|
1
|
Khalid MB, Nagorna A, Rippel N, Ezaz G, Schiano TD, Crismale JF. Early neurologic complications after liver transplant are associated with reduced long-term survival and increased rates of rejection. Liver Transpl 2023; 29:1079-1088. [PMID: 37147847 DOI: 10.1097/lvt.0000000000000172] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/28/2023] [Indexed: 05/07/2023]
Abstract
Neurologic complications (NCs) are common following liver transplantation (LT) and have been associated with impaired short-term survival. The impact of NC on long-term survival is less defined. We aimed to characterize these outcomes and assess for risk factors for post-LT NC. We performed a single-center, retrospective review of 521 patients with LT from 2016 to 2020. Baseline clinical and laboratory factors, intraoperative events, and outcomes were compared between patients with and without NC. The 5-year overall and rejection-free survival was estimated using the Kaplan-Meier analysis. Multivariable logistic regression assessed for an independent relationship between risk factors and the development of NC. Among 521 LT recipients, 24% experienced post-LT NC. Overall and rejection-free survival at 5 years was, respectively, 69% and 75% among those with NC versus 87% and 88% among those without NC (log-rank < 0.001). Among those who survived the first 3 months after LT, overall survival but not rejection-free survival was reduced among patients with NC. Risk factors for developing NC included peri-LT serum sodium (ΔSNa) ≥ 6 (29.4% vs. 20.5%, p = 0.04), grade 3 or 4 HE pre-LT, SNa < 125 pre-LT, and more intraoperative transfusions. In a multivariable logistic regression model controlling for described variables, SNa < 125 (or 0.21, 95% CI, 0.06-0.74) at LT and pre-LT HE grade 3 or 4 (or 0.45, 95% CI, 0.26-0.76) was independently associated with NC. Long-term survival was reduced among patients who developed NC in the immediate post-transplant period, even when censoring those who died in the first 3 months. Post-LT NC was associated with perioperative ΔSNa ≥ 6. Optimization of SNa pre-LT > 125 and limiting perioperative ΔSNa <6 mEq/L might have a beneficial impact in decreasing NC post-LT, which may improve long-term post-LT survival.
Collapse
Affiliation(s)
- Mian B Khalid
- Department of Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Agnieszka Nagorna
- Department of Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Noa Rippel
- Department of Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Ghideon Ezaz
- Recanati/Miller Transplantation Institute, Division of Liver Disease, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Thomas D Schiano
- Recanati/Miller Transplantation Institute, Division of Liver Disease, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - James F Crismale
- Recanati/Miller Transplantation Institute, Division of Liver Disease, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| |
Collapse
|
|
2
|
Cerebral Diseases in Liver Transplant Recipients: Systematic Review of Clinical Evidence. J Clin Med 2022; 11:jcm11040979. [PMID: 35207251 PMCID: PMC8878041 DOI: 10.3390/jcm11040979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/27/2022] [Accepted: 02/08/2022] [Indexed: 12/04/2022] Open
Abstract
This systematic review presents clinical evidence on early and long-term cerebral diseases in liver transplant recipients. The literature search led to the retrieval of 12 relevant studies. Early postoperative cerebral complications include intracranial hemorrhage associated with a coexisting coagulopathy, perioperative hypertension, and higher MELD scores and is more frequent in critically ill recipients; central pontine and extrapontine myelinolysis are associated with notable perioperative changes in the plasma Na+ concentration and massive transfusion. Long-term follow-up cerebral complications include focal brain lesions, cerebrovascular diseases, and posterior reversible encephalopathy; there is no proven relationship between the toxicity immunosuppressive drugs and cerebral complications. This SR confirms a very low incidence of opportunistic cerebral infections.
