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Kang M, Koh HH, Kim DG, Yim SH, Choi MC, Min EK, Lee JG, Kim MS, Joo DJ. Clinical Impact and Risk Factors of Seizure After Liver Transplantation: A Nested Case-Control Study. Transpl Int 2024; 37:12342. [PMID: 38476214 PMCID: PMC10930032 DOI: 10.3389/ti.2024.12342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/19/2024] [Indexed: 03/14/2024]
Abstract
Seizures are a frequent neurological consequence following liver transplantation (LT), however, research on their clinical impact and risk factors is lacking. Using a nested case-control design, patients diagnosed with seizures (seizure group) within 1-year post-transplantation were matched to controls who had not experienced seizures until the corresponding time points at a 1:5 ratio to perform survival and risk factor analyses. Seizures developed in 61 of 1,243 patients (4.9%) at median of 11 days after LT. Five-year graft survival was significantly lower in the seizure group than in the controls (50.6% vs. 78.2%, respectively, p < 0.001) and seizure was a significant risk factor for graft loss after adjusting for variables (HR 2.04, 95% CI 1.24-3.33). In multivariable logistic regression, body mass index <23 kg/m2, donor age ≥45 years, intraoperative continuous renal replacement therapy and delta sodium level ≥4 mmol/L emerged as independent risk factors for post-LT seizure. Delta sodium level ≥4 mmol/L was associated with seizures, regardless of the severity of preoperative hyponatremia. Identifying and controlling those risk factors are required to prevent post-LT seizures which could result in worse graft outcome.
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Affiliation(s)
| | | | - Deok-Gie Kim
- Department of Surgery, The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
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2
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Khalid MB, Nagorna A, Rippel N, Ezaz G, Schiano TD, Crismale JF. Early neurologic complications after liver transplant are associated with reduced long-term survival and increased rates of rejection. Liver Transpl 2023; 29:1079-1088. [PMID: 37147847 DOI: 10.1097/lvt.0000000000000172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/28/2023] [Indexed: 05/07/2023]
Abstract
Neurologic complications (NCs) are common following liver transplantation (LT) and have been associated with impaired short-term survival. The impact of NC on long-term survival is less defined. We aimed to characterize these outcomes and assess for risk factors for post-LT NC. We performed a single-center, retrospective review of 521 patients with LT from 2016 to 2020. Baseline clinical and laboratory factors, intraoperative events, and outcomes were compared between patients with and without NC. The 5-year overall and rejection-free survival was estimated using the Kaplan-Meier analysis. Multivariable logistic regression assessed for an independent relationship between risk factors and the development of NC. Among 521 LT recipients, 24% experienced post-LT NC. Overall and rejection-free survival at 5 years was, respectively, 69% and 75% among those with NC versus 87% and 88% among those without NC (log-rank < 0.001). Among those who survived the first 3 months after LT, overall survival but not rejection-free survival was reduced among patients with NC. Risk factors for developing NC included peri-LT serum sodium (ΔSNa) ≥ 6 (29.4% vs. 20.5%, p = 0.04), grade 3 or 4 HE pre-LT, SNa < 125 pre-LT, and more intraoperative transfusions. In a multivariable logistic regression model controlling for described variables, SNa < 125 (or 0.21, 95% CI, 0.06-0.74) at LT and pre-LT HE grade 3 or 4 (or 0.45, 95% CI, 0.26-0.76) was independently associated with NC. Long-term survival was reduced among patients who developed NC in the immediate post-transplant period, even when censoring those who died in the first 3 months. Post-LT NC was associated with perioperative ΔSNa ≥ 6. Optimization of SNa pre-LT > 125 and limiting perioperative ΔSNa <6 mEq/L might have a beneficial impact in decreasing NC post-LT, which may improve long-term post-LT survival.
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Affiliation(s)
- Mian B Khalid
- Department of Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Agnieszka Nagorna
- Department of Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Noa Rippel
- Department of Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Ghideon Ezaz
- Recanati/Miller Transplantation Institute, Division of Liver Disease, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Thomas D Schiano
- Recanati/Miller Transplantation Institute, Division of Liver Disease, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - James F Crismale
- Recanati/Miller Transplantation Institute, Division of Liver Disease, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
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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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Kidney Replacement Therapy in Patients with Acute Liver Failure and End-Stage Cirrhosis Awaiting Liver Transplantation. Clin Liver Dis 2022; 26:245-253. [PMID: 35487608 DOI: 10.1016/j.cld.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Providing dialysis to patients with liver failure is challenging because of their tenuous hemodynamics and refractory ascites. With better machinery and increased availability, continuous kidney replacement therapy has been successfully delivered to acutely ill patients in liver failure over the past few decades. Intermittent hemodialysis continues to remain the modality of choice outside the intensive care unit and on occasion needs to be complemented with paracentesis. Peritoneal dialysis has not been widely used, but recent literature shows promising outcomes barring for publication bias. Albumin dialysis could be a lifesaving procedure for a carefully selected subgroup of patients with liver failure.
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Viticchi G, Falsetti L, Salvemini S, Bartolini M, Ranghino A, Buratti L, Silvestrini M. Headache changes after kidney transplant. Acta Neurol Belg 2022; 122:83-90. [PMID: 33687728 DOI: 10.1007/s13760-021-01637-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 02/22/2021] [Indexed: 11/25/2022]
Abstract
Headache is considered as a possible complication of dialytic treatment in chronic kidney disease (CKD). The aim of this study was to evaluate possible change in headache characteristics after kidney transplantation in patients with CKD. During a 1-year period, we enrolled 110 subjects submitted to a kidney transplant in the previous 5 years. Headache characteristics before and after the transplant were investigated by a specific questionnaire. Possible effects of pharmacological therapies were also evaluated. 65.5% of patients complained of headache before the transplant (38.2% migraine and 14.5% dialysis headache). After transplant, 53.6% of patients reported changes in headache characteristics. In particular, 27.3% of the patients had a complete resolution, 19.1% presented a headache improvement and 7.2% showed a worsening. In both migraine and dialysis headache subgroups, steroids, beta-blockers and calcium channel blockers were associated with a significant improvement of headache. Kidney transplantation seems to impact significantly headache frequency and severity in patients with CKD. A careful evaluation and use of targeted treatments could improve both patients' compliance to therapies and quality of life.
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Affiliation(s)
- Giovanna Viticchi
- Neurological Clinic, Marche Polytechnic University, Via Conca 1, 60020, Ancona, Italy.
