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Serper M, Chafale A, Burdzy A, Kim M, Asrani SK, Yoshino Benavente J, Gershon R, Reese PP, Schaubel DE, Boike JR, Blanco MC, Wolf MS. Cognitive function, self-management, and outcomes among liver transplant recipients: LivCog, a multicenter, prospective study. Hepatol Commun 2023; 7:e0259. [PMID: 37916863 PMCID: PMC10545399 DOI: 10.1097/hc9.0000000000000259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/13/2023] [Indexed: 11/03/2023] Open
Abstract
Liver transplantation is a life-saving option for decompensated cirrhosis. Liver transplant recipients require advanced self-management skills, intact cognitive skills, and care partner support to improve long-term outcomes. Gaps remain in understanding post-liver transplant cognitive and health trajectories, and patient factors such as self-management skills, care partner support, and sleep. Our aims are to (1) assess pre-liver transplant to post-liver transplant cognitive trajectories and identify risk factors for persistent cognitive impairment; (2) evaluate associations between cognitive function and self-management skills, health behaviors, functional health status, and post-transplant outcomes; and (3) investigate potential mediators and moderators of associations between cognitive function and post-liver transplant outcomes. LivCog is a longitudinal, prospective observational study that will enroll 450 adult liver transplant recipients and their caregivers/care partners. The duration of the study is 5 years with 24 additional months of patient follow-up. Data will be collected from participants at 1, 3, 12, and 24 months post-transplant. Limited pre-liver transplant data will also be collected from waitlisted candidates. Data collection methods include interviews, surveys, cognitive assessments, and actigraphy/sleep diary measures. Patient measurements include sociodemographic characteristics, pretransplant health status, cognitive function, physical function, perioperative measures, medical history, transplant history, self-management skills, patient-reported outcomes, health behaviors, and clinical outcomes. Caregiver measures assess sociodemographic variables, health literacy, health care navigation skills, self-efficacy, care partner preparedness, nature and intensity of care, care partner burden, and community participation. By elucidating various health trajectories from pre-liver transplant to 2 years post-liver transplant, LivCog will be able to better characterize recipients at higher risk of cognitive impairment and compromised self-management. Findings will inform interventions targeting health behaviors, self-management, and caregiver supports to optimize outcomes.
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Affiliation(s)
- Marina Serper
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adwait Chafale
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alex Burdzy
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Minjee Kim
- Department of Neurology, Division of Neurocritical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Surgery, Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sumeet K. Asrani
- Department of Medicine, Baylor University Medical Center, Baylor Scott and White, Dallas, Texas, USA
| | - Julia Yoshino Benavente
- Department of Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Richard Gershon
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter P. Reese
- Department of Medicine, Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Douglas E. Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Justin R. Boike
- Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Maria C. Blanco
- Clinical Research Computing Unit (CRCU), The Center for Clinical Epidemiology and Biostatistics (CCEB), Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael S. Wolf
- Department of Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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2
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Kaplan A, Korenjak M, Brown RS. Post-liver transplantation patient experience. J Hepatol 2023; 78:1234-1244. [PMID: 37208108 DOI: 10.1016/j.jhep.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/02/2023] [Accepted: 01/12/2023] [Indexed: 05/21/2023]
Abstract
Given improvements in post-transplant patient and graft survival, there is a growing need to focus on patient experience and health-related quality of life (HRQOL). Though liver transplantation can be life-saving, it can also be associated with significant morbidity and complications. Patient HRQOL improves after transplantation, but it may not improve to that of age-matched cohorts. Understanding patient experience and the factors that contribute to it, including physical and psychological health, immunosuppression and medication adherence, return to employment or school, financial burden, and expectations, helps when thinking creatively about potential interventions to improve HRQOL.
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Affiliation(s)
- Alyson Kaplan
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell School of Medicine, New York Presbyterian, New York, NY, USA
| | | | - Robert S Brown
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell School of Medicine, New York Presbyterian, New York, NY, USA.
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3
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Zhou Y, Huang J, Si Z, Zhou Q, Li L. Pathogenic factors of cognitive dysfunction after liver transplantation: an observational study. Eur J Gastroenterol Hepatol 2023; 35:668-673. [PMID: 37115967 DOI: 10.1097/meg.0000000000002551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
OBJECTIVES Neurocognitive complications significantly reduce long-term health-related quality of life in patients undergoing liver transplantation; however, few studies have focused on their perioperative cognitive status. The authors designed a prospective observational study to determine the incidence and risk factors of posttransplant cognitive dysfunction. METHODS This study included patients with end-stage liver disease who were on the liver transplantation waiting list. We performed an investigation with a neuropsychological battery before and 1 week after the successful transplant, analyzed the changes, and further explored the complicated perioperative factors that contribute to cognitive dysfunction. RESULTS A total of 132 patients completed all the investigations. Compared with healthy controls and preoperative cognitive performance, 54 patients experienced deterioration, 50 patients remained unchanged, and 28 patients showed rapid improvement. Logistic regression analysis showed that age [odds ratio (OR) = 1.15, 95% confidence interval (CI, 1.07-1.22), P < 0.001], the model for end-stage liver disease (MELD) score [OR = 1.07, 95% CI (1.03-1.13), P = 0.038], systemic circulation pressure [OR = 0.95, 95% CI (0.91-0.99), P = 0.026] within the first 30 min after portal vein opening, and total bilirubin concentration [OR = 1.02, 95% CI (1.01-1.03), P = 0.036] on the seventh day post-transplant were closely related to the deterioration of cognitive function. CONCLUSION The incidences of deterioration, maintenance, and improvement in cognitive function were 40.9%, 37.9%, and 21.2%, respectively. Increasing age, higher MELD score, lower perfusion pressure in the early stage of the new liver, and higher total bilirubin concentration postoperatively may be independent pathogenic factors.
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Affiliation(s)
- Yongpeng Zhou
- Department of Anesthesiology, The Second Affiliated Hospital of Air Force Medical University, Xi'an
| | - Jun Huang
- Department of Urology, The Second Xiangya Hospital of Central South University
| | - Zhongzhou Si
- Department of Liver Transplantation, The Second Xiangya Hospital of Central South University
| | - Qin Zhou
- Department of Anaesthesiology, The Second Xiangya Hospital of Central South University, Changsha, PR China
| | - Liwen Li
- Department of Anaesthesiology, The Second Xiangya Hospital of Central South University, Changsha, PR China
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Jing W, Bi C, Fang Z, Qian C, Chen J, Yu J, Tian G, Ye M, Liu Z. Neuropsychiatric sequelae after liver transplantation and their possible mechanism via the microbiota-gut-liver-brain axis. Biomed Pharmacother 2023; 163:114855. [PMID: 37163780 DOI: 10.1016/j.biopha.2023.114855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/04/2023] [Accepted: 05/04/2023] [Indexed: 05/12/2023] Open
Abstract
Patients after liver transplantation are often impacted by mental and even neuropsychiatric disorders, including depression, sleep disorders, anxiety, and post-traumatic stress disorder. Neuropsychiatric sequelae have an adverse impact on rehabilitation and can even incapacitate people, reducing their quality of life. Despite screening tools and effective treatments, neuropsychiatric sequelae after liver transplantation (NSALT) have not been fully diagnosed and treated. Current research suggests that NSALT may be partly related to intestinal microbial variation, but the detailed mechanism remains unclear. In this review, we describe the clinical and diagnostic features, prevalence, prediction, clinical course and outcome, management, and treatment of NSALT; we also summarize their mechanisms through the microbiota-gut-liver-brain axis. Finally, we propose to improve NSALT on the basis of adjusting the gastrointestinal flora, immune inflammation or vagus nerve (VN), providing a novel strategy for clinical prevention and treatment.
