE and/or performance in attention tests, we performed a longitudinal follow-up study 10-18 months after the first study. In total, 31 of 37 patients without MHE were included in the follow-up. Two patients were not included because they underwent liver transplantation, 1 died, and 3 did not want to collaborate. A total of 14 of 23 patients with MHE were included in the follow-up. Four patients

did not want to collaborate and another 5 died PDK4 (only 1 by complication of liver cirrhosis). All patients in the longitudinal study were stable, with no clinical or therapeutic changes. Parameters remained stable during the follow-up time, with no incident derived from diuretics, digestive hemorrhage, or taking antibiotics. MHE was diagnosed using the PHES, which is recommended as the “gold standard.”2 PHES comprises five psychometric tests: the digit symbol test (DST), number connection test A (NCT-A), number connection test B (NCT-B), the serial dotting test (SD), and the line-tracing test (LTT).29, 30 The score in each of the tests and the PHES were calculated by adjusting for age and education level by means of Spanish normality tables freely available since 2004 at http://www.redeh.org. Patients were classified as having MHE when the score was less than −4 points.29 Critical flicker frequency (CFF) has been proposed as an alternative procedure for detection of MHE in cirrhotic patients.31, 32 CFF was measured as described previously.