| | - Lorenzo Falsetti
- Internal and Subintesive Medicine, Ospedali Riuniti Ancona, Ancona, Italy
| | - Sergio Salvemini
- Neurological Clinic, Marche Polytechnic University, Via Conca 1, 60020, Ancona, Italy
| | - Marco Bartolini
- Neurological Clinic, Marche Polytechnic University, Via Conca 1, 60020, Ancona, Italy
| | - Andrea Ranghino
- Nephrology, Dialysis and Kidney Transplant Unit, Ospedali Riuniti Ancona, Ancona, Italy
| | - Laura Buratti
- Neurological Clinic, Marche Polytechnic University, Via Conca 1, 60020, Ancona, Italy
| | - Mauro Silvestrini
- Neurological Clinic, Marche Polytechnic University, Via Conca 1, 60020, Ancona, Italy
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Danish A, Mughal SI, Zaidi U, Dildar S, Samad S, Jamal A, Sharif Z, Shamsi T. Frequency and Risk Factors of Cyclosporine-Induced Neurotoxicity in Allogeneic Stem Cell Transplant Recipients. Cureus 2021; 13:e19824. [PMID: 34963841 PMCID: PMC8696087 DOI: 10.7759/cureus.19824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 11/16/2022] Open
Abstract
Background and objective The calcineurin inhibitor cyclosporine A is routinely used for prophylaxis against graft-versus-host-disease (GvHD) in human leukocyte antigen (HLA)-matched allogeneic stem-cell transplant patients and is a major etiological factor for neuropathological symptoms that are reversible in most cases. In this study, we aimed to determine the frequency and risk factors of cyclosporine-induced neurotoxicity (CIN) in HLA-matched allogeneic stem cell transplant patients. Methods The study spanned the period from January 2016 to December 2019. Consecutive HLA-matched allogeneic stem-cell transplant patients of all ages were included in the study. Descriptive and risk factor analyses for the development of CIN with respect to age, sex, primary diagnosis, conditioning regimen, electrolyte abnormalities, and cyclosporine trough levels during the neurological episode were performed. Results A total of 106 HLA-matched patients with a median age of 6.3 years [interquartile range (IQR): 0.5-46 years], of which 37 (35%) were females, were included in the study. The mean cyclosporine trough level was 500 ±286 mg/dl. Neurological symptoms were found in 27 (26%) patients. A total of 14 (13%) patients were diagnosed with CIN. The frequency of other neurological symptoms included headache in 46 (43%), disorientation in 17 (16%), seizures in 12 (11%), visual disturbance in 11 (10%), and aphasia in seven (7%) patients. Posterior reversible encephalopathy syndrome (PRES) was found in six (6%) patients. All patients with CIN had hypertension and none had a fever. Multivariate logistic analysis showed that the presence of seizures [odds ratio (OR): 10.0, p<0.001] and the absence of fever (OR: 0.02, p<0.001) were associated with the diagnosis of CIN. Conclusion The prevalence of CIN is not uncommon (13%) in patients receiving cyclosporine for GvHD prophylaxis. Neurological complications, especially seizures, are common in CIN, and fever might indicate an alternative diagnosis. Prompt recognition of neurological signs and symptoms and early intervention can halt the progression of the disease.
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Saigal G, Ezuddin NS, Vega GDL. Neurologic Emergencies in Pediatric Patients Including Accidental and Nonaccidental Trauma. Neuroimaging Clin N Am 2018; 28:453-470. [DOI: 10.1016/j.nic.2018.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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8
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Lähteenmäki A, Höckerstedt K, Kajaste S, Huttunen M. Quality of life before and after liver transplantation: experiences with 7 patients with primary biliary cirrhosis in a 2-year follow-up. Transpl Int 2018. [DOI: 10.1111/tri.1992.5.s1.705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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9
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Lening C, Agopian VG, Busuttil RW, Liebeskind DS. Incidence, Etiology, and Outcomes of Altered Mental Status in the Perioperative Setting of Liver Transplantation. Neurohospitalist 2017; 8:124-128. [PMID: 29977442 DOI: 10.1177/1941874417738689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background We examined neurologic consultations for altered mental status in perioperative liver transplant patients to determine the overall incidence, to assess the presumed etiology and the data reviewed to determine that etiology, and to assess outcomes. Methods Retrospective chart review conducted for all 728 adult patients receiving orthotopic liver transplantation (OLT) between January 01, 2010, to June 30, 2014, with identification of 218 receiving neurology consults between 30 days pre-OLT and 90 days post-OLT, with review of all records necessary to determine initial findings and follow-up examination. Results Seventy-three consults for 69 patients were identified, with 27 felt to be altered since a procedure, 20 with sudden-onset altered mentation, and 26 with gradual or waxing-waning course. A single underlying etiology was identified in only 19 cases, with multiple factors involved in all others, with metabolic, toxic, infectious, and structural etiologies most often implicated. There was no statistically significant difference in outcome for those with altered mental status consults versus the total OLT population, though the sudden-onset presentation group did show significantly increased mortality rates. Conclusions This systematic study illustrates the variety of potential causes of altered mentation within the perioperative setting of liver transplantation. Workup including neuroimaging (preferably magnetic resonance imaging), infectious cultures, and expanded metabolic laboratory tests should be undertaken.
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Affiliation(s)
- Christopher Lening
- Department of Neurology, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Vatche G Agopian
- Division of Liver Transplantation, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Ronald W Busuttil
- Division of Liver Transplantation, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - David S Liebeskind
- Department of Neurology, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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Sato K, Kobayashi Y, Nakamura A, Fukushima D, Satomi S. Early post-transplant hyperbilirubinemia is a possible predictive factor for developing neurological complications in pediatric living donor liver transplant patients receiving tacrolimus. Pediatr Transplant 2017; 21. [PMID: 27804185 DOI: 10.1111/petr.12843] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2016] [Indexed: 11/29/2022]
Abstract
The cause of post-transplant CNI-NCs is multifactorial and not ascribed solely to CNI toxicity. A total of 90 children (aged <20 years) who underwent LDLT were evaluated to investigate the predictive factors associated with CNI-NCs. Twelve patients (13.3%) developed CNI-NCs after LDLT (age range, 2-15 years). The symptoms of CNI-NCs were seizures, VD, and stupor. The median onset of CNI-NCs was 10 days (range, 5-30 days) post-transplant. In the univariate analysis, higher recipient age at LDLT, donor age and recipient's BW, lower actual GV/SLV and TAC dosage/BW, and higher mean T-Bil and sodium level for 7 days after transplantation were independently significantly associated with TAC-NCs. Multivariate analysis showed that the T-Bil level in the first week after LDLT was the only significant independent predictive factor for TAC-NCs (HR, 1.588; 95% CI, 1.042-2.358; P=.031). In conclusion, CNI-NCs occurred most frequently in children over 5 years and were associated with hyperbilirubinemia for 7 days post-transplant, regardless of TAC levels. The transplant team should refer to a neurologist to define the diagnosis and to collaborate to resolve the neurological problems.
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Affiliation(s)
- Kazushige Sato
- Department of general medicine, Tosendo Hospital, Wakuya, Japan.,Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Yoshinobu Kobayashi
- Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Atsushi Nakamura
- Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Daizo Fukushima
- Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Susumu Satomi
- Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan
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Bican Demir A, Erer Özbek S, Bora I, Hakyemez B, Tırnova I, Kaya E. Two Cases With Developing Neurologic Complications After Liver Transplant. EXP CLIN TRANSPLANT 2015; 14:685-687. [PMID: 26643318 DOI: 10.6002/ect.2014.0204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The widespread use of immunosuppressive agents has significantly increased the rates of successful solid-organ and stem cell transplants, especially with liver and kidney. Cyclosporine and tacrolimus are most commonly used for this purpose. Although these agents have different mechanisms of action, both have various adverse effects, including nausea, vomiting, headache, hypertension, nephrotoxicity, and rarely epileptic seizures. In our first case, a patient presented with epileptic seizures and hemiparesis after a liver transplant, and posterior reversible encephalopathy syndrome related to cyclosporine toxicity was considered. Once cyclosporine levels in the blood decreased, the patient had both clinical and radiologic improvements. In our second case, a patient presented with delirium after a liver transplant. Again, when cyclosporine levels in the blood decreased, the patient showed improvement in clinical findings. Neurologic complications may develop after liver transplant, and these complications are encountered most frequently within the first postoperative month. Neurologic complications are multifactorial; insufficient graft function, intracranial bleeding, cerebral infarcts, infections, and immunosuppressive drug toxicity (tacrolimus and cyclosporine) may be considered among these factors. As shown in our presented cases, most neurologic complications can be successfully treated by correcting the underlying factor.