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Affiliation(s)
- Wenhao Jing
- Department of Psychiatry, Shaoxing seventh people's hospital, Mental Health Center, School of Medicine, Shaoxing University, Shaoxing 312000, Zhejiang, China; Department of Pharmacology, School of Medicine, Shaoxing University, Shaoxing, Zhejiang 312000, China; Department of Clinical Medicine, School of Medicine, Shaoxing University, Shaoxing, Zhejiang 312000, China
| | - Chenchen Bi
- Department of Clinical Medicine, School of Medicine, Shaoxing University, Shaoxing, Zhejiang 312000, China
| | - Zhou Fang
- Department of General Practice, Lizhu Branch, Shaoxing Second Hospital, Shaoxing 312000, Zhejiang, China
| | - Chao Qian
- Department of Psychiatry, Shaoxing seventh people's hospital, Mental Health Center, School of Medicine, Shaoxing University, Shaoxing 312000, Zhejiang, China
| | - Jiaqi Chen
- Department of Pharmacology, School of Medicine, Shaoxing University, Shaoxing, Zhejiang 312000, China; Department of Emergency Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong, China
| | - Jingru Yu
- Department of Clinical Medicine, School of Medicine, Shaoxing University, Shaoxing, Zhejiang 312000, China
| | - Guoqiang Tian
- Department of Psychiatry, Shaoxing seventh people's hospital, Mental Health Center, School of Medicine, Shaoxing University, Shaoxing 312000, Zhejiang, China
| | - Mengfei Ye
- Department of Psychiatry, Shaoxing seventh people's hospital, Mental Health Center, School of Medicine, Shaoxing University, Shaoxing 312000, Zhejiang, China.
| | - Zheng Liu
- Department of Pharmacology, School of Medicine, Shaoxing University, Shaoxing, Zhejiang 312000, China.
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Siddiqui OM, Baskaran AB, Lin KA, Najam N, Shah T, Beestrum ML, Thuluvath A, Bonakdarpour B, Kim M, Dietch Z, Wolf M, Ladner DP. Cognitive Impairment in Liver Transplant Recipients With a History of Cirrhosis: A Systematic Review. Transplant Direct 2023; 9:e1479. [PMID: 37096151 PMCID: PMC10121435 DOI: 10.1097/txd.0000000000001479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/16/2023] [Indexed: 04/26/2023] Open
Abstract
Cognitive impairment is common among patients with cirrhosis and may persist post-transplantation. This systematic review seeks to (1) describe the prevalence of cognitive impairment in liver transplant (LT) recipients with a history of cirrhosis, (2) describe risk factors for this population, and (3) describe associations between post-transplant cognitive impairment and quality outcome measures. Methods Studies in PubMed, Embase, Scopus, PsychINFO, and the Cochrane Database of Controlled Trials were included through May 2022. Inclusion criteria included (1) population - LT recipient, age ≥18 y, (2) exposure - history of cirrhosis before transplant, and (3) outcome - cognitive impairment after transplant (per validated cognitive testing). Exclusion criteria included (1) wrong study type, (2) abstract-only publication, (3) full-text unavailable, (4) wrong population, (5) wrong exposure, and (6) wrong outcome. The risk of bias was assessed using the Newcastle-Ottawa Scale and the Appraisal tool for Cross-Sectional Studies. The Grading of Recommendations, Assessment, Development, and Evaluations system was used to assess evidence certainty. Data from individual tests were categorized into six cognitive domains: attention, executive function, working memory, long-term memory, visuospatial, and language. Results Twenty-four studies were included covering 847 patients. Follow-up ranged from 1 mo to 1.8 y after LT. Studies had a median of 30 (interquartile range 21.5-50.5) patients. The prevalence of cognitive impairment after LT ranged from 0% to 36%. Forty-three unique cognitive tests were used, the most common being the Psychometric Hepatic Encephalopathy Score. The most frequently assessed cognitive domains were attention (10 studies) and executive function (10 studies). Conclusions The prevalence of cognitive impairment after LT varied across studies depending on cognitive tests utilized and follow-up duration. Attention and executive function were most impacted. Generalizability is limited due to small sample size and heterogeneous methodology. Further studies are needed to examine differences in the prevalence of post-LT cognitive impairment by etiology, risk factors, and ideal cognitive measures.
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Affiliation(s)
- Osama M. Siddiqui
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Archit B. Baskaran
- Department of Neurology, University of Chicago Medical Center, University of Chicago, Chicago, IL
| | - Katherine A. Lin
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Naela Najam
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Tahir Shah
- Department of Neuroscience, University of Cincinnati, Cincinnati, OH
| | - Molly L. Beestrum
- Galter Health Sciences Library, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Avesh Thuluvath
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern Medicine, Chicago, IL
| | - Borna Bonakdarpour
- Division of Behavioral Neurology, Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Minjee Kim
- Division of Neurocritical Care, Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Zachary Dietch
- Division of Transplant, Department of Surgery, Northwestern Medicine, Chicago, IL
| | - Michael Wolf
- Division of General Internal Medicine & Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Daniela P. Ladner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Transplant, Department of Surgery, Northwestern Medicine, Chicago, IL
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6
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Thabut D, Bouzbib C, Meunier L, Haas M, Weiss N, Louvet A, Imbert-Bismut F, Mochel F, Nadjar Y, Santiago A, Thevenot T, Duhalde V, Oberti F, Francoz C, Coilly A, Hilleret MN, Lebray P, Liou-Schischmanoff A, Barbier L, Duvoux C, Pageaux GP, Bismuth M, Galanaud D, Broucker TD, Cadranel JF, Leroy V, Di Martino V, Larrey D, Camus C, Scatton O, De Ledinghen V, Mallat A, Rudler M, Bureau C. Diagnosis and management of hepatic encephalopathy: The French recommendations. Liver Int 2023; 43:750-762. [PMID: 36625084 DOI: 10.1111/liv.15510] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/27/2022] [Accepted: 12/31/2022] [Indexed: 01/11/2023]
Abstract
Hepatic encephalopathy (HE) is a frequent and severe complication of liver disease with poor patient outcomes. However, it is a poorly understood complication, with no consensus for diagnosis. Therefore, HE is often underdiagnosed. Differential diagnosis may be cumbersome because of non-specific symptoms, such as confusion, cognitive disorders, the aetiological factors of cirrhosis and comorbidities, which are often observed in cirrhotic patients. Therefore, an overt or covert form of HE should be systematically investigated. Advice is provided to drive patient work-up. Effective treatments are available to prevent or treat HE bouts, but the issue of single or combination therapy has not been resolved. Transjugular intrahepatic portosystemic shunt (TIPS) placement largely improved the prognosis of cirrhotic patients, but HE occurrence of HE is often a fear, even when post-TIPS HE can be avoided by a careful selection of patients and preventive treatment. HE is an indication of liver transplantation. However, its reversibility post-transplantation and the consequences of transplantation in patients with other causes of neurological disorders remain controversial, which supports the performance of an extensive work-up in expert centres for this subset of patients. The present guidelines assist clinicians in the diagnosis of the overt or covert form of HE to implement curative and preventive treatments and clarify which patients require referral to expert centres for consideration for liver transplantation. These guidelines are very clinically oriented and address different frequent clinical issues to help physicians make bedside decisions.
