@parrot53 I am 1.5 years out from my liver transplant. When I was still sick I had one episode of HE pre lactulose, and 3 episodes after; they had to adjust the dose and within a few months it stopped happening. Those episodes knocked my socks off, scary. As gross as lactulose is, it’s much better that HE so you may want to try it. Are you also taking xixifan? It helps address the bacteria in your gut that promote these episodes. Good luck!