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Affiliation(s)
- Aylin Bican Demir
- Department of Neurology, Uludag University Faculty of Medicine, Bursa, Turkey
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Das SK, Sharma RK, Gupta A, Prasad N, Kaul A, Bhaduria D. Neurological complications in renal transplant patients: A single-center experience. INDIAN JOURNAL OF TRANSPLANTATION 2015. [DOI: 10.1016/j.ijt.2015.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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13
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Robuccio A, Ssentongo P, Sather MD, Claxton DF, Gilliam FG. Intractable myoclonic seizures in an allogeneic stem cell transplant recipient: A rare case of myoclonic epilepsy. EPILEPSY & BEHAVIOR CASE REPORTS 2015; 4:48-51. [PMID: 26288756 PMCID: PMC4536288 DOI: 10.1016/j.ebcr.2015.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 06/12/2015] [Accepted: 06/15/2015] [Indexed: 11/30/2022]
Abstract
Introduction Myoclonus may be a rare complication of stem cell transplant but has limited discussion in the scientific literature. Case We present a case of an acute myeloid leukemia survivor who developed refractory myoclonic epilepsy four years after graft versus host disease (GVHD) developed six days following matched unrelated allogeneic hematopoietic stem cell transplant. Discussion Graft versus host disease occurs in 30–50% of allogenic hematopoietic stem cell transplant patients and may cause pharmacoresistant myoclonic epilepsy; however, the mechanisms by which GVHD leads to recurrent myoclonic seizures are not well understood (Lee, 2005) [1]. The paucity of clinical reports of such manifestation makes it difficult to diagnose and effectively manage these patients.
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Affiliation(s)
- Anna Robuccio
- Center for Neural Engineering, Science and Mechanics, The Pennsylvania State University, University Park, PA 16802, USA ; Department of Engineering, Science and Mechanics, The Pennsylvania State University, University Park, PA 16802, USA
| | - Paddy Ssentongo
- Center for Neural Engineering, Science and Mechanics, The Pennsylvania State University, University Park, PA 16802, USA ; Department of Engineering, Science and Mechanics, The Pennsylvania State University, University Park, PA 16802, USA
| | - Michael D Sather
- Department of Neurosurgery, Penn State Hershey College of Medicine, 500 University Drive, Hershey, PA 17033, USA
| | - David F Claxton
- Penn State Cancer Institute, Penn State Hershey College of Medicine, 500 University Drive, Hershey, PA 17033, USA
| | - Frank G Gilliam
- Center for Neural Engineering, Science and Mechanics, The Pennsylvania State University, University Park, PA 16802, USA ; Department of Neurology, Penn State Hershey College of Medicine, 500 University Drive, Hershey, PA 17033, USA ; Department of Neurosurgery, Penn State Hershey College of Medicine, 500 University Drive, Hershey, PA 17033, USA
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Kim JM, Jung KH, Lee ST, Chu K, Roh JK. Central nervous system complications after liver transplantation. J Clin Neurosci 2015; 22:1355-9. [DOI: 10.1016/j.jocn.2015.03.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 03/01/2015] [Indexed: 12/25/2022]
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Hemin protects against hippocampal damage following orthotopic autologous liver transplantation in adult rats. Life Sci 2015; 135:27-34. [PMID: 26092480 DOI: 10.1016/j.lfs.2015.05.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 04/13/2015] [Accepted: 05/23/2015] [Indexed: 02/08/2023]
Abstract
AIMS Induction of heme oxygenase-1 (HO-1) has been widely accepted to be neuro-protective. This study aimed to examine whether hemin (a HO-1 inducer) attenuates neuronal damage in the hippocampus induced by orthotopic autologous liver transplantation (OALT) in adult rats. MAIN METHODS Rats were randomly allocated into four groups (n=8 each): (i) Sham control group; (ii) OALT model group; (iii) Hemin+OALT group, with intra-peritoneal (i.p.) injection of hemin (5 mg/kg) 24 hours (h) before the OALT; and (iv) ZnPP (a HO-1 inhibitor)+OALT group, with i.p. injection of ZnPP (32 mg/kg) 24h before the OALT. Twenty four hours after the surgery, the hippocampal tissues were collected for electron microscopic examination and terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) analysis. The levels of hippocampal HO-1 protein and serum S-100β, the concentrations of regional tumor necrosis factor-α (TNF-α) and interleukins (IL-6, IL-10), as well as the status of malondialdehyde (MDA), superoxide dismutase (SOD) and catalase (CAT) in the hippocampus were assessed. KEY FINDINGS Rats suffered severe neuronal damage in the hippocampus after OALT, mainly in apoptosis. Pre-treatment with hemin obviously alleviated the damage; up-regulated the HO-1 protein level; inhibited the release of TNF-α, IL-6 and MDA; and promoted the activities of SOD, CAT and IL-10; however, pre-treatment with ZnPP did not exhibit the opposite effect, except that a marked increase in serum S-100β level was detected. SIGNIFICANCE Hemin up-regulated the expression of HO-1 and attenuated hippocampal neuronal damage induced by OALT.
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Risk Factors for Central Pontine and Extrapontine Myelinolysis After Liver Transplantation. Transplantation 2015; 99:1257-64. [DOI: 10.1097/tp.0000000000000496] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Sørensen H, Grocott HP, Secher NH. Near infrared spectroscopy for frontal lobe oxygenation during non-vascular abdominal surgery. Clin Physiol Funct Imaging 2015; 36:427-435. [DOI: 10.1111/cpf.12244] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 02/20/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Henrik Sørensen
- Department of Anesthesia, Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - Hilary P. Grocott
- Department of Anesthesia & Perioperative Medicine; University of Manitoba; Winnipeg MB Canada
| | - Niels H. Secher
- Department of Anesthesia, Rigshospitalet; University of Copenhagen; Copenhagen Denmark
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Bémeur C, Butterworth RF. Reprint of: Nutrition in the Management of Cirrhosis and its Neurological Complications. J Clin Exp Hepatol 2015; 5:S131-40. [PMID: 26041952 PMCID: PMC4442848 DOI: 10.1016/j.jceh.2015.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 05/19/2013] [Indexed: 12/12/2022] Open
Abstract
Malnutrition is a common feature of chronic liver diseases that is often associated with a poor prognosis including worsening of clinical outcome, neuropsychiatric complications as well as outcome following liver transplantation. Nutritional assessment in patients with cirrhosis is challenging owing to confounding factors related to liver failure. The objectives of nutritional intervention in cirrhotic patients are the support of liver regeneration, the prevention or correction of specific nutritional deficiencies and the prevention and/or treatment of the complications of liver disease per se and of liver transplantation. Nutritional recommendations target the optimal supply of adequate substrates related to requirements linked to energy, protein, carbohydrates, lipids, vitamins and minerals. Some issues relating to malnutrition in chronic liver disease remain to be addressed including the development of an appropriate well-validated nutritional assessment tool, the identification of mechanistic targets or therapy for sarcopenia, the development of nutritional recommendations for obese cirrhotic patients and liver-transplant recipients and the elucidation of the roles of vitamin A hepatotoxicity, as well as the impact of deficiencies in riboflavin and zinc on clinical outcomes. Early identification and treatment of malnutrition in chronic liver disease has the potential to lead to better disease outcome as well as prevention of the complications of chronic liver disease and improved transplant outcomes.