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Affiliation(s)
- Dominique Thabut
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Charlotte Bouzbib
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Lucy Meunier
- Service d'hépato-gastroentérologie A et Transplantation, Hôpital Saint-Eloi, CHU de Montpellier, Montpellier, France
| | - Manon Haas
- APHP-Paris Saclay, Centre Hépato-Biliaire, Hôpital Paul Brousse, Université Paris-saclay, Villejuif, France
| | - Nicolas Weiss
- APHP-Sorbonne Université, Service de réanimation neurologique, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Alexandre Louvet
- Services des maladies de l'appareil digestif, CHRU de Lille, Lille, France
| | - Francois Imbert-Bismut
- APHP-Sorbonne Université, Service de biochimie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Fanny Mochel
- APHP-Sorbonne Université, Service de génétique, Hôpital Pitié-Salpêtrière, Paris, France
| | - Yann Nadjar
- APHP-Sorbonne Université, Service de neurologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Antoine Santiago
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Thierry Thevenot
- Service d'hépatologie, Hôpital Jean Minjoz, CHU de Besançon, Besançon, France
| | - Véronique Duhalde
- Service de pharmacie, Hôpital Rangueil, CHU de Toulouse, Toulouse, France
| | - Frédéric Oberti
- Laboratoire HIFIH, UPRES-EA2170, Faculté de Médecine, Service d'hépato-gastroentérologie, CHU ANGERS, Angers, France
| | - Claire Francoz
- APHP-Hôpital Beaujon, Service d'hépatologie, Clichy, France
| | - Audrey Coilly
- APHP-Paris Saclay, Centre Hépato-Biliaire, Hôpital Paul Brousse, Université Paris-saclay, Villejuif, France
| | | | - Pascal Lebray
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | | | - Louise Barbier
- Service de chirurgie hépatique et transplantation, CHU de Tours, Tours, France
| | | | - Georges-Philippe Pageaux
- Service d'hépato-gastroentérologie A et Transplantation, Hôpital Saint-Eloi, CHU de Montpellier, Montpellier, France
| | - Michael Bismuth
- Service d'hépato-gastroentérologie B, Hôpital Saint Eloi, CHU de Montpellier, Montpellier, France
| | - Damien Galanaud
- APHP-Sorbonne Université, Service de neuro-radiologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Thomas De Broucker
- Service de Neurologie Hôpital Pierre Delafontaine, Centre Hospitalier de Saint-Denis, Saint-Denis, France
| | - Jean-François Cadranel
- Service d'hépato-gastroentérologie de nutrition et d'Alcoologie-GHPSO site de Creil, Creil, France
| | - Vincent Leroy
- APHP Hôpital Henri-Mondor, Service d'hépatologie, Créteil, France
| | - Vincent Di Martino
- Service d'hépatologie, Hôpital Jean Minjoz, CHU de Besançon, Besançon, France
| | - Dominique Larrey
- Service d'hépato-gastroentérologie A et Transplantation, Hôpital Saint-Eloi, CHU de Montpellier, Montpellier, France
| | - Christophe Camus
- Service de réanimation Médicale, Hôpital Pontchaillou, CHU de Rennes, Rennes, France
| | - Olivier Scatton
- APHP-Sorbonne Université, Service de chirurgie et transplantation hépatique, Hôpital Pitié-Salpêtrière, Paris, France
| | - Victor De Ledinghen
- Service d'hépato-gastroentérologie, Hôpital du Haut-Lévêque, CHU de Bordeaux, Bordeaux, France
| | - Ariane Mallat
- APHP Hôpital Henri-Mondor, Service d'hépatologie, Créteil, France
| | - Marika Rudler
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Christophe Bureau
- Service d'hépatologie, Hôpital Rangueil, CHU de Toulouse, Toulouse, France
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Hansen MKG, Kjærgaard K, Eriksen LL, Grønkjær LL, Mikkelsen ACD, Sandahl TD, Vilstrup H, Thomsen KL, Lauridsen MME. Psychometric methods for diagnosing and monitoring minimal hepatic encephalopathy -current validation level and practical use. Metab Brain Dis 2022; 37:589-605. [PMID: 35102491 DOI: 10.1007/s11011-022-00913-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/14/2022] [Indexed: 02/07/2023]
Abstract
Hepatic encephalopathy (HE) is cerebral dysfunction caused by liver failure and inflicts 30-40% of patients with liver cirrhosis during their disease course. Clinically manifest HE is often preceded by minimal HE (MHE) - a clinically undetectable cognitive disturbance closely associated with loss of quality of life. Accordingly, detecting and treating MHE improve the patients' daily functioning and prevent HE-related hospital admissions. The scope of this review article is to create an overview of the validation level and usage of psychometric tests used to detect MHE: Portosystemic hepatic encephalopathy test, continuous reaction time test, Stroop EncephalApp, animal naming test, critical flicker frequency test, and inhibitory control test. Our work is aimed at the clinician or scientist who is about to decide on which psychometric test would fit best in their clinic, cohort, or study. First, we outline psychometric test validation obstacles and requirements. Then, we systematically approach the literature on each test and select well-conducted studies to answer the following questions:• Which percentage of patients with cirrhosis does the test deem as having MHE?• Is the test able to predict clinically manifest HE?• Is there a well-known test-retest variation and inter-observer variation?• Is the test able to detect a treatment response?• Is the test result affected by age, educational level, gender, or comorbidities?
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Affiliation(s)
- Mads Kingo Guldberg Hansen
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark.
| | - Kristoffer Kjærgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Lotte Lindgreen Eriksen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Lea Ladegaard Grønkjær
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark
| | - Anne Catrine Daugaard Mikkelsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Thomas Damgaard Sandahl
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Karen Louise Thomsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Mette Munk Enok Lauridsen
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark
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8
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Ko D, Dietrich MS, Gifford KA, Ridner SH. Subjective Cognition Reported by Caregivers Is Correlated With Objective Cognition in Liver Transplant Recipients. Liver Transpl 2022; 28:269-279. [PMID: 34137503 PMCID: PMC8785255 DOI: 10.1002/lt.26213] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 06/09/2021] [Accepted: 06/13/2021] [Indexed: 02/03/2023]
Abstract
Objective cognitive assessments, a gold standard diagnostic tool for cognitive impairment, may not be feasible in busy liver transplantation (LT) practice because they are often time consuming. This study determined whether subjective cognition, patients' self-ratings and/or caregivers' ratings of patients' cognition, reflects objective cognition in LT recipients. A convenience sample of 60 adult LT recipients and their caregivers, recruited at a single transplant center, participated in this cross-sectional descriptive study. Subjective cognition (ie, recipient self-rated and caregiver rated) was measured using the Everyday Cognition (ECog; global and 6 domain scores). Objective global and domain-specific cognition of recipients was measured using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Trail Making Test parts A and B, Digit Span Backward, and Rey-Osterrieth Complex Figure. Agreement between LT recipients' ECog scores and those of their caregivers was fair to moderate (intraclass correlation coefficient = 0.48 for global score, 0.35-0.56 for domain scores). Significant, albeit rather weak, correlations were found between subjective and objective scores. Recipients' ECog visuospatial abilities scores were correlated with Rey-Osterrieth Complex Figure scores (rs = -0.39; P = 0.007), whereas caregivers' ECog global, attention, visuospatial abilities, and organization scores were, respectively, correlated with the scores of RBANS global (rs = -0.33; P = 0.04) and attention (rs = -0.46; P = 0.005), Rey-Osterrieth Complex Figure (Copy; rs = -0.34; P = 0.03), and Trail Making Test part A (rs = 0.31; P = 0.049). The findings suggest that caregivers may estimate LT recipients' cognition better than recipients themselves. Caregivers may provide supplemental information that could be useful for clinicians when considering the cognitive functioning of LT recipients.
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Affiliation(s)
- Dami Ko
- School of Nursing, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
| | - Mary S. Dietrich
- School of Nursing, Vanderbilt University, Nashville, Tennessee,Department of Biostatistics, School of Medicine, Vanderbilt University, Nashville, Tennessee,Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Katherine A. Gifford
- Vanderbilt Memory and Alzheimer’s Center, Vanderbilt University Medical Center, Nashville, Tennessee,Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sheila H. Ridner
- School of Nursing, Vanderbilt University, Nashville, Tennessee,Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee
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9
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Serper M, Asrani S, VanWagner L, Reese PP, Kim M, Wolf MS. Redefining Success After Liver Transplantation: From Mortality Toward Function and Fulfillment. Liver Transpl 2022; 28:304-313. [PMID: 34608746 DOI: 10.1002/lt.26325] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/31/2021] [Accepted: 09/29/2021] [Indexed: 01/13/2023]
Abstract
Liver transplantation (LT), the only cure for end-stage liver disease, is a lifesaving, costly, and limited resource. LT recipients (LTRs) are aging with an increasing burden of medical comorbidities. Patient and graft survival rates exceed 70% at 5 years; however, patient-centered health outcomes beyond survival have received relatively little attention. LTRs must have strong self-management skills to navigate health systems, adhere to clinical monitoring, and take complex, multidrug regimens. All of these tasks require formidable cognitive abilities for active learning and problem solving. Yet, LTRs are at higher risk for impaired cognition as a result of the high prevalence of pretransplant hepatic encephalopathy, multiple chronic conditions, alcohol use, physical frailty, sarcopenia, and older age. Cognitive impairment after transplant may persist and has been causally linked to poor self-management skills, worse physical function, and inferior health outcomes in other health care settings, yet its impact after LT is largely unknown. There is a need to study potentially modifiable, posttransplant targets including caregiver support, physical activity, sleep, and treatment adherence to inform future health system responses to promote the long-term health and well-being of LTRs. Prospective, longitudinal data collection that encompasses key sociodemographic, cognitive-behavioral, psychosocial, and medical factors is needed to improve risk prediction and better inform patient and caregiver expectations. Interventions with proactive monitoring, reducing medical complexity, and improved care coordination can be tailored to optimize posttransplant care. We propose a research agenda focused on understudied, potentially modifiable risk factors to improve the long-term health of LTRs. Our conceptual model accounts for cognitive function, caregiver and patient self-management skills, health behaviors, and patient-centered outcomes beyond mortality. We propose actionable health-system, patient, and caregiver-directed interventions to fill knowledge gaps and improve outcomes.