Collapse
|
|
3
|
Acharya C, Bajaj JS. Hepatic Encephalopathy and Liver Transplantation: The Past, Present, and Future Toward Equitable Access. Liver Transpl 2021; 27:1830-1843. [PMID: 34018659 DOI: 10.1002/lt.26099] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 04/22/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023]
Abstract
Cirrhosis is a debilitating chronic disease with high morbidity and mortality, with the only real cure being liver transplantation (LT). Currently, we allocate organs for transplantation based on the Model for End-Stage Liver Disease-Sodium (MELD-Na) score that does not account for hepatic encephalopathy (HE). HE affects patients, families, and the health care system because of high rates of recurrence and major readmission burden. Moreover, HE casts a long shadow even after LT. Accounting for HE and incorporating it into the current allocation system has many proponents, but the framework to do this is currently lacking because of differences in consensus or in operationalization parameters. We review the latest evidence of the burden of HE, management of HE before and after LT, and evaluate pros and cons of several methods of diagnosing HE objectively to ensure early and equitable access to LT in this underserved population.
Collapse
Affiliation(s)
- Chathur Acharya
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA
| |
Collapse
|
|
4
|
Verbeek TA, Stine JG, Saner FH, Bezinover D. Osmotic demyelination syndrome: are patients with end-stage liver disease a special risk group? Minerva Anestesiol 2020; 86:756-767. [DOI: 10.23736/s0375-9393.20.14120-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|
|
5
|
Abstract
Neurologic complications of surgery can be devastating. The authors review neurologic considerations and complications associated with liver transplantation and discuss strategies to prevent, identify, and treat such adverse outcomes in the perioperative period.
Collapse
|
|
6
|
Te HS. Altered mental status after liver transplant. Clin Liver Dis (Hoboken) 2017; 10:36-41. [PMID: 30992757 PMCID: PMC6467109 DOI: 10.1002/cld.651] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 06/15/2017] [Accepted: 06/22/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Helen S. Te
- Center for Liver DiseasesUniversity of Chicago MedicineChicagoIL
| |
Collapse
|
|
7
|
Wu SY, Chen TW, Feng AC, Fan HL, Hsieh CB, Chung KP. Comprehensive risk assessment for early neurologic complications after liver transplantation. World J Gastroenterol 2016; 22:5548-5557. [PMID: 27350733 PMCID: PMC4917615 DOI: 10.3748/wjg.v22.i24.5548] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 04/26/2016] [Accepted: 05/23/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine risk factors for early neurologic complications (NCs) after liver transplantation from perspective of recipient, donor, and surgeon.
METHODS: In all, 295 adult recipients were enrolled consecutively between August 2001 and February 2014 from a single medical center in Taiwan. Any NC in the first 30 d post-liver transplantation, and perioperative variables from multiple perspectives were collected and analyzed. The main outcome was a 30-d NC. Generalized additive models were used to detect the non-linear effect of continuous variables on outcome, and to determine cut-off values for categorizing risk. Risk factors were identified using multiple logistic regression analysis.
RESULTS: In all, 288 recipients were included, of whom 142 (49.3%) experienced at least one NC, with encephalopathy being the most common 106 (73%). NCs prolonged hospital stay (35.15 ± 43.80 d vs 20.88 ± 13.58 d, P < 0.001). Liver recipients’ age < 29 or ≥ 60 years, body mass index < 21.6 or > 27.6 kg/m2, Child-Pugh class C, history of preoperative hepatoencephalopathy or mental disorders, day 7 tacrolimus level > 8.9 ng/mL, and postoperative intra-abdominal infection were more likely associated with NCs. Novel risk factors for NCs were donor age < 22 or ≥ 40 years, male-to-male gender matching, graft-recipient weight ratio 0.9%-1.9%, and sequence of transplantation between 31 and 174.
CONCLUSION: NCs post- liver transplantation occurs because of factors related to recipient, donor, and surgeon. Our results provide a basis of risk stratification for surgeon to minimize neurotoxic factors during transplantation.