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Key Words
- AAAs, aromatic amino acids
- BCAAs, branched-chain amino acids
- BMI, body mass index
- CNS, central nervous system
- CONUT, controlling nutritional status
- HE, hepatic encephalopathy
- ISHEN, International Society for Hepatic Encephalopathy and Nitrogen metabolism
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steato-hepatitis
- PNI, prognostic nutritional index
- complications
- hepatic encephalopathy
- liver disease
- liver transplantation
- nutritional status
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Affiliation(s)
- Chantal Bémeur
- Département de nutrition, Faculté de médecine, Université de Montréal, Montréal, Canada
- Unité de recherche en sciences neurologiques, Hôpital Saint-Luc (CHUM), Université de Montréal, Montréal, Canada
| | - Roger F. Butterworth
- Unité de recherche en sciences neurologiques, Hôpital Saint-Luc (CHUM), Université de Montréal, Montréal, Canada
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Park SE, Lee JY, Shin SJ, Kim CW, Kim SS. Cyclosporine-Induced Posterior Reversible Encephalopathy Syndrome in a Patient with Pemphigus Vulgaris. Ann Dermatol 2015; 27:454-6. [PMID: 26273167 PMCID: PMC4530161 DOI: 10.5021/ad.2015.27.4.454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 07/20/2014] [Accepted: 08/12/2014] [Indexed: 11/08/2022] Open
Affiliation(s)
- So Eun Park
- Department of Dermatology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Jin Yong Lee
- Department of Dermatology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Soo Jung Shin
- Department of Dermatology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Chul Woo Kim
- Department of Dermatology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Sang Seok Kim
- Department of Dermatology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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Bösche K, Weissenborn K, Christians U, Witzke O, Engler H, Schedlowski M, Hadamitzky M. Neurobehavioral consequences of small molecule-drug immunosuppression. Neuropharmacology 2014; 96:83-93. [PMID: 25529273 DOI: 10.1016/j.neuropharm.2014.12.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/05/2014] [Accepted: 12/08/2014] [Indexed: 12/29/2022]
Abstract
60 years after the first successful kidney transplantation in humans, transplant patients have decent survival rates owing to a broad spectrum of immunosuppressive medication available today. Not only transplant patients, but also patients with inflammatory autoimmune diseases or cancer benefit from these life-saving immunosuppressive and anti-proliferative medications. However, this success is gained with the disadvantage of neuropsychological disturbances and mental health problems such as depression, anxiety and impaired quality of life after long-term treatment with immunosuppressive drugs. So far, surprisingly little is known about unwanted neuropsychological side effects of immunosuppressants and anti-proliferative drugs from the group of so called small molecule-drugs. This is partly due to the fact that it is difficult to disentangle whether and to what extent the observed neuropsychiatric disturbances are a direct result of the patient's medical history or of the immunosuppressive treatment. Thus, here we summarize experimental as well as clinical data of mammalian and human studies, with the focus on selected small-molecule drugs that are frequently employed in solid organ transplantation, autoimmune disorders or cancer therapy and their effects on neuropsychological functions, mood, and behavior. These data reveal the necessity to develop immunosuppressive and anti-proliferative drugs inducing fewer or no unwanted neuropsychological side effects, thereby increasing the quality of life in patients requiring long term immunosuppressive treatment. This article is part of a Special Issue entitled 'Neuroimmunology and Synaptic Function'.
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Affiliation(s)
- Katharina Bösche
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital, Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany.
| | - Karin Weissenborn
- Department of Neurology, Hannover Medical School, 30625 Hannover, Germany
| | - Uwe Christians
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Oliver Witzke
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, 45122 Essen, Germany
| | - Harald Engler
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital, Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany
| | - Manfred Schedlowski
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital, Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany
| | - Martin Hadamitzky
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital, Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany.
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Sørensen H, Grocott HP, Niemann M, Rasmussen A, Hillingsø JG, Frederiksen HJ, Secher NH. Ventilatory strategy during liver transplantation: implications for near-infrared spectroscopy-determined frontal lobe oxygenation. Front Physiol 2014; 5:321. [PMID: 25202281 PMCID: PMC4142416 DOI: 10.3389/fphys.2014.00321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 08/04/2014] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND As measured by near infrared spectroscopy (NIRS), cerebral oxygenation (ScO2) may be reduced by hyperventilation in the anhepatic phase of liver transplantation surgery (LTx). Conversely, the brain may be subjected to hyperperfusion during reperfusion of the grafted liver. We investigated the relationship between ScO2 and end-tidal CO2 tension (EtCO2) during the various phases of LTx. METHODS In this retrospective study, 49 patients undergoing LTx were studied. Forehead ScO2, EtCO2, minute ventilation (VE), and hemodynamic variables were recorded from the beginning of surgery through to the anhepatic and reperfusion phases during LTx. RESULTS In the anhepatic phase, ScO2 was reduced by 4.3% (95% confidence interval: 2.5-6.0%; P < 0.0001), EtCO2 by 0.3 kPa (0.2-0.4 kPa; P < 0.0001), and VE by 0.4 L/min (0.1-0.7 L/min; P = 0.0018). Conversely, during reperfusion of the donated liver, ScO2 increased by 5.5% (3.8-7.3%), EtCO2 by 0.7 kPa (0.5-0.8 kPa), and VE by 0.6 L/min (0.3-0.9 L/min; all P < 0.0001). Changes in ScO2 were correlated to those in EtCO2 (Pearson r = 0.74; P < 0.0001). CONCLUSION During LTx, changes in ScO2 are closely correlated to those of EtCO2. Thus, this retrospective analysis suggests that attention to maintain a targeted EtCO2 would result in a more stable ScO2 during the operation.
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Affiliation(s)
- Henrik Sørensen
- Department of Anesthesia, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Hilary P. Grocott
- Department of Anesthesia and Perioperative Medicine, St. Boniface Hospital, University of ManitobaWinnipeg, MB, Canada
| | - Mads Niemann
- Department of Anesthesia, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Allan Rasmussen
- Department of Surgery and Transplantation, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Jens G. Hillingsø
- Department of Surgery and Transplantation, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Hans J. Frederiksen
- Department of Anesthesia, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Niels H. Secher
- Department of Anesthesia, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
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Bémeur C, Butterworth RF. Nutrition in the management of cirrhosis and its neurological complications. J Clin Exp Hepatol 2014; 4:141-50. [PMID: 25755550 PMCID: PMC4116712 DOI: 10.1016/j.jceh.2013.05.008] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 05/19/2013] [Indexed: 12/12/2022] Open
Abstract
Malnutrition is a common feature of chronic liver diseases that is often associated with a poor prognosis including worsening of clinical outcome, neuropsychiatric complications as well as outcome following liver transplantation. Nutritional assessment in patients with cirrhosis is challenging owing to confounding factors related to liver failure. The objectives of nutritional intervention in cirrhotic patients are the support of liver regeneration, the prevention or correction of specific nutritional deficiencies and the prevention and/or treatment of the complications of liver disease per se and of liver transplantation. Nutritional recommendations target the optimal supply of adequate substrates related to requirements linked to energy, protein, carbohydrates, lipids, vitamins and minerals. Some issues relating to malnutrition in chronic liver disease remain to be addressed including the development of an appropriate well-validated nutritional assessment tool, the identification of mechanistic targets or therapy for sarcopenia, the development of nutritional recommendations for obese cirrhotic patients and liver-transplant recipients and the elucidation of the roles of vitamin A hepatotoxicity, as well as the impact of deficiencies in riboflavin and zinc on clinical outcomes. Early identification and treatment of malnutrition in chronic liver disease has the potential to lead to better disease outcome as well as prevention of the complications of chronic liver disease and improved transplant outcomes.
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Key Words
- AAAs, aromatic amino acids
- BCAAs, branched-chain amino acids
- BMI, body mass index
- CNS, central nervous system
- CONUT, controlling nutritional status
- HE, hepatic encephalopathy
- ISHEN, International Society for Hepatic Encephalopathy and Nitrogen metabolism
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steato-hepatitis
- PNI, prognostic nutritional index
- complications
- hepatic encephalopathy
- liver disease
- liver transplantation
- nutritional status
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Affiliation(s)
- Chantal Bémeur
- Département de nutrition, Faculté de médecine, Université de Montréal, Montréal, Canada ; Unité de recherche en sciences neurologiques, Hôpital Saint-Luc (CHUM), Université de Montréal, Montréal, Canada
| | - Roger F Butterworth
- Unité de recherche en sciences neurologiques, Hôpital Saint-Luc (CHUM), Université de Montréal, Montréal, Canada
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Wijdicks EF, Hocker SE. Neurologic complications of liver transplantation. HANDBOOK OF CLINICAL NEUROLOGY 2014; 121:1257-66. [DOI: 10.1016/b978-0-7020-4088-7.00085-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
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Abstract
Neurologic complications are common side-effects of immunosuppressive medications used in the prevention of graft rejection after organ transplantation. The medications most commonly encountered include the calcineurin inhibitors and mycophenolate mofetil. Depression is the most commonly encountered neurotoxicity; however, severe but rare adverse neurological effects related to these therapies have been reported. Interferons, ribavirin, and protease inhibitors are therapeutic options commonly encountered in the treatment of hepatitis. Nucleoside analogs such as adefovir dipivoxil and entecavir carry significant risks for the development of lactic acidosis and hepatic dysfunction; however, most common adverse effects to these therapies in general are mild. While the mechanisms of action are poorly elucidated, they are discussed along with treatment strategies.