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Affiliation(s)
- Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | | | - Lisa VanWagner
- Division of Gastroenterology & Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.,Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Peter P Reese
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA.,Division of Renal Electrolyte and Hypertension, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Minjee Kim
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL.,Center for Circadian and Sleep Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.,Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michael S Wolf
- Division of General Internal Medicine & Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
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10
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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: 4] [Impact Index Per Article: 1.3] [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.
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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
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11
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Clément MA, Bosoi CR, Oliveira MM, Tremblay M, Bémeur C, Rose CF. Bile-duct ligation renders the brain susceptible to hypotension-induced neuronal degeneration: Implications of ammonia. J Neurochem 2021; 157:561-573. [PMID: 33382098 DOI: 10.1111/jnc.15290] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 12/11/2022]
Abstract
Hepatic encephalopathy (HE) is a debilitating neurological complication of cirrhosis. By definition, HE is considered a reversible disorder, and therefore HE should resolve following liver transplantation (LT). However, persisting neurological complications are observed in as many as 47% of LT recipients. LT is an invasive surgical procedure accompanied by various perioperative factors such as blood loss and hypotension which could influence outcomes post-LT. We hypothesize that minimal HE (MHE) renders the brain frail and susceptible to hypotension-induced neuronal cell death. Six-week bile duct-ligated (BDL) rats with MHE and respective SHAM-controls were used. Several degrees of hypotension (mean arterial pressure of 30, 60 and 90 mm Hg) were induced via blood withdrawal from the femoral artery and maintained for 120 min. Brains were collected for neuronal cell count and apoptotic analysis. In a separate group, BDL rats were treated for MHE with the ammonia-lowering strategy ornithine phenylacetate (OP; MNK-6105), administered orally (1 g/kg) for 3 weeks before induction of hypotension. Hypotension 30 and 60 mm Hg (not 90 mm Hg) significantly decreased neuronal marker expression (NeuN) and cresyl violet staining in the frontal cortex compared to respective hypotensive SHAM-operated controls as well as non-hypotensive BDL rats. Neuronal degeneration was associated with an increase in cleaved caspase-3, suggesting the mechanism of cell death was apoptotic. OP treatment attenuated hyperammonaemia, improved anxiety and activity, and protected the brain against hypotension-induced neuronal cell death. Our findings demonstrate that rats with chronic liver disease and MHE are more susceptible to hypotension-induced neuronal cell degeneration. This highlights MHE at the time of LT is a risk factor for poor neurological outcome post-transplant and that treating for MHE pre-LT might reduce this risk.
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Affiliation(s)
- Marc-André Clément
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | - Cristina R Bosoi
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | - Mariana M Oliveira
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | - Mélanie Tremblay
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | - Chantal Bémeur
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | - Christopher F Rose
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
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12
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Ko D, Bratzke LC. Cognitive Function in Liver Transplant Recipients Who Survived More Than 6 Months. Prog Transplant 2020; 30:335-341. [DOI: 10.1177/1526924820958144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Introduction: Current research in the areas of liver transplant and cognitive function has primarily examined cognitive changes from pre- to 1-year posttransplant, resulting in an insufficient understanding of cognitive trajectory beyond early periods of transplant and its impact on self-management. This study aimed (1) to describe global and domain-specific cognitive function in liver transplant recipients who survived more than 6 months after transplant and (2) to describe patient and clinical characteristics of recipients with impaired global and/or domain-specific cognitive function. Further, this study explored the potential relationships between cognitive function and self-management by examining differences in cognitive function by levels of self-management. Design: This secondary data analysis included 107 adult liver transplant recipients, who had a functioning transplant for at least 6 months. Data of cognitive function, demographic and clinical characteristics, and self-management were extracted for this study. T tests, Mann-Whitney tests, and Kruskal-Wallis tests were used to examine differences in cognitive function by variables. Results: More than half of the recipients had global cognitive impairment. Significant differences were found in global and domain-specific cognitive function. Older, male, married, or deceased donor recipients had lower cognitive test scores than younger, female, single, or living donor recipients. There were no significant differences in global and domain-specific cognitive function by time since transplant and levels of self-management. Discussion: Future longitudinal studies should examine the long-term trajectory of cognitive function posttransplant. Other factors such as caregivers’ participation in self-management should be accounted for in future studies when examining the relationship between cognitive function and self-management.
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Affiliation(s)
- Dami Ko
- School of Nursing, Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA
| | - Lisa C. Bratzke
- School of Nursing, University of Wisconsin-Madison, Madison, WI, USA
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13
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Abstract
PURPOSE OF REVIEW Liver transplantation (LT) remains the only way to cure patients with severe liver diseases. Important questions about neurological sequelae and quality of life after LT have emerged. In this review, we discuss the neurocognitive changes associated with LT and we conclude with recommendations in this regard for patients, caregivers, and physicians. RECENT FINDINGS Compared with other solid organ recipients, LT patients tend to have a higher incidence (up to 30%) of neurological complications post-LT. Even in absence of previous episodes of hepatic encephalopathy (HE), some patients display new onset of neurological symptoms post-LT, raising the concern about the role of other factors that may have a direct impact on cognitive function. SUMMARY Different mechanisms have been postulated to explain these postoperative neurological symptoms. They include sequelae of HE, persistent impairment of cognitive function due to cirrhosis, or postoperative decompensation of an unknown or undiagnosed neurodegenerative disorder.
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Affiliation(s)
- Somaya A. M. Albhaisi
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298-0341 USA
| | - Jasmohan S. Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA USA
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14
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Pflugrad H, Nösel P, Ding X, Schmitz B, Lanfermann H, Barg-Hock H, Klempnauer J, Schiffer M, Weissenborn K. Brain function and metabolism in patients with long-term tacrolimus therapy after kidney transplantation in comparison to patients after liver transplantation. PLoS One 2020; 15:e0229759. [PMID: 32155172 PMCID: PMC7064204 DOI: 10.1371/journal.pone.0229759] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 02/13/2020] [Indexed: 12/21/2022] Open
Abstract
Background About 50% of the patients 5–7 years after kidney transplantation show impairment of memory, attention and executive function. Tacrolimus frequently induces neurological complications in the first few weeks after transplantation. Furthermore, tacrolimus treatment is associated with impaired cognitive function in the long-term in patients after liver transplantation. We hypothesize that long-term tacrolimus therapy is associated with cognitive dysfunction and alterations of brain structure and metabolism in patients after kidney transplantation. Methods Twenty-one patients 10 years after kidney transplantation underwent cognitive testing, magnetic resonance imaging and whole brain 31-phosphor magnetic resonance spectroscopy for the assessment of brain function, structure and energy metabolism. Using a cross-sectional study design the results were compared to those of patients 1 (n = 11) and 5 years (n = 10) after kidney transplantation, and healthy controls (n = 17). To further analyze the share of transplantation, tacrolimus therapy and kidney dysfunction on the results patients after liver transplantation (n = 9) were selected as a patient control group. Results Patients 1 and 10 years after kidney transplantation (p = 0.02) similar to patients 10 years after liver transplantation (p<0.01) showed significantly worse cognitive function than healthy controls. In contrast to patients after liver transplantation patients after kidney transplantation showed significantly reduced adenosine triphosphate levels in the brain compared to healthy controls (p≤0.01). Patients 1 and 5 years after kidney transplantation had significantly increased periventricular hyperintensities compared to healthy controls (p<0.05). Conclusions Our data indicate that cognitive impairment in the long-term after liver and kidney transplantation cannot exclusively be explained by CNI neurotoxicity.