Collapse
|
|
8
|
Restrepo DP, Tamayo A. [Affective syndromes in liver transplant recipients: ¿mediated neurotoxicity immunosuppressive?]. ACTA ACUST UNITED AC 2015; 44:121-7. [PMID: 26578335 DOI: 10.1016/j.rcp.2015.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 10/07/2014] [Accepted: 01/13/2015] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The onset of affective and psychotic in liver transplant patients symptoms, raises the need to explore the possible etiologies of mental symptoms. METHODOLOGY Case report and literature review. RESULTS Four clinical cases of patients undergoing orthotopic liver transplantation, who in the early post transplant showed affective symptoms, delusions and psychomotor agitation for which they needed psychiatric hospitalization and treatment with psychotropic drugs are presented. Three of the patients had clinical improvement and one patient died by suicide. DISCUSSION The development of mental symptoms in the post-transplant period opens the possibility of considering the secondary organic mental disorder a basic condition. CONCLUSIONS The adverse drug reaction may explain affective mental disorders in these four cases were reported.
Collapse
Affiliation(s)
- Diana Patricia Restrepo
- Médica Psiquiatra de Enlace, Docente Universidad CES, Estudiante de Maestría en Epidemiología Universidad CES, Medellín, Colombia.
| | - Alejandra Tamayo
- Médica Psiquiatra, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| |
Collapse
|
|
9
|
Comorbidities have a limited impact on post-transplant survival in carefully selected cirrhotic patients: a population-based cohort study. Ann Hepatol 2015. [DOI: 10.1016/s1665-2681(19)31172-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
|
|
10
|
Fu KA, DiNorcia J, Sher L, Velani SA, Akhtar S, Kalayjian LA, Sanossian N. Predictive factors of neurological complications and one-month mortality after liver transplantation. Front Neurol 2014; 5:275. [PMID: 25566180 PMCID: PMC4269112 DOI: 10.3389/fneur.2014.00275] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 12/03/2014] [Indexed: 12/11/2022] Open
Abstract
Background: Neurological complications are common after orthotopic liver transplantation (OLT). We aimed to characterize the risk factors associated with neurological complications and mortality among patients who underwent OLT in the post-model for end-stage liver disease (MELD) era. Methods: In a retrospective review, we evaluated 227 consecutive patients at the Keck Hospital of the University of Southern California before and after OLT to define the type and frequency of and risk factors for neurological complications and mortality. Results: Neurological complications were common (n = 98), with encephalopathy being most frequent (56.8%), followed by tremor (26.5%), hallucinations (11.2%), and seizure (8.2%). Factors associated with neurological complications after OLT included preoperative dialysis, hepatorenal syndrome, renal insufficiency, intra-operative dialysis, preoperative encephalopathy, preoperative mechanical ventilation, and infection. Preoperative infection was an independent predictor of neurological complications (OR 2.83, 1.47–5.44). One-month mortality was 8.8% and was independently associated with urgent re-transplant, preoperative intubation, and intra-operative arrhythmia. Conclusion: Neurological complications are common in patients undergoing OLT in the post-MELD era, with encephalopathy being most frequent. An improved understanding of the risk factors related to both neurological complications and one-month mortality post-transplantation can better guide perioperative care and help improve outcomes among OLT patients.