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Affiliation(s)
| | - Edward M Manno
- Neurological Intensive Care Unit, Cleveland Clinic, Cleveland, OH, USA.
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Morard I, Gasche Y, Kneteman M, Toso C, Mentha A, Meeberg G, Mentha G, Kneteman N, Giostra E. Identifying Risk Factors for Central Pontine and Extrapontine Myelinolysis After Liver Transplantation: A Case–Control Study. Neurocrit Care 2013; 20:287-95. [DOI: 10.1007/s12028-013-9928-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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26
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Chung I, Weber GM, Cuffy MC, Vedula G, Samstein B, Moitra VK. A 59-year-old woman who is awake yet unresponsive and stuporous after liver transplantation. Chest 2013; 143:1163-1165. [PMID: 23546491 DOI: 10.1378/chest.12-1498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Insung Chung
- Department of Anesthesiology and Critical Care Mount Sinai School of Medicine, Columbia University, New York, NY.
| | - Garret M Weber
- Department of Anesthesiology, Critical Care Division, Columbia University, New York, NY
| | - Madison C Cuffy
- Department of Surgery, Liver Transplantation Division, Columbia University, New York, NY
| | - Giridhar Vedula
- Department of Surgery, Liver Transplantation Division, Columbia University, New York, NY
| | - Benjamin Samstein
- Department of Surgery, Liver Transplantation Division, Columbia University, New York, NY
| | - Vivek K Moitra
- Department of Anesthesiology, Critical Care Division, Columbia University, New York, NY
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Bemeur C. Neurological complications post-liver transplantation: impact of nutritional status. Metab Brain Dis 2013; 28:293-300. [PMID: 23129292 DOI: 10.1007/s11011-012-9352-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 10/22/2012] [Indexed: 12/11/2022]
Abstract
Nutritional status is significantly altered in patients with end-stage liver disease (cirrhosis). Malnutrition is a common complication of cirrhosis and is known to be associated with a greater risk of post-operative complications and mortality, especially following liver transplantation. Neurological complications occur frequently after transplant and the nature and extent of these complications may relate to nutritional deficits such as protein-calorie malnutrition as well as vitamin and micronutrient deficiencies. A consensus document from the International Society on Hepatic Encephalopathy and Nitrogen metabolism (ISHEN) has been established in order to address these concerns. Careful assessment of nutritional status followed by prompt treatment of nutritional deficits has the potential to impact on transplant outcome and, in particular, on post-transplant neurological disorders in patients with cirrhosis.
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Affiliation(s)
- Chantal Bemeur
- Department of Nutrition, University of Montreal, Montreal, Québec, Canada.
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28
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Chavarria L, Cordoba J. Encephalopathy and liver transplantation. Metab Brain Dis 2013; 28:285-92. [PMID: 23154925 DOI: 10.1007/s11011-012-9350-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 10/22/2012] [Indexed: 12/11/2022]
Abstract
Liver transplantation (LT) candidates experience frequently episodic or persistent hepatic encephalopathy. In addition, these patients can exhibit neurological comorbidities that contribute to cognitive impairment in the pre-transplant period. Assessment of the respective contribution of hepatic encephalopathy or comorbidities in the cognitive manifestations is critical to estimate the neurological benefits of restoring liver function. Magnetic resonance imaging and spectroscopy are useful to assess the impact of liver failure or comorbidities. This assessment is critical to decide liver transplant in difficult cases. In the early postoperative period, LT is commonly complicated by a confusional syndrome. The possible role of persisting hepatic encephalopathy in its development has not been clearly established. The origin is usually considered multifactorial and relates to complications following LT, such as infections, rejection, primary liver dysfunction, immunosuppressors, etc.… The diagnosis and treatment is based in the recognition of comorbidities and optimal care of metabolic disturbances. Several studies have demonstrated recovery of cognitive function after LT in patients that have exhibited hepatic encephalopathy. However, some deficits may persist specifically among patients with persistent HE. Other factors present before LT that contribute to a worse neuropsychological outcome after LT are diabetes mellitus and alcohol consumption. Long-term after LT, cognitive function may worsen in relation to vascular risk factors.
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Abstract
OBJECTIVE We studied neurological complications (NCs) after liver transplantation (LT) in children. METHODS We performed an institutional review board-approved retrospective review of patients with LT ≤21 years during a period of 30 years (1980-2010). NCs were classified as early (within 3 months post-LT) and delayed (beyond 3 months post-LT). RESULTS Of 65 children with LT, 20 (30.7%) had NCs; 16 were girls. Mean age was 11.8±5.9 years. Early NCs were found in 13.8% (9/65) of the patients: seizures in 7 and encephalopathy in 2. Abnormal neuroimaging findings were posterior reversible leukoencephalopathy syndrome (1), intracranial hemorrhage (1), mild cerebral edema (1), and bilateral basal ganglia T1W hyperintensities in magnetic resonance imaging (1). On follow-up, there were 3 deaths (unrelated to NCs). One with intracranial hemorrhage had residual hemiparesis and was taking a long-term antiepileptic drug. Late NCs are found in 16.9% (11/65) of the patients: seizures in 4, headache in 4, encephalopathy in 3 (1 had seizures in addition), and paresthesias caused by possible small-fiber neuropathy in 1. Abnormal neuroimaging findings were hypoxic-ischemic encephalopathy (1), encephalomalacia caused by old hemorrhage (1), and hyperintensity of the posterior periventricular white matter in magnetic resonance imaging (1). On follow-up, all of the patients survived; 1 had papilledema with secondary optic atrophy requiring optic nerve sheath fenestration and 1 needed long-term antiepileptic drug. CONCLUSIONS NCs are common in children after LT, seizures being the most common. In contrary to the previous studies, we found delayed complications more often than early complications. Early detection and appropriate management of NCs is important.
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30
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Vizzini G, Asaro M, Miraglia R, Gruttadauria S, Filì D, D'Antoni A, Petridis I, Marrone G, Pagano D, Gridelli B. Changing picture of central nervous system complications in liver transplant recipients. Liver Transpl 2011; 17:1279-85. [PMID: 21770016 DOI: 10.1002/lt.22383] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Central nervous system (CNS) complications are common after liver transplantation (LT). According to the literature, the most common causes are infections and the neurotoxicity of immunosuppressive drugs (cyclosporine and tacrolimus). The aim of this study was to evaluate the incidence, clinical presentations, etiologies, and outcomes of CNS complications in a series of 395 consecutive LT recipients whose immunosuppression regimen was designed for low tacrolimus blood levels. An analysis of the 12-hour trough concentrations of tacrolimus in the study population showed that the target drug levels, which were designed to maintain minimal immunosuppression, were usually achieved. In all, 64 patients (16.2%) developed major neurological symptoms (37 within 30 days of LT). None of the observed CNS complications were caused by infections (viral, bacterial, or fungal), and only 3 of the 395 patients (0.8%) received a diagnosis of tacrolimus-related leukoencephalopathy. Cerebrovascular disease was identified in 15 patients (3.8%; 8 had cerebral hemorrhages, 5 had ischemic strokes, and 2 had subdural hemorrhages). Pontine myelinolysis was found in 2 patients (0.5%). Notably, no clear cause was identified for the remaining 44 cases (11.1%): brain imaging was negative for 22 cases, and diffuse hypoxic changes were present for the other 22. CNS complications were significantly associated with a reduction in 3-month patient survival (88.8% versus 95.4%) and 5-year patient survival (57.3% versus 84.1%). Among the pretransplant variables that were analyzed, the incidence of portosystemic encephalopathy, the peak serum bilirubin levels, and the lowest serum total cholesterol levels were significantly different between the 64-patient group with CNS complications and the asymptomatic group of 331 patients.