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Affiliation(s)
- Henning Pflugrad
- Department of Neurology, Hannover Medical School, Hannover, Germany
- Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
- * E-mail:
| | - Patrick Nösel
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Xiaoqi Ding
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Birte Schmitz
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Heinrich Lanfermann
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Hannelore Barg-Hock
- Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
- Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Mario Schiffer
- Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
- Clinic for Nephrology, Hannover Medical School, Hannover, Germany
| | - Karin Weissenborn
- Department of Neurology, Hannover Medical School, Hannover, Germany
- Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
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15
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Hopp AE, Dirks M, Petrusch C, Goldbecker A, Tryc AB, Barg-Hock H, Strassburg C, Klempnauer J, Weissenborn K, Pflugrad H. Hepatic Encephalopathy Is Reversible in the Long Term After Liver Transplantation. Liver Transpl 2019; 25:1661-1672. [PMID: 31437344 DOI: 10.1002/lt.25626] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 08/10/2019] [Indexed: 12/14/2022]
Abstract
Cognitive dysfunction caused by hepatic encephalopathy (HE) improves within the first year after liver transplantation (LT). However, cognitive restitution seems to be incomplete in a subset of patients and after LT a new-onset cognitive decline was described. Data about the longterm development of cognitive function after liver transplantation (LT) are sparse. This prospective study analyzed whether a history of hepatic encephalopathy (HE) before LT had an impact on the longterm outcome of cognitive function after LT and if patients who underwent LT 5 years earlier showed worse cognitive function than healthy controls. The cognitive function of 34 patients was assessed before LT and at 1 year and 5 years after LT by psychometric tests, including the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and the portosystemic encephalopathy syndrome test, which provides the psychometric hepatic encephalopathy score (PHES). Furthermore, patients completed surveys to assess health-related quality of life (HRQOL). An 22 additional patients were included after LT. Patients were subdivided by having a history of HE before LT. The control group consisted of 55 healthy patients adjusted for age and education. Before LT, patients performed significantly worse than controls in the psychometric tests: RBANS Total Scale (TS), mean ± standard deviation (SD), 92.6 ± 13.3 versus 99.9 ± 12.0, P = 0.01; and PHES, median (interquartile range [IQR]), 0 (-3 to 1) versus 1 (0-2), P < 0.001. At 1 year after LT, patients with a history of HE still showed cognitive impairment compared with controls: RBANS TS, mean ± SD, 89.8 ± 15.1 versus 99.9 ± 12.0, P < 0.01; and PHES, median (IQR), 0 (-2 to 1.25) versus 1 (0-2), P = 0.03. At 5 years after LT, patients with and without a history of HE showed normal cognitive function and improved HRQOL. In conclusion, HE-associated cognitive impairment seems to be reversible within 5 years after LT.
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Affiliation(s)
| | - Meike Dirks
- Department of Neurology, Hannover Medical School, Hannover, Germany.,Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
| | | | - Annemarie Goldbecker
- Department of Neurology, Hannover Medical School, Hannover, Germany.,Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
| | - Anita Blanka Tryc
- Department of Neurology, Hannover Medical School, Hannover, Germany.,Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
| | - Hannelore Barg-Hock
- Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Strassburg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany.,Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Karin Weissenborn
- Department of Neurology, Hannover Medical School, Hannover, Germany.,Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
| | - Henning Pflugrad
- Department of Neurology, Hannover Medical School, Hannover, Germany.,Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
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16
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Kornerup LS, Pflugrad H, Weissenborn K, Vilstrup H, Dam G. Cognitive impairment after liver transplantation: residual hepatic encephalopathy or posttransplant encephalopathy? Hepat Med 2019; 11:41-46. [PMID: 31040728 PMCID: PMC6456244 DOI: 10.2147/hmer.s144667] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Liver transplantation (LT) represents the definitive treatment for end-stage liver disease. Cognitive impairment following LT is frequent, referred to as postliver transplant encephalopathy (PLTE). LT removes the underlying chronic liver disease, and until recently hepatic encephalopathy (HE) was assumed to be fully reversible after LT. However, increasing evidence indicates that some degree of cognitive impairment may be present after LT. To which extent PLTE reflects cognitive impairment caused by residual HE (RHE) or the combined effect of other factors affecting brain function before, during, and after LT is not clarified. None of the available psychometric and neurophysiological tests used for detecting HE is shown to be able to distinguish between etiologies. The available, mostly retrospective, clinical studies indicate a high prevalence of abnormal psychometric tests after LT, and not all seem to recover completely. The patients with earlier HE show the most marked improvements, suggesting that the clinical picture of the early PLTE, in fact, represents RHE. Other early post-LT etiologies for PLTE comprise cerebral ischemia, critical illness encephalopathy, and immunosuppressive therapy. Late-onset etiologies comprise diabetes and hypertension, among others. PLTE regardless of etiology is a worrying issue and needs more attention in the form of mechanistic research, development of diagnostic/discriminative tools, and standardized prospective clinical studies.
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Affiliation(s)
- Linda Skibsted Kornerup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus N, Denmark
| | - Henning Pflugrad
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus N, Denmark
| | - Gitte Dam
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus N, Denmark
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17
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Weissenborn K. Minimal/Covert Hepatic Encephalopathy - Impact of Comorbid Conditions. J Clin Exp Hepatol 2019; 9:109-111. [PMID: 30765943 PMCID: PMC6363959 DOI: 10.1016/j.jceh.2018.08.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 08/31/2018] [Indexed: 12/12/2022] Open
Abstract
Mild cognitive dysfunction as in minimal or covert hepatic encephalopathy (HE) can be found in a variety of metabolic disturbances, several neurological diseases, and even older age. Because liver cirrhosis usually is accompanied by one or the other of these, a differentiation between HE and cognitive decline because of comorbidities is difficult. Somehow discriminating is the impairment of motor speed and accuracy, which is more prominent in HE than in any of the comorbidities. The observation that, for example, diabetes mellitus, renal dysfunction, infections, or hyponatremia as well as older age increase the risk of developing HE indicates the interaction between these factors and liver dysfunction in the development of HE and the necessity to adjust the therapy accordingly.
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Affiliation(s)
- Karin Weissenborn
- Address for correspondence: Karin Weissenborn, Clinic for Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany. Tel.: +49 511 532 2339; fax: +49 511 532 3115.
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18
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Ko D, Bratzke LC, Muehrer RJ, Brown RL. Self-management in liver transplantation. Appl Nurs Res 2018; 45:30-38. [PMID: 30683248 DOI: 10.1016/j.apnr.2018.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 10/15/2018] [Accepted: 11/05/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Self-management is crucial for liver transplant (LT) recipients to maintain transplants and optimize health outcomes. However, previous literature has been primarily limited to examining medication adherence; there is a knowledge gap regarding self-management in the LT population. AIM The aims of this study were to 1) comprehensively describe self-management behaviors and activities in LT recipients, 2) explore levels of overall self-management, and 3) explore the relationships of self-efficacy, cognition, and health information seeking behavior with self-management. METHODS Adult LT recipients (n = 113) who had a functioning transplant for at least 6 months participated in this cross-sectional, descriptive study. Participants were asked to identify self-management behaviors and rate their performance of those behaviors, including symptom management and medication adherence. They also completed a cognitive assessment and questionnaires measuring self-efficacy and health information seeking behavior. Descriptive statistics, latent profile analysis, and probit model for path analysis were used for the data analysis. RESULTS LT recipients acknowledged engaging in various self-management behaviors including symptom management, physical activity, maintenance of positive attitudes, and communication with healthcare providers. Three levels of self-management (i.e., low, medium, and high) were found; a high level of self-management was related to self-efficacy and health information seeking behavior. CONCLUSIONS The findings indicate that self-management may be improved with interventions aimed at increasing self-efficacy and health information seeking behavior. Findings from this study will inform future interventions, to improve self-management and subsequent health outcomes in this population. Future longitudinal studies are necessary to confirm the causality of the identified relationships.