Collapse
Affiliation(s)
- Katherine A Fu
- Keck School of Medicine, University of Southern California , Los Angeles, CA , USA
| | - Joseph DiNorcia
- Keck School of Medicine, University of Southern California , Los Angeles, CA , USA ; Department of Hepatobiliary, Pancreas and Abdominal Organ Transplant Surgery, University of Southern California , Los Angeles, CA , USA
| | - Linda Sher
- Keck School of Medicine, University of Southern California , Los Angeles, CA , USA ; Department of Hepatobiliary, Pancreas and Abdominal Organ Transplant Surgery, University of Southern California , Los Angeles, CA , USA
| | - Shamsha A Velani
- Keck School of Medicine, University of Southern California , Los Angeles, CA , USA ; Department of Neurology, University of Southern California , Los Angeles, CA , USA
| | - Shahrzad Akhtar
- Keck School of Medicine, University of Southern California , Los Angeles, CA , USA
| | - Laura A Kalayjian
- Keck School of Medicine, University of Southern California , Los Angeles, CA , USA ; Department of Neurology, University of Southern California , Los Angeles, CA , USA
| | - Nerses Sanossian
- Keck School of Medicine, University of Southern California , Los Angeles, CA , USA ; Department of Neurology, University of Southern California , Los Angeles, CA , USA
| |
Collapse
|
|
11
|
Živković SA. Neurologic complications after liver transplantation. World J Hepatol 2013; 5:409-416. [PMID: 24023979 PMCID: PMC3767839 DOI: 10.4254/wjh.v5.i8.409] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 06/21/2013] [Accepted: 07/13/2013] [Indexed: 02/06/2023] Open
Abstract
Neurologic complications are relatively common after solid organ transplantation and affect 15%-30% of liver transplant recipients. Etiology is often related to immunosuppressant neurotoxicity and opportunistic infections. Most common complications include seizures and encephalopathy, and occurrence of central pontine myelinolysis is relatively specific for liver transplant recipients. Delayed allograft function may precipitate hepatic encephalopathy and neurotoxicity of calcineurin inhibitors typically manifests with tremor, headaches and encephalopathy. Reduction of neurotoxic immunosuppressants or conversion to an alternative medication usually result in clinical improvement. Standard preventive and diagnostic protocols have helped to reduce the prevalence of opportunistic central nervous system (CNS) infections, but viral and fungal CNS infections still affect 1% of liver transplant recipients, and the morbidity and mortality in the affected patients remain fairly high. Critical illness myopathy may also affect up to 7% of liver transplant recipients. Liver insufficiency is also associated with various neurologic disorders which may improve or resolve after successful liver transplantation. Accurate diagnosis and timely intervention are essential to improve outcomes, while advances in clinical management and extended post-transplant survival are increasingly shifting the focus to chronic post-transplant complications which are often encountered in a community hospital and an outpatient setting.
Collapse
|
|
12
|
Increase of beta-amyloid and C-reactive protein in liver transplant recipients with postoperative cognitive dysfunction. Hepatobiliary Pancreat Dis Int 2013; 12:370-6. [PMID: 23924494 DOI: 10.1016/s1499-3872(13)60058-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative cognitive dysfunction (POCD) is an adverse condition characterized by declined cognitive functions following surgeries and anesthesia. POCD has been associated with increased hospital stay and mortality. There are histological similarities to Alzheimer's disease. Most early studies were conducted in patients receiving cardiac surgery. Since there is no information about POCD in liver transplant recipients, we measured the incidence of POCD in patients after liver transplantation and examined the correlation between neurological dysfunction and biological markers of dementia-based diseases. METHODS We studied 25 patients who had a liver transplan-tation between July 2008 and February 2009. Patients with prior encephalopathy or risk factors associated with the development of POCD were excluded from the study. Five validated neuropsychiatric tests were used for diagnosis. The diagnosis was based on one standard deviation decline in two of the five neuropsychiatric tests. The correlation between patient variables and the development of POCD was examined. Serum levels of beta-amyloid and C-reactive protein were measured by standard ELISA and compared between patients with and without POCD. RESULTS POCD was present in 11 (44%) of the 25 patients. Patients with POCD had significantly higher MELD scores, were more often Child-Pugh class C and received more blood transfusion during surgery. The serum beta-amyloid protein and C-reactive protein concentrations were significantly increased at 24 hours after surgery in the POCD group. CONCLUSIONS The incidence of POCD in our group of liver transplant patients was greater than that reported in other surgical patients. The increase in the serum biomarkers of dementia in the POCD patients supports the hypothesis that chronic cognitive defects are due to a process similar to that seen in Alzheimer's disease.