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Affiliation(s)
- Giovanni Vizzini
- Mediterranean Institute for Transplantation and High Specialization Therapies, University of Pittsburgh Medical Center in Italy, Palermo, Italy.
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Yilmaz M, Cengiz M, Sanli S, Yegin A, Mesci A, Dinckan A, Hadimioglu N, Dosemeci L, Ramazanoglu A. Neurological Complications after Liver Transplantation. J Int Med Res 2011; 39:1483-9. [DOI: 10.1177/147323001103900437] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
This was a single-centre, prospective study to assess the frequency of neurological complications and their impact on prolonged hospitalization in 137 liver transplant patients presenting between September 1997 and June 2010. Neurological complications were seen in 22 (16%) patients during their postoperative stay in the intensive care unit. Complications included new-onset, recurrent headache (five patients), generalized seizures (four patients), dysarthria (two patients), delirium with agitation (three patients), persistent flapping tremor (two patients), alteration in level of consciousness (three patients), central pontine myelinolysis (one patient), myopathy (one patient) and visual hallucinations (one patient). Seizures were associated with immunosuppressive drug toxicity (tacrolimus). Myopathy presenting as quadriplegia was diagnosed by muscle biopsy. The patient with central pontine myelinolysis lived in a persistent vegetative state for 2 years and died of pneumonia. In conclusion, neurological complications are frequently encountered after liver transplantation, and are an important cause of severe morbidity and prolonged intensive care unit and hospital stay.
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Affiliation(s)
- M Yilmaz
- Department of Anaesthesiology and Intensive Care Medicine, Akdeniz University, Antalya, Turkey
| | - M Cengiz
- Department of Anaesthesiology and Intensive Care Medicine, Akdeniz University, Antalya, Turkey
| | - S Sanli
- Department of Anaesthesiology and Intensive Care Medicine, Akdeniz University, Antalya, Turkey
| | - A Yegin
- Department of Anaesthesiology and Intensive Care Medicine, Akdeniz University, Antalya, Turkey
| | - A Mesci
- Department of Surgery, School of Medicine, Akdeniz University, Antalya, Turkey
| | - A Dinckan
- Department of Surgery, School of Medicine, Akdeniz University, Antalya, Turkey
| | - N Hadimioglu
- Department of Anaesthesiology and Intensive Care Medicine, Akdeniz University, Antalya, Turkey
| | - L Dosemeci
- Anaesthesiology and ICU, Medicalpark Hospital Complex, Antalya, Turkey
| | - A Ramazanoglu
- Department of Anaesthesiology and Intensive Care Medicine, Akdeniz University, Antalya, Turkey
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Pustavoitau A, Bhardwaj A, Stevens R. Analytic Review: Neurological Complications of Transplantation. J Intensive Care Med 2011; 26:209-22. [DOI: 10.1177/0885066610389549] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Recipients of solid organ or hematopoietic cell transplants are at risk of life-threatening neurological disorders including encephalopathy, seizures, infections and tumors of the central nervous system, stroke, central pontine myelinolysis, and neuromuscular disorders—often requiring admission to, or occurring in, the intensive care unit (ICU). Many of these complications are linked directly or indirectly to immunosuppressive therapy. However, neurological disorders may also result from graft versus host disease, or be an expression of the underlying disease which prompted transplantation, as well as injury induced during radiation, chemotherapy, surgery, and ICU stay. In rare cases, neuroinfectious pathogens may be transmitted with the transplanted tissue or organ. Diagnosis may be a challenge because clinical symptoms and findings on neuroimaging lack specificity, and a biological specimen or tissue diagnosis is often needed for definitive diagnosis. Management is centered on preventing further neurological injury, etiology-targeted therapy, and balancing the benefits and toxicities of specific immunosuppressive agents.
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Affiliation(s)
- Aliaksei Pustavoitau
- Departments of Anesthesiology Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anish Bhardwaj
- Departments of Neurology and Neurological Surgery, Tufts University School of Medicine, Boston, MA, USA,
| | - Robert Stevens
- Departments of Anesthesiology Critical Care Medicine, Neurology, Neurosurgery, and Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Desideri F, Marignani M, Vanovermeire O, Colle I, Delle Fave G, Hemelsoet D, Geerts A, Van Vlierberghe H. Moyamoya disease as a possible cause of neurological impairment following liver transplantation for Wilson's disease. Hepatol Res 2011; 41:282-6. [PMID: 21338457 DOI: 10.1111/j.1872-034x.2010.00764.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
In Wilson's disease, liver transplantation can constitute the only option for patients presenting with fulminant hepatic failure or decompensated liver disease unresponsive to drug therapy. We report the case of a 29-year-old woman receiving a liver transplant for end-stage Wilson's disease who developed neurological complications after transplantation. After an accurate evaluation of possible differential causes of neurological complications developing as the result of liver transplantation, moyamoya disease was diagnosed. Moyamoya disease is a rare cerebrovascular disease of unknown etiology. However, data exist supporting a possible role for some immunosuppressive regimens in determining the peculiar vascular alterations observed in moyamoya disease. To the best of our knowledge, the association with post-transplantation state for Wilson's disease has not been previously described.
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Affiliation(s)
- Federico Desideri
- Digestive and Liver Disease Department, S. Andrea Hospital, II Medical School, University "Sapienza", Rome, Italy Departments of Vascular and Interventional Radiology Faculty of Medicine and Health Sciences, Hepatology and Gastroenterology Neurology, Laboratory for Clinical and Experimental Neurophysiology, Ghent University, Ghent, Belgium
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Klawitter J, Gottschalk S, Hainz C, Leibfritz D, Christians U, Serkova NJ. Immunosuppressant neurotoxicity in rat brain models: oxidative stress and cellular metabolism. Chem Res Toxicol 2010; 23:608-19. [PMID: 20148532 DOI: 10.1021/tx900351q] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Coadministration of the calcineurin inhibitor cyclosporine (CsA) and the mTOR inhibitors sirolimus (SRL) or everolimus (RAD) increases the efficacy of immunosuppression after organ transplantation. Neurotoxicity of CsA is a major clinical problem. Our goal was to assess the effects of CsA, SRL, and RAD on brain cell metabolism. The studies included the comparison of immunosuppressant-mediated effects on glucose metabolism, energy production, and reactive oxygen species (ROS) formation in perfused rat brain slices, primary rat astrocytes, and C6 glioma cells. In brain slices and astrocytes, CsA inhibited Krebs cycle metabolism, while activating anaerobic glycolysis, most likely to compensate for the inhibition of mitochondrial energy production. SRL and RAD inhibited cytosolic glycolysis but did not cause changes in mitochondrial energy production. CsA + SRL inhibited Krebs cycle and glycolysis, thus reducing the ability of the cell to compensate for the negative effects of CsA on mitochondrial nucleoside triphosphate synthesis. In contrast to SRL at the concentrations tested, RAD reduced the CsA-induced ROS formation and antagonized CsA-induced effects on glucose and energy metabolism. Surprisingly, in C6 cells, SRL and RAD exposure resulted in high ROS concentrations without significant impairment of cell metabolism. Our results suggested that SRL enhances CsA-induced ROS formation and negative metabolic effects in brain cells, while RAD seems to antagonize the CsA effects. However, the three models showed different metabolic responses when challenged with the study drugs. In contrast to SRL, RAD enhances ROS formation in C6 glioma cells but has only minor effects on normal rat brain tissue.