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Affiliation(s)
- Dami Ko
- School of Nursing, University of Wisconsin-Madison, 701 Highland Ave., Madison, WI 53705, United States of America.
| | - Lisa C Bratzke
- School of Nursing, University of Wisconsin-Madison, 701 Highland Ave., Room 5127, Madison, WI 53705, United States of America.
| | - Rebecca J Muehrer
- School of Nursing, University of Wisconsin-Madison, 701 Highland Ave., Madison, WI 53705, United States of America
| | - Roger L Brown
- School of Nursing, University of Wisconsin-Madison, 701 Highland Ave., Room 4187, Madison, WI 53705, United States of America.
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19
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Zhang G, Cheng Y, Shen W, Liu B, Huang L, Xie S. The short-term effect of liver transplantation on the low-frequency fluctuation of brain activity in cirrhotic patients with and without overt hepatic encephalopathy. Brain Imaging Behav 2018; 11:1849-1861. [PMID: 27917450 DOI: 10.1007/s11682-016-9659-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Previous neuropsychological studies have demonstrated that liver transplantation (LT) is an effective method for improving the cognitive function of cirrhotic patients. However, the neural basis underlying the effects of LT is still unclear. Neuroimaging studies investigating changes in brain structures or functional networks mainly focus on patients without overt hepatic encephalopathy (HE). In this study, we recruited patients with and without overt HE and studied alterations in resting-state brain activity by quantizing the amplitude of low-frequency fluctuation (ALFF) before and 1 month after LT to study the short-term effect of LT in each group. Neuropsychological analyses indicated significant improvement of cognitive function in both groups. ALFF analysis showed that the brain activity in regions regulating motor function, vision, attention, and working memory were restored in both groups, reflecting the neuroplasticity of the brain. However, some persistent impairments and new-onset impairments in other regions related to these cognitive functions were observed in each group. Between-group comparison showed that although cognitive performance improved in both groups, the specific neural basis of LT in each group was different. The significant correlations of altered brain activity in regions showing LT and group effect with altered performance in neuropsychological and biochemical tests suggest a possible neuroimaging marker for the monitoring of short-term recovery of HE and the difference in individual recovery of cognitive performance. The findings in the present study help us further understand the neural effect of LT in patients with and without overt HE.
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Affiliation(s)
- Gaoyan Zhang
- School of Computer Science and Technology, Tianjin Key Laboratory of Cognitive Computing and Application, Tianjin University, Tianjin, 300350, People's Republic of China
| | - Yue Cheng
- Department of Radiology, Tianjin First Central Hospital, Fukang Road No. 24, Nankai District, Tianjin, 300192, People's Republic of China.
| | - Wen Shen
- Department of Radiology, Tianjin First Central Hospital, Fukang Road No. 24, Nankai District, Tianjin, 300192, People's Republic of China
| | - Baolin Liu
- School of Computer Science and Technology, Tianjin Key Laboratory of Cognitive Computing and Application, Tianjin University, Tianjin, 300350, People's Republic of China.,State Key Laboratory of Intelligent Technology and Systems, National Laboratory for Information Science and Technology, Tsinghua University, Beijing, 100084, People's Republic of China
| | - Lixiang Huang
- Department of Radiology, Tianjin First Central Hospital, Fukang Road No. 24, Nankai District, Tianjin, 300192, People's Republic of China
| | - Shuangshuang Xie
- Department of Radiology, Tianjin First Central Hospital, Fukang Road No. 24, Nankai District, Tianjin, 300192, People's Republic of China
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20
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Pflugrad H, Schrader AK, Tryc AB, Ding X, Lanfermann H, Jäckel E, Schrem H, Beneke J, Barg-Hock H, Klempnauer J, Weissenborn K. Longterm calcineurin inhibitor therapy and brain function in patients after liver transplantation. Liver Transpl 2018; 24:56-66. [PMID: 29156491 DOI: 10.1002/lt.24984] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 10/05/2017] [Accepted: 10/19/2017] [Indexed: 02/07/2023]
Abstract
Calcineurin inhibitors (CNIs) frequently induce neurological complications early after orthotopic liver transplantation (OLT). We hypothesize that longterm CNI therapy after OLT causes dose-dependent cognitive dysfunction and alteration of brain structure. In this study, 85 OLT patients (20 with CNI-free, 35 with CNI low-dose, and 30 with standard-dose CNI immunosuppression) underwent psychometric testing and cerebral magnetic resonance imaging approximately 10 years after OLT to assess brain function and structural brain alterations. A total of 33 healthy patients adjusted for age, sex, and education served as controls. Patients receiving CNI showed a significantly worse visuospatial/constructional ability compared with controls (P ≤ 0.04). Furthermore, patients on low-dose CNI therapy had an overall impaired cognitive function compared with controls (P = 0.01). The tacrolimus total dose and mean trough level were negatively correlated to cognitive function. CNI doses had been adjusted in 91% of the patients in the low-dose and CNI-free groups in the past due to CNI-induced kidney damage. Patients treated with CNI showed significantly more white matter hyperintensities (WMH) than patients on CNI-free immunosuppression and controls (P < 0.05). Both the mean cyclosporine A and tacrolimus trough levels correlated significantly with WMH. In conclusion, longterm CNI therapy carries a risk of cognitive dysfunction especially in patients who already showed nephrotoxic side effects indicating an increased susceptibility of these patients against toxic CNI effects. This subgroup of patients might benefit from a change to CNI-free immunosuppression. Liver Transplantation 24 56-66 2018 AASLD.
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Affiliation(s)
- Henning Pflugrad
- Departments of Neurology.,Integrated Research and Treatment Centre Transplantation
| | | | - Anita Blanka Tryc
- Departments of Neurology.,Integrated Research and Treatment Centre Transplantation
| | - Xiaoqi Ding
- Diagnostic and Interventional Neuroradiology
| | | | - Elmar Jäckel
- Gastroenterology, Hepatology and Endocrinology.,Integrated Research and Treatment Centre Transplantation
| | - Harald Schrem
- Core Facility Quality Management Transplantation.,Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jan Beneke
- Core Facility Quality Management Transplantation
| | - Hannelore Barg-Hock
- Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- Integrated Research and Treatment Centre Transplantation.,Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Karin Weissenborn
- Departments of Neurology.,Integrated Research and Treatment Centre Transplantation
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21
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Bajaj JS, Fagan A, Sikaroodi M, White MB, Sterling RK, Gilles H, Heuman D, Stravitz RT, Matherly SC, Siddiqui MS, Puri P, Sanyal AJ, Luketic V, John B, Fuchs M, Ahluwalia V, Gillevet PM. Liver transplant modulates gut microbial dysbiosis and cognitive function in cirrhosis. Liver Transpl 2017; 23:907-914. [PMID: 28240840 DOI: 10.1002/lt.24754] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 02/09/2017] [Accepted: 02/13/2017] [Indexed: 12/14/2022]
Abstract
Liver transplantation (LT) improves daily function and cognition in patients with cirrhosis, but a subset of patients can remain impaired. Unfavorable microbiota or dysbiosis is observed in patients with cirrhosis, but the effect of LT on microbial composition, especially with poor post-LT cognition, is unclear. The aims were to determine the effect of LT on gut microbiota and to determine whether gut microbiota are associated with cognitive dysfunction after LT. We enrolled outpatient patients with cirrhosis on the LT list and followed them until 6 months after LT. Cognition (Psychometric Hepatic Encephalopathy score [PHES]), health-related quality of life (HRQOL), and stool microbiota (multitagged sequencing for diversity and taxa) tests were performed at both visits. Persistent cognitive impairment was defined as a stable/worsening PHES. Both pre-/post-LT data were compared with age-matched healthy controls. We enrolled 45 patients (56 ± 7 years, Model for End-Stage Liver Disease score 26 ± 8). They received LT 6 ± 3 months after enrollment and were re-evaluated 7 ± 2 months after LT with a stable course. A significantly improved HRQOL, PHES, with increase in microbial diversity, increase in autochthonous, and decrease in potentially pathogenic taxa were seen after LT compared with baseline. However, there was continued dysbiosis and HRQOL/cognitive impairment after LT compared with controls in 29% who did not improve PHES after LT. In these, Proteobacteria relative abundance was significantly higher and Firmicutes were lower after LT, whereas the reverse occurred in the group that improved. Delta PHES was negatively correlated with delta Proteobacteria and positively with delta Firmicutes. In conclusion, LT improves gut microbiota diversity and dysbiosis compared with pre-LT baseline but residual dysbiosis remains compared with controls. There is cognitive and HRQOL enhancement in general after LT, but a higher Proteobacteria relative abundance change is associated with posttransplant cognitive impairment. Liver Transplantation 23 907-914 2017 AASLD.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia
| | - Andrew Fagan
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia
| | | | - Melanie B White
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia
| | - Richard K Sterling
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia
| | - HoChong Gilles
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia
| | - Douglas Heuman
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia
| | - Richard T Stravitz
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia
| | - Scott C Matherly
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia
| | - Mohammed S Siddiqui
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia
| | - Puneet Puri
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia
| | - Arun J Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia
| | - Velimir Luketic
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia
| | - Binu John
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia
| | - Michael Fuchs
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia
| | - Vishwadeep Ahluwalia
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia
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22
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Reiberger T, Trebicka J. New liver - Fresh microbiome: Implications on brain function. Liver Transpl 2017; 23:873-874. [PMID: 28509434 DOI: 10.1002/lt.24787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 05/09/2017] [Indexed: 01/13/2023]
Affiliation(s)
- Thomas Reiberger
- Department of Internal Medicine III Division of Gastroenterology and Hepatology Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Jonel Trebicka
- Department of Internal Medicine I, University of Bonn, Bonn, Germany.,European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.,Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Institute for Bioengineering of Catalonia, Barcelona, Spain
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23
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Nardelli S, Allampati S, Riggio O, Mullen KD, Prakash R, Gioia S, Unser A, White MB, Fagan AC, Wade JB, Farcomeni A, Gavis EA, Bajaj JS. Hepatic Encephalopathy Is Associated with Persistent Learning Impairments Despite Adequate Medical Treatment: A Multicenter, International Study. Dig Dis Sci 2017; 62:794-800. [PMID: 28039670 DOI: 10.1007/s10620-016-4425-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 12/16/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hepatic encephalopathy (HE) is considered reversible regarding mental status but may not be cognitively in single-center studies. AIM To evaluate persistence of learning impairment in prior HE compared to those who never experienced HE (no-HE) in a multicenter study. METHODS A total of 174 outpatient cirrhotics from three centers (94 Virginia, 30 Ohio, and 50 Rome; 36 prior HE) underwent psychometric hepatic encephalopathy score (PHES) and inhibitory control (ICT) testing at baseline and then at least 7 days apart. ICT learning (change in 2nd half lures compared to 1st half) was compared between patient groups at both visits. Change in the PHES individual sub-tests and total score between visits was compared in both groups. US versus Italian trends were also analyzed. RESULTS HE patients had worse PHES and ICT results compared to no-HE patients at baseline. Significant improvement (1st half 7.1 vs. 2nd half 6.2, p < 0.0001) was observed in no-HE, but not in HE (1st half 7.9 vs. 2nd half 7.8, p = 0.1) at baseline. At retesting (median 20 days later), no-HE patients continued with significant learning (1st half 6.0 vs. 2nd half 5.4, p < 0.0001), while HE patients again did not improve (1st half 7.8 vs. 2nd half 6.9, p = 0.37). Between visits, no-HE patients improved significantly on four PHES sub-tests and overall score, while HE patients only improved on two sub-tests with similar overall PHES score. Trends were similar between US and Italian subjects. CONCLUSION In this multicenter study, prior HE patients showed persistent significant learning impairment compared to those without prior HE, despite adequate medical therapy. This persistent change should increase efforts to reduce the first HE episode.
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Affiliation(s)
- Silvia Nardelli
- Division of Gastroenterology, Sapienza University of Rome, Rome, Italy
| | - Sanath Allampati
- Division of Gastroenterology, Metrohealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Oliviero Riggio
- Division of Gastroenterology, Sapienza University of Rome, Rome, Italy
| | - Kevin D Mullen
- Division of Gastroenterology, Metrohealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Ravi Prakash
- Division of Gastroenterology, Metrohealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Stefania Gioia
- Division of Gastroenterology, Sapienza University of Rome, Rome, Italy
| | - Ariel Unser
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, 23249, USA
| | - Melanie B White
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, 23249, USA
| | - Andrew C Fagan
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, 23249, USA
| | - James B Wade
- Department of Psychiatry, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Alessio Farcomeni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Edith A Gavis
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, 23249, USA
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, 23249, USA.
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24
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Ahluwalia V, Wade JB, White MB, Gilles HS, Heuman DM, Fuchs M, Gavis EA, Fagan A, Tinsley F, Ganapathy D, Thacker LR, Sterling RK, Stravitz RT, Puri P, Sanyal AJ, Siddiqui MS, Matherly S, Luketic V, Steinberg J, Moeller FG, Bajaj JS. Liver transplantation significantly improves global functioning and cerebral processing. Liver Transpl 2016; 22:1379-90. [PMID: 27339647 PMCID: PMC5036999 DOI: 10.1002/lt.24498] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 06/01/2016] [Accepted: 06/13/2016] [Indexed: 01/13/2023]
Abstract
The functional basis of cognitive and quality of life changes after liver transplant is unclear. We aimed to evaluate the neurometabolic and functional brain changes as modulators of cognition and quality of life after transplant in patients with cirrhosis who were with/without pretransplant cognitive impairment and hepatic encephalopathy (HE). Patients with cirrhosis underwent detailed cognitive and quality of life assessment at enrollment and 6 months after transplant. A subset underwent brain magnetic resonance imaging (functional magnetic resonance imaging [fMRI], diffusion tensor imaging [DTI], and magnetic resonance spectroscopy [MRS]) before and after transplant. Changes before and after transplant were analyzed in all patients and by dividing groups in those with/without pretransplant cognitive impairment or with/without pretransplant HE. MRS evaluated ammonia-related metabolites; fMRI studied brain activation for correct lure inhibition on the inhibitory control test; and DTI studied white matter integrity. Sixty-six patients (mean Model for End-Stage Liver Disease score, 21.8; 38 HE patients and 24 cognitively impaired [CI] patients) were enrolled. Quality of life was significantly worse in CI and HE groups before transplant, which improved to a lesser extent in those with prior cognitive impairment. In the entire group after transplant, there was (1) significantly lower brain activation needed for lure inhibition (shown on fMRI); (2) reversal of pretransplant ammonia-associated changes (shown on MRS); and (3) improved white matter integrity (shown on DTI). Importantly, study findings suggest that pretransplant cognitive impairment serves as a marker for clinical outcomes. Regardless of pretransplant history of HE, it was the pretransplant cognitive impairment that was predictive of both posttransplant cognitive and psychosocial outcomes. Therefore, when working with patients and their families, a clinician may rely on the pretransplant cognitive profile to develop expectations regarding posttransplant neurobehavioral recovery. We conclude that functional brain changes after liver transplant depend on pretransplant cognitive impairment and are ultimately linked with posttransplant cognition and quality of life in cirrhosis. Liver Transplantation 22 1379-1390 2016 AASLD.