Collapse
|
|
13
|
Xia YF, Wang ZP, Zhou YC, Yan T, Li ST. Cerebral protective effect of nicorandil premedication on patients undergoing liver transplantation. Hepatobiliary Pancreat Dis Int 2012; 11:132-6. [PMID: 22484579 DOI: 10.1016/s1499-3872(12)60137-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Neurological injury is a common complication in the early period after liver transplantation, posing an enormous obstacle to treatment efficiency and patient survival. Nicorandil is a mitochondrial ATP-sensitive potassium channel (mitoKATP) opener. It has been reported to be effective in reducing brain injury in recent studies. However, it is still unclear whether nicorandil has cerebral protective effect in patients undergoing liver transplantation. METHODS Fifty patients scheduled for liver transplantation were randomly divided into a nicorandil group (group N) (n=25), in which patients received 10 mg nicorandil through a nasogastric tube 30 minutes before induction of anesthesia, and a control group (group C) (n=25) who received 10 mL normal saline. The Mini-Mental State Examination (MMSE) was performed before anesthesia (day 0), and on days 3 and 7 after surgery. Blood samples were obtained before induction of anesthesia (T1), and at 12 (T2) and 36 hours (T3) after surgery for determination of serum neuron-specific enolase (NSE) and S100β protein (S100β) concentrations. RESULTS During surgery, 5 patients in each group were eliminated due to severe reperfusion or renal insufficiency. Therefore, 20 patients remained in each group. The MMSE scores after operation were significantly lower than those before operation in group C. However, there was no difference at days 3 and 7 compared with day 0 in group N. Serum NSE concentrations after surgery were significantly higher than baseline (at T1) in both groups, except at T3 in group N. Serum S100β concentration after surgery was significantly higher than baseline (at T1) in both groups. The MMSE scores at days 3 and 7 in group N were significantly higher than those in group C. The concentrations of serum NSE and S100β at T2 and T3 in group N were significantly lower than those in group C. CONCLUSIONS Oral nicorandil, as a premedication before liver transplantation, improves postoperative MMSE scores. It also attenuates the increase of NSE and S100β in blood, indicating its cerebral protective effect.
Collapse
Affiliation(s)
- Yun-Fei Xia
- Department of Anesthesiology, Shanghai First People's Hospital, Medical College, Shanghai Jiaotong University, Shanghai 200080, China
| | | | | | | | | |
Collapse
|
|
14
|
|
|
15
|
A predictive model for amyotrophic lateral sclerosis (ALS) diagnosis. J Neurol Sci 2011; 312:68-72. [PMID: 21907354 DOI: 10.1016/j.jns.2011.08.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Revised: 08/09/2011] [Accepted: 08/11/2011] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The clinical diagnosis of amyotrophic lateral sclerosis (ALS) usually takes several months. The delay in diagnosis compromises the effective therapeutic interventions. Therefore, the present study was aimed to develop a statistical model for predicting the risk of ALS at earlier stages for better management of ALS patients. METHODS The study recruited 44 sporadic ALS patients and 29 normal controls. Thirteen different independent variables (predictors) which were believed to be associated with ALS were included in the study. Forward stepwise (likelihood ratio) binary logistic regression was used to find significant variables and probability of disease prediction. RESULTS The Hosmer-Lemeshow goodness of fit statistic (χ(2)=4.379, df=8, p=0.821) indicate the appropriateness of forward stepwise (likelihood ratio) binary logistic regression model. Serum chemokine ligand-2, chemokine ligand-2 mRNA, vascular endothelial growth factor-A mRNA, smoking and alcohol consumption are the independent variables found significant to predict risk of ALS (p<0.05). The current model yielded 93.2% sensitivity and 86.2% specificity with 90.4% overall validity of correct ALS prediction. CONCLUSION Forward stepwise (likelihood ratio) binary logistic regression model is an accurate method to predict ALS in the presence of serum CCL2, CCL2 mRNA, VEGFA mRNA, smoking and alcohol consumption with high sensitivity and specificity. However, bed side diagnostic utility of these variables needs to be validated further in larger ALS cohorts.