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Affiliation(s)
- Jelena Klawitter
- Clinical Research & Development, Department of Anesthesiology, and University of Colorado Cancer Center, University of Colorado Denver, Aurora, Colorado 80045, USA.
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A Long-Term Study of Changes in the Volume of Brain Ventricles and White Matter Lesions After Successful Liver Transplantation. Transplantation 2010; 89:589-94. [DOI: 10.1097/tp.0b013e3181ca7bb3] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Campagna F, Biancardi A, Cillo U, Gatta A, Amodio P. Neurocognitive-neurological complications of liver transplantation: a review. Metab Brain Dis 2010; 25:115-24. [PMID: 20204483 DOI: 10.1007/s11011-010-9183-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Accepted: 01/28/2010] [Indexed: 12/20/2022]
Abstract
Neurological complications are common after liver transplantation (LT) and they are associated with a significant morbidity. Long-term effects of LT on cognitive and psychological outcomes are not clear. The objective of this study was to summarize the present knowledge on the neurological and cognitive complications of LT, resulting from a systematic review of the literature in the last 10 years. Several studies have investigated the incidence and the pathophysiology of neurological complications; in contrast, the knowledge of cognitive and psychological status after LT is poor. Currently, the effect of LT on mental performance is debated. Some studies have shown an improvement of cognitive function after OLTX and, at the same time, a persistence of different cognitive deficits. In addition, the quality of life (QoL) and the psychological status after LT seem to improve but LT recipients have significant deficiencies in most QoL domains. Consequently, future studies are necessary in order to investigate cognitive alterations and QoL in LT recipients.
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Affiliation(s)
- Francesca Campagna
- Department of Clinical and Experimental Medicine, University of Padova, Clinica Medica 5, Via Giustiniani, 35128, Padova, Italy.
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Goralczyk AD, Meier V, Ramadori G, Obed A, Lorf T. Acute paranoid psychosis as sole clinical presentation of hepatic artery thrombosis after living donor liver transplantation. BMC Surg 2010; 10:7. [PMID: 20175918 PMCID: PMC2836309 DOI: 10.1186/1471-2482-10-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Accepted: 02/22/2010] [Indexed: 11/10/2022] Open
Abstract
Background Hepatic artery thrombosis is a devastating complication after orthotopic liver transplantation often requiring revascularization or re-transplantation. It is associated with considerably increased morbidity and mortality. Acute cognitive dysfunction such as delirium or acute psychosis may occur after major surgery and may be associated with the advent of surgical complications. Case presentation Here we describe a case of hepatic artery thrombosis after living-donor liver transplantation which was not preceded by signs of liver failure but rather by an episode of acute psychosis. After re-transplantation the patient recovered without sequelae. Conclusion This case highlights the need to remain cautious when psychiatric disorders occur in patients after liver transplantation. The diagnostic procedures should not be restricted to medical or neurological causes of psychosis alone but should also focus vascular complications related to orthotopic liver transplantation.
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Affiliation(s)
- Armin D Goralczyk
- Department of General and Visceral Surgery, University Medical Center Göttingen, Göttingen, Germany.
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Rebora AE, Regesta G. Reversible posterior leukoencephalopathy: a possible threat for psoriatic patients treated with biological agents. J Eur Acad Dermatol Venereol 2010; 24:97-8. [PMID: 20050291 DOI: 10.1111/j.1468-3083.2009.03317.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Cyclosporine A reduces dendritic outgrowth of neuroblasts in the subgranular zone of the dentate gyrus in C57BL/6 mice. Neurochem Res 2009; 35:465-72. [PMID: 19856205 DOI: 10.1007/s11064-009-0082-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2009] [Indexed: 10/20/2022]
Abstract
In the present study, we observed the effects of cyclosporine A (CsA), an efficient immunosuppressant, on cell proliferation and neuroblast differentiation in the subgranular zone of the dentate gyrus (SZDG) in normal C57BL/6 mice using Ki67 and doublecortin (DCX) immunohistochemical staining, respectively. At 8 weeks of age, vehicle (physiological saline) or CsA was daily administered (40 mg/kg, i.p.) for 1 week. Animals were sacrificed at 2 weeks after last administration. CsA treatment did not show any influences in neurons, astrocytes and microglia based on immunohistochemistry for its markers, respectively. However, in the CsA-treated group, Fluoro-Jade B, a marker for neurodegeneration, positive cells were found in the SZDG, not in the vehicle-treated group. In the vehicle-treated group, Ki67 immunoreactive (+) nuclei were clustered in the SZDG, whereas in the CsA-treated group Ki67(+) nuclei were scattered in the SZDG, showing no difference in cell numbers. Numbers of DCX(+) neuroblasts with well-developed processes (tertiary dendrites) were much lower in the CsA-treated group than those in the vehicle-treated group; however, numbers of DCX(+) neuroblasts with secondary dendrites were similar in both the groups. These results suggest that CsA significantly reduces dendritic outgrowth and complexity from neuroblasts in the SZDG without any affecting in neurons, astrocytes and microglia in normal mice.
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Saner FH, Gensicke J, Olde Damink SWM, Pavlaković G, Treckmann J, Dammann M, Kaiser GM, Sotiropoulos GC, Radtke A, Koeppen S, Beckebaum S, Cicinnati V, Nadalin S, Malagó M, Paul A, Broelsch CE. Neurologic complications in adult living donor liver transplant patients: an underestimated factor? J Neurol 2009; 257:253-8. [PMID: 19727899 PMCID: PMC2910891 DOI: 10.1007/s00415-009-5303-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Revised: 08/08/2009] [Accepted: 08/18/2009] [Indexed: 02/06/2023]
Abstract
Liver transplantation is the only curative treatment in patients with end-stage liver disease. Neurological complications (NC) are increasingly reported to occur in patients after cadaveric liver transplantation. This retrospective cohort study aims to evaluate the incidence and causes of NC in living donor liver transplant (LDLT) patients in our transplant center. Between August 1998 and December 2005, 121 adult LDLT patients were recruited into our study. 17% of patients experienced NC, and it occurred significantly more frequently in patients with alcoholic cirrhosis (42%) and autoimmune hepatitis (43%) as compared with patients with hepatitis B or C (9/10%, P = 0.013). The most common NC was encephalopathy (47.6%) followed by seizures (9.5%). The choice of immunosuppression by calcineurin inhibitor (Tacrolimus or Cyclosporin A) showed no significant difference in the incidence of NC (19 vs. 17%). The occurrence of NC did not influence the clinical outcome, since mortality rate, median ICU stay and length of hospital stay were similar between the two groups. Most patients who survived showed a nearly complete recovery of their NC. NCs occur in approximately 1 in 6 patients after LDLT and seem to be predominantly transient in nature, without major impact on clinical outcome.
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Affiliation(s)
- Fuat Hakan Saner
- Department of General-, Visceral- and Transplant Surgery, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany.
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Maggioni F, Mantovan MC, Rigotti P, Cadrobbi R, Mainardi F, Mampreso E, Ermani M, Cortelazzo S, Zanchin G. Headache in kidney transplantation. J Headache Pain 2009; 10:455-60. [PMID: 19711000 PMCID: PMC3476211 DOI: 10.1007/s10194-009-0148-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Accepted: 07/30/2009] [Indexed: 01/06/2023] Open
Abstract
The aim of this retrospective study was to determine the relevance of the symptom “headache” in kidney transplanted patients, since few studies have considered headache as a clinically significant complication in this condition. A total of 83 consecutive kidney transplant patients underwent to neurological examination and a detailed headache history was taken. The headache history considered the period before kidney disease, during renal failure, during dialysis treatment and after transplantation. Diagnosis was made according to International Headache Criteria (ICDH-II) (2004). Our results reveal an occurrence of headache after kidney transplantation in 44.5% of the patients, which is higher than rates reported for the general population and in the only specific comparable study on liver transplant patients. These data suggest the need for prospective studies to explore the causal mechanisms by which headache develops with frequency in kidney transplant patients, and in particular to determine the role of immunosuppressive therapy.
