Reviewed by Dr. Branden Tarlow
Bajaj J, et al. Hepatology, 2017 June 6

Hepatic encephalopathy is a disabling complication of advanced liver diseases. Prior studies have shown that the microbiome in cirrhotics is altered and that enrichment of certain potentially pathogenic species of bacterium are linked to cognitive impairment. The main treatments for hepatic encephalopathy—lactulose and rifaximin —are thought to change the gut microbial functionality and makeup; however, relapses of encephalopathy are common on therapy.

Here, Bajaj et al conducted an open label randomized control trial to determine the safety and efficacy of fecal microbiota transplantation (FMT) in cirrhotic patients with recurrent hepatic encephalopathy. The study randomized outpatients in a VA hospital with average MELD score of 12 to standard of care or FMT; all patients could continue lactulose and rifaximin. FMT from a single donor was delivered by enema.

FMT appeared safe in patients with cirrhosis: it did not increase rates of infection, bacterial peritonitis, or significantly alter MELD scores. FMT produced a significant compositional change in the intestinal flora including an increase in Proteobacteria and beneficial taxa (Lactobacillacea, Bifidobactereiaceae). In the 115 days after treatment, serious adverse events requiring hospitalization were significantly less likely in the FMT (2/10 patients) versus the control group (8/10 patients, p = 0.02).

Patients in the FMT arm showed significant improvement in encephalopathy symptoms on a standardized questionnaire compared to pre-treatment baseline (P = 0.003) but the control group did not (P = 0.98).