Collapse
|
|
16
|
Balderramo D, Prieto J, Cárdenas A, Navasa M. Hepatic encephalopathy and post-transplant hyponatremia predict early calcineurin inhibitor-induced neurotoxicity after liver transplantation. Transpl Int 2011; 24:812-9. [DOI: 10.1111/j.1432-2277.2011.01280.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|
|
17
|
Córdoba J. New assessment of hepatic encephalopathy. J Hepatol 2011; 54:1030-40. [PMID: 21145874 DOI: 10.1016/j.jhep.2010.11.015] [Citation(s) in RCA: 149] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2010] [Revised: 11/22/2010] [Accepted: 11/23/2010] [Indexed: 12/12/2022]
Abstract
Hepatic encephalopathy (HE) is a common complication of cirrhosis that requires careful appraisal of the clinical manifestations, evaluation of the underlying neurological disorders, and assessment of liver function and the portal-systemic circulation. This article reviews recent developments in the assessment of HE and discusses the controversy regarding the use of a categorical or a continuous approach in measuring the severity of this condition. New scales facilitate effective monitoring and assessment of episodic HE. Neuropsychological test batteries and neurophysiological tests are of value for evaluating cognitive function in outpatients and can establish the diagnosis of minimal HE, and the severity of low-grade HE. These tools allow better evaluation of the origin of cognitive complaints and help in estimating the risk of accidents. It is now possible to complete the evaluation with measurement of the effects of cognitive impairment on daily living. In difficult cases, imaging of the brain and portal-systemic circulation with magnetic resonance imaging is especially helpful. Based on these studies, neurological signs and symptoms can be attributed to HE in patients with mild liver disease and in those with complex neurological manifestations. The new methods presented are also valuable for investigating the neurological manifestations occurring after liver transplantation.
Collapse
Affiliation(s)
- Juan Córdoba
- Servei de Medicina Interna-Hepatologia, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Paseo Vall d'Hebron 119, Barcelona 08035, Spain.
| |
Collapse
|
|
18
|
DiMartini A, Chopra K. The importance of hepatic encephalopathy: pre-transplant and post-transplant. Liver Transpl 2009; 15:121-3. [PMID: 19177448 DOI: 10.1002/lt.21638] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
|
19
|
Yoon JS, Kim YR, Choi JW, Ko JS, Gwak MS, Kim GS. Risk factors of postoperative delirium following liver transplantation. Korean J Anesthesiol 2009; 57:584-589. [DOI: 10.4097/kjae.2009.57.5.584] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jin Sun Yoon
- Department of Anesthesiology and Pain Medicine, Seoul Veterans Hospital, Seoul, Korea
| | - Young Ri Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Won Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Justin Sangwook Ko
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mi Sook Gwak
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
|
20
|
Abstract
PURPOSE OF REVIEW Significant changes have been witnessed recently in patients presenting for liver transplantation. The growing number of liver transplantations performed, the increasingly successful outcomes, the expansion of indications, and the implementation of the Model for End-Stage Liver Disease (MELD) system are driving forces for those changes. The purpose of this review is to examine those changes and their effect in perioperative management. RECENT FINDINGS Patients who present for liver transplantation today have higher MELD scores and more advanced liver disease. Studies show that high MELD score patients are associated with high perioperative risks and undergo a more difficult perioperative course than patients with low MELD score. More specifically, they have more preoperative comorbidities, more baseline laboratory abnormalities, and higher requirements for intraoperative transfusion and vasopressors. Progress has been also made in management in patients with hepatocellular carcinoma, fulminant hepatic failure, and coronary artery disease prior to liver transplantation. SUMMARY Patients who present for liver transplantation today are more acutely ill compared with a few years ago and have more comorbidities, higher perioperative risks, and a more difficult perioperative course. Further characterization of the changes and associated perioperative risks and strategies to manage those risks are needed.