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Affiliation(s)
- Ferdinando Maggioni
- Headache Centre, Department of Neurosciences, University of Padua, Via Giustiniani, 5, 35128 Padua, Italy.
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Friedman D, Claassen J, Hirsch LJ. Continuous electroencephalogram monitoring in the intensive care unit. Anesth Analg 2009; 109:506-23. [PMID: 19608827 DOI: 10.1213/ane.0b013e3181a9d8b5] [Citation(s) in RCA: 186] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Because of recent technical advances, it is now possible to record and monitor the continuous digital electroencephalogram (EEG) of many critically ill patients simultaneously. Continuous EEG monitoring (cEEG) provides dynamic information about brain function that permits early detection of changes in neurologic status, which is especially useful when the clinical examination is limited. Nonconvulsive seizures are common in comatose critically ill patients and can have multiple negative effects on the injured brain. The majority of seizures in these patients cannot be detected without cEEG. cEEG monitoring is most commonly used to detect and guide treatment of nonconvulsive seizures, including after convulsive status epilepticus. In addition, cEEG is used to guide management of pharmacological coma for treatment of increased intracranial pressure. An emerging application for cEEG is to detect new or worsening brain ischemia in patients at high risk, especially those with subarachnoid hemorrhage. Improving quantitative EEG software is helping to make it feasible for cEEG (using full scalp coverage) to provide continuous information about changes in brain function in real time at the bedside and to alert clinicians to any acute brain event, including seizures, ischemia, increasing intracranial pressure, hemorrhage, and even systemic abnormalities affecting the brain, such as hypoxia, hypotension, acidosis, and others. Monitoring using only a few electrodes or using full scalp coverage, but without expert review of the raw EEG, must be done with extreme caution as false positives and false negatives are common. Intracranial EEG recording is being performed in a few centers to better detect seizures, ischemia, and peri-injury depolarizations, all of which may contribute to secondary injury. When cEEG is combined with individualized, physiologically driven decision making via multimodality brain monitoring, intensivists can identify when the brain is at risk for injury or when neuronal injury is already occurring and intervene before there is permanent damage. The exact role and cost-effectiveness of cEEG at the current time remains unclear, but we believe it has significant potential to improve neurologic outcomes in a variety of settings.
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Affiliation(s)
- Daniel Friedman
- Department of Neurology, Comprehensive Epilepsy Center, Columbia University, NewYork City, New York, USA
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Donmez FY, Guvenc Z, Emiroglu FK, Coskun M, Haberal M. Evaluation of neurological complications in pediatric liver transplant recipients: MRI versus CT. J Child Neurol 2009; 24:656-63. [PMID: 19168829 DOI: 10.1177/0883073808329531] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
With the aim of guiding choice of the best imaging modality for specific clinical conditions, we retrospectively evaluated neuroradiological findings in pediatric liver transplant recipients with neurological complications. Computed tomography (CT) was used to examine 31 patients with acute neurological symptoms after liver transplantation, and magnetic resonance imaging (MRI) was used for 35 such patients. A total of 16 patients belonged to both groups. Headache was the most common symptom in patients with computed tomography; seizure was most common among patients with magnetic resonance imaging. Magnetic resonance imaging detected additional abnormalities in 5 patients presenting with seizures whose computed tomography results were normal or insufficient to explain the clinical picture. In conclusion, liver transplant recipients with seizure should undergo magnetic resonance imaging emergently when possible; omitting computed tomography. Choice of imaging modality should be directed by nature of symptoms and time interval between transplantation and symptom onset.
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Near-Infrared Spectroscopy for Evaluation of Cerebral Autoregulation During Orthotopic Liver Transplantation. Neurocrit Care 2009; 11:235-41. [DOI: 10.1007/s12028-009-9226-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Accepted: 04/21/2009] [Indexed: 10/20/2022]
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Saner FH, Nadalin S, Radtke A, Sotiropoulos GC, Kaiser GM, Paul A. Liver transplantation and neurological side effects. Metab Brain Dis 2009; 24:183-7. [PMID: 19139982 DOI: 10.1007/s11011-008-9119-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Accepted: 10/28/2008] [Indexed: 02/07/2023]
Abstract
Advances in liver transplantation (LT), particularly in immunosuppression and intensive care treatment have had increased the number of long-term survivors following liver transplantation. In order of more long-term survivors, reports about neurological complication following liver transplantation are increasing. Neurological complications are not uncommon in liver transplant recipients, which contribute to a longer ICU- and in-hospital stay. Every effort should be focused on early detection to prevent the patient from this life-threatening event, which is often associated with poor life quality.
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Affiliation(s)
- Fuat H Saner
- Department of General-, Visceral and Transplant Surgery, University Hospital Essen, Hufelandstr. 55, 45122 Essen, Germany.
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Posterior reversible encephalopathy syndrome (PRES) induced by cyclosporine use in a patient with collapsing focal glomeruloesclerosis. Int Urol Nephrol 2008; 40:1095-8. [DOI: 10.1007/s11255-008-9431-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2008] [Accepted: 06/30/2008] [Indexed: 10/21/2022]
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Perioperative neurological complications after liver transplantation are best predicted by pre-transplant hepatic encephalopathy. Neurocrit Care 2008; 8:253-8. [PMID: 17928960 DOI: 10.1007/s12028-007-9020-4] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Liver transplant (LT) recipients are at significant risk for the development of neurological complications, such as altered mental status and seizures, in the postoperative period. Identifying accurate predictors of these events may allow optimal selection and preparation of candidates, and minimize risk after transplantation. METHODS One hundred and one consecutive adult LT recipients were evaluated retrospectively for neurological morbidity occurring in the first 30 days postoperatively. These events were analyzed in relation to specific predictive variables including preoperative complications of liver failure, such as hepatic encephalopathy (HE). RESULTS Median age was 50 years, 63% were male and hepatitis C was the most common indication for LT (n = 36). Median Child-Pugh score was 9 with 45% being Class C. Over half (n = 52) had experienced clinical HE prior to LT, while one quarter (n = 26) were encephalopathic at the time of LT. Neurological complications occurred in 31 patients in the postoperative period, with encephalopathy occurring in 28 and seizures occurring in 4; drug toxicity was responsible for neurological morbidity in 12 patients (39%). Length of hospital stay was significantly prolonged (median 19 vs. 12 days, P = 0.005) and all mortality (n = 3) occurred in those with neurological complications. There was no association between etiology of liver failure and complications; logistic regression identified active preoperative HE as the strongest predictor of postoperative morbidity (OR 10.7 95% CI 3.8-29.9). CONCLUSION Neurological events, manifesting most often as encephalopathy, occurred in almost one-third of patients after LT. Those suffering from HE at the time of LT may be more vulnerable to the metabolic stresses of surgery and the neurotoxicity of the drugs used, and were at highest risk for such complications.
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Updates in the Management of Seizures and Status Epilepticus in Critically Ill Patients. Neurol Clin 2008; 26:385-408, viii. [DOI: 10.1016/j.ncl.2008.03.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Sato Y, Onaka T, Kobayashi E, Seo N. The Differential Effect of Cyclosporine on Hypnotic Response and Pain Reaction in Mice. Anesth Analg 2007; 105:1489-93, table of contents. [DOI: 10.1213/01.ane.0000286173.60987.72] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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