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Affiliation(s)
- Vishwadeep Ahluwalia
- Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - James B Wade
- Psychiatry, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Melanie B White
- Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - HoChong S Gilles
- Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Douglas M Heuman
- Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Michael Fuchs
- Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Edith A Gavis
- Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Andrew Fagan
- Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | | | - Dinesh Ganapathy
- Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Leroy R Thacker
- Biostatistics, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Richard K Sterling
- Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - R Todd Stravitz
- Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Puneet Puri
- Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Arun J Sanyal
- Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Muhammad S Siddiqui
- Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Scott Matherly
- Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Velimir Luketic
- Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Joel Steinberg
- Psychiatry, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - F Gerard Moeller
- Psychiatry, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Jasmohan S Bajaj
- Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
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25
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Utility of pretransplant psychological measures to predict posttransplant outcomes in liver transplant patients: a systematic review. Gen Hosp Psychiatry 2016; 40:4-11. [PMID: 26947255 DOI: 10.1016/j.genhosppsych.2016.01.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 01/18/2016] [Accepted: 01/20/2016] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Evaluation of liver transplant (LT) candidacy involves psychosocial evaluation to ensure appropriate organ allocation. However, the utility of pre-LT psychiatric and neuropsychological factors in predicting posttransplant outcomes remains uncertain. We reviewed current evidence on the prognostic value of pre-LT psychological factors for outcomes after LT. METHOD We conducted a systematic review of studies with adult LT recipients that investigate the relationship between pre-LT psychiatric and neuropsychological variables and posttransplant outcomes. We searched Ovid, MEDLINE, PsycINFO, EMBASE/Scopus, Cochrane Controlled trials register and Web of Science (January 1975 to May 2015) for longitudinal, peer-reviewed studies of at least 20 subjects and written in English. RESULTS The 19 studies included in this review are heterogeneous in population, prognosis and duration of follow-up (from 20days to more than 3 years). Findings on the prognostic value of pre-LT depression or anxiety on post-LT outcomes are mixed, though depression appears to predict lower quality of life (QOL). Pre-LT suicidal thoughts in particular are associated with post-LT depression. High submissiveness may predict rejection within 20days of LT, and low conscientiousness is associated with greater nonadherence. Whereas pre-LT cognitive performance has not been shown to predict survival, poorer performance may predict poorer QOL after LT. CONCLUSION Further studies are needed to examine this important element of LT candidacy evaluation. Studies should evaluate psychiatric factors in large samples, include systematic evaluations by mental health clinicians and explore broader neuropsychological domains in predicting posttransplant outcomes.
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Abstract
PURPOSE OF REVIEW Psychiatrists and other mental health professionals typically assist with evaluating and treating psychiatric and behavioral issues in transplant candidates, recipients, and living organ donors. In this review recent findings on specific psychiatric issues in adult solid organ transplant candidates and recipients, as well as living donors are discussed as well as their relevance to clinical practice. RECENT FINDINGS Patients with complex mental health and addiction histories can have outcomes similar to patients without these disorders but may require specialized pretransplant preparation or posttransplant interventions to optimize their outcomes. Specific attention to the preparation and wellbeing of living donors is needed. SUMMARY As transplant programmes increasingly consider patients with complex mental health histories, psychiatrists, and mental health professionals evaluating and treating these patients need to consider plans for early identification and treatment. Psychiatric care provided across the preoperative to postoperative periods will best address the longitudinal care needs of patients with mental health disorders. Abstinence from substances and complete adherence to medical directives provides the best chance for optimal outcomes. Treatment of depression may improve transplant outcomes. Research is needed to identify effective interventions and the best strategies to engage patients to improve adherence. VIDEO ABSTRACT http://links.lww.com/YCO/A30.
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27
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Freudenreich O, Huffman JC, Sharpe M, Beach SR, Celano CM, Chwastiak LA, Cohen MA, Dickerman A, Fitz-Gerald MJ, Kontos N, Mittal L, Nejad SH, Niazi S, Novak M, Philbrick K, Rasimas JJ, Shim J, Simpson SA, Walker A, Walker J, Wichman CL, Zimbrean P, Söllner W, Stern TA. Updates in Psychosomatic Medicine: 2014. PSYCHOSOMATICS 2015; 56:445-59. [DOI: 10.1016/j.psym.2015.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 03/30/2015] [Accepted: 03/31/2015] [Indexed: 01/21/2023]
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28
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Long-and short-range functional connectivity density alteration in non-alcoholic cirrhotic patients one month after liver transplantation: A resting-state fMRI study. Brain Res 2015; 1620:177-87. [DOI: 10.1016/j.brainres.2015.04.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 04/14/2015] [Accepted: 04/17/2015] [Indexed: 02/08/2023]
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29
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Abstract
Minimal hepatic encephalopathy (mHE) is diagnosed in patients with severe liver disease but no clinical symptoms of encephalopathy if either neuropsychological or neurophysiological tests indicate cerebral dysfunction and other possible causes of brain dysfunction have been excluded. mHE is characterized by deficits in attention, visuospatial orientation, visuoconstructive abilities and motor function. Accordingly, mHE can be expected to interfere with a subject's working ability, especially in those occupations that require handiwork, and driving ability. Indeed, about 60% of blue-collar workers with mHE have been shown to be assessed as unfit for work compared to only 20% of white-collar workers, and about 50% of patients with mHE have been judged unfit to drive a car in several studies. mHE interferes with a patient's quality of life and is associated with an increased risk of developing overt HE as well as increased mortality. Whether mHE is of importance for cognitive function after liver transplantation has still to be clarified.
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30
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Abstract
PURPOSE OF REVIEW Successful outcomes in patient, graft survival, and quality of life depend on the prevention, early detection, and treatment of possible complications. The aim of the study was to highlight the common outcomes focusing on the unique features in children. Medical follow-up of children after liver transplantation includes monitoring of surgical complications: biliary and vascular, rejection, infections, posttransplant lymphoproliferative disease, other malignancies, recurrent disease, graft function, hypertension, diabetes, renal failure, among other conditions. The goal is to maintain normal graft function on minimal immunosuppression to avoid medication-induced side-effects. RECENT FINDINGS Recent findings include the importance of meticulous follow-up of Epstein-Barr virus and Cytomegalic virus viral load, leading to early diagnosis and improved prognosis, increased prevalence of renal toxicity, cognitive dysfunction, autoimmune, atopic and eosinophilic disease, oral hygiene and chronic hepatitis, and fibrosis of allografts. SUMMARY Caring for children after liver transplantation is extremely rewarding; however, careful attention must be paid to a variety of systems with understanding of the distinctiveness of pediatrics to assure optimal outcomes.
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31
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Aceto P, Perilli V, Lai C, Ciocchetti P, Vitale F, Sollazzi L. Postoperative cognitive dysfunction after liver transplantation. Gen Hosp Psychiatry 2015; 37:109-15. [PMID: 25550172 DOI: 10.1016/j.genhosppsych.2014.12.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 11/30/2014] [Accepted: 12/02/2014] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Postoperative cognitive dysfunction (POCD) in liver transplant (LT) recipients is defined as a "more than expected" postoperative deterioration in cognitive domains, including short-term and long-term memory, mood, consciousness and circadian rhythm. It is diagnosed, after exclusion of other neurological complications, by using specific neuropsychological tests that need preoperative baseline. The aim of this systematic review was to assess the prevalence of POCD after LT and to analyze patients' symptoms, type and timing of assessment used. METHODS PubMed, MEDLINE and The Cochrane Li-brary were searched up from January 1986 to August 2014. Study eligibility criteria are as follows: prospective and retrospective studies on human adult subjects describing prevalence of POCD and/or its sequelae after LT episodes were included. RESULTS Eighteen studies were identified. The timing of testing for POCD may vary between different studies and within the single study, ranging from 0.5 to 32 weeks. POCD occurs in up to 50% of LT recipient. CONCLUSION Future studies should be focused on detecting preoperative and intraoperative factors associated to POCD in order to carry out appropriate strategies aimed at reducing this disabling health condition. Relationship between POCD and long-term outcome needs to be investigated.
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Affiliation(s)
- Paola Aceto
- Department of Anesthesiology and Intensive Care, "A. Gemelli" Hospital, Rome, Italy.
| | - Valter Perilli
- Department of Anesthesiology and Intensive Care, "A. Gemelli" Hospital, Rome, Italy
| | - Carlo Lai
- Dynamic and Clinical Psychology Department, Sapienza University of Rome, Rome, Italy
| | - Pierpaolo Ciocchetti
- Department of Anesthesiology and Intensive Care, "A. Gemelli" Hospital, Rome, Italy
| | - Francesca Vitale
- Department of Anesthesiology and Intensive Care, "A. Gemelli" Hospital, Rome, Italy
| | - Liliana Sollazzi
- Department of Anesthesiology and Intensive Care, "A. Gemelli" Hospital, Rome, Italy
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