Collapse
|
|
21
|
DiMartini A, Fontes P, Dew MA, Lotrich FE, DeVera M. Age, model for end-stage liver disease score, and organ functioning predict posttransplant tacrolimus neurotoxicity. Liver Transpl 2008; 14:815-22. [PMID: 18508372 PMCID: PMC2900193 DOI: 10.1002/lt.21427] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Calcineurin-inhibiting immunosuppressive medications are the mainstay of posttransplant immunosuppression. Although these highly beneficial drugs are critical for posttransplant survival, significant numbers of transplant recipients experience side effects, some requiring a switch to a different immunosuppressive regimen. Neurotoxicity is one of the most debilitating side effects because of its impact on mental status and cognition. As our center uses tacrolimus as the initial immunosuppressant for all liver transplant (LTX) recipients, we were interested in those patients who required a switch because of neurotoxic side effects. Over a 5-year period, 827 adult LTX recipients received their first graft at our center. Ninety-four patients were no longer on tacrolimus by 2 months post-LTX (86 switched because of concerns over neurotoxicity, and 8 switched because of renal function concerns). Of those experiencing neurotoxic side effects, the majority (64%) had altered mental status, and 26% had seizures (first onset post-LTX). On the basis of our prior work, we hypothesized that patients with a pre-LTX history of excessive alcohol use would be at higher risk for neurotoxic effects. We also hypothesized that the elderly and those who had more advanced illness (that is, higher Model for End-Stage Liver Disease scores) at LTX would be at risk as well. We found that patients with a pre-LTX diagnosis of alcoholic liver disease were not more likely to be switched from tacrolimus. Furthermore, we found that in addition to older age and higher Model for End-Stage Liver Disease scores, poorer hepatic functioning was significantly associated with a switch from tacrolimus. We discuss the implications of these findings and the relevance for future clinical care in these high-risk patients.
Collapse
Affiliation(s)
- Andrea DiMartini
- Department of Psychiatry, University of Pittsburgh Medical Center, Department of Transplantation Surgery, University of Pittsburgh Medical Center, Starzl Transplant Institute
| | - Paulo Fontes
- Department of Transplantation Surgery, University of Pittsburgh Medical Center, Starzl Transplant Institute
| | - Mary Amanda Dew
- Department of Psychiatry, University of Pittsburgh Medical Center, Department of Psychology, University of Pittsburgh Medical Center, Department of Epidemiology, University of Pittsburgh Medical Center
| | | | - Michael DeVera
- Department of Transplantation Surgery, University of Pittsburgh Medical Center, Starzl Transplant Institute
| |
Collapse
|
|
22
|
Panzera P, Cicco G, Memeo R, Catalano G, Greco L, Staffieri F, Lupo L, Memeo V. MELD Predictive Value of Alterations of Brain Perfusion During Liver Transplantation. Transplant Proc 2005; 37:2622-5. [PMID: 16182766 DOI: 10.1016/j.transproceed.2005.06.094] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The systemic circulation of patients with liver failure is characterized by low vascular resistance and a compensatorily increased cardiac output. In addition, some patients show functional loss of the autoregulation system for cerebral blood flow, creating enhanced risk during orthotopic liver transplantation (OLT), a possible cause of the high incidence of central nervous system complications after OLT. PATIENTS AND METHODS Sixteen consecutive patients undergoing OLT were enrolled and characterized by the Child-Pugh (CTP), the MELD, and the HCC-adjusted-MELD score before surgery. OLT was performed with the "piggyback" technique. Brain perfusion and oxygenation was monitored by NIRO300 by Hamamatsu. This instrument detects concentration changes in oxygenated hemoglobin (DeltaHbO(2)), deoxygenated hemoglobin (DeltaHHb), and total volume of hemoglobin (DeltaHbT). It also calculates the tissue oxygenation index (TOI), namely HbO(2)/HbT expressed as a percentage, and the tissue hemoglobin index (THI). RESULTS The lowest levels of brain perfusion were recorded at the washout, DeltaHbO(2) = -13.95 (-20/-5.3) micromol L(-1) and TOI = 51.5 (35.2/70.7)%, while immediately after, at reperfusion, the highest peaks were observed: DeltaHbO(2) was 0.16 (16.9/13) micromol L(-1); DeltaHbT was 1.1 (22.3/11.8) mumol L(-1); and TOI was 73.6 (78.1/65.3)%. CONCLUSIONS Patients with more severe liver deficiency scores showed higher levels of brain perfusion and oxygenation during surgery. Both the MELD and the CTP score predict alterations in brain perfusion.
Collapse
Affiliation(s)
- P Panzera
- Dipartimento di Chirurgia Generale e Trapianto di Fegato, University of Bari, Bari, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
|
23
|
Yu J, Zheng SS, Liang TB, Shen Y, Wang WL, Ke QH. Possible causes of central pontine myelinolysis after liver transplantation. World J Gastroenterol 2004; 10:2540-3. [PMID: 15300900 PMCID: PMC4572157 DOI: 10.3748/wjg.v10.i17.2540] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM: To sum up the clinical characteristics of patients with central pontine myelinolysis (CPM) after orthotopic liver transplantation (OLT) and to document the possible causes of CPM.
METHODS: Data of 142 patients undergoing OLT between January 1999 to May 2003 were analyzed retrospectively. Following risk factors during perioperation were analyzed in patients with and without CPM: primary liver disease, preoperative serum sodium level, magnesium level and plasma osmolality, fluctuation degree of serum sodium concentration, and immunosuppressive drug level, etc.
RESULTS: A total of 13 (9.2%) neurologic symptoms appeared in 142 patients post-operation including 5 cases (3.5%) with CPM and 8 cases (5.6%) with cerebral hemorrhage or infarct. Two patients developing CPM after OLT had a hyponatremia history before operation (serum sodium < 130 mmol/L), their mean serum sodium level was 130.6 ± 5.54 mmol/L. The serum sodium level was significantly lower in CPM patients than in patients without neurologic complications or with cerebral hemorrhage/infarct (P < 0.05).The increase in serum sodiumduring perioperative 48 h after OLT in patients with CPM was significantly greater than that in patients with cerebral hemorrhage/infarct but without neurologic complications (19.5 ± 6.54 mmol/L, 10.1 ± 6.43 mmol/L, 4.5 ± 4.34 mmol/L, respectively, P < 0.05). Plasma osmolality was greatly increased postoperation in patients with CPM. Hypomagnesemia was noted in all patients perioperation, but there were no significant differences between groups. The duration of operation on patients with CPM was longer than that on others (492 ± 190.05 min, P < 0.05). Cyclosporin A (CsA) levels were normal in all patients, but there were significant differences between patients with or without neurologic complications (P < 0.05).
CONCLUSION: CPM may be more prevalent following liver transplantation. Although the diagnosis of CPM after OLT can be made by overall neurologic evaluations including magnetic resonance imaging (MRI) of the head, the mortality is still very high. The occurance of CPM may be associated with such factors as hyponatremia, rapid rise of serum sodium concentration, plasma osmolality increase postoperation, the duration of operation, and high CsA levels.
Collapse
Affiliation(s)
- Jun Yu
- Department of Hepatobiliary Surgery, the First Affiliated Hospital, Medical School of Zhejiang University,Hangzhou 310003, Zhejiang Province, China
| | | | | | | | | | | |
Collapse
|
|
24
|
Abstract
PURPOSE OF REVIEW The field of liver transplantation continues to evolve. This review discusses the major themes of controversy and investigation over the past 12 months. RECENT FINDINGS Organ allocation remains a major area of investigation and controversy in liver transplantation. The MELD system, which has been implemented since 2002, appears to adequately predict both death on the waiting list and short-term survival after OLT. However, regional variations in allocation remain despite this system. In an attempt to further increase available organs, living donor adult transplantation has gained interest. However, with continued high rates of reported complications and additional reports of donor deaths, interest has been tempered and more diligent evaluation of the ethics and techniques for this procedure have been sought. As more patients continue to survive for longer periods after OLT, medical complications from medications are now seen and require skillful management in these individuals. Recurrent viral disease after transplant remains a significant challenge as will the increasing need for retransplantation in these patients. SUMMARY The review of the literature in liver transplantation continues to raise more issues than answer questions. It is likely that going into the future the key themes reviewed here will remain as further studies of larger patient populations will be required to more specifically identify "best practice" for care of these individuals.
Collapse
|