Severe acute polyneuropathy complicating orthotopic liver allograft failure

Intensive Care Unit-Acquired Weakness after Liver Transplantation: Analysis of Seven Cases and a Literature Review

Intensive Care Unit (ICU)-Acquired Weakness (ICU-AW) is a generalized muscle weakness that is clinically detected in critical patients and has no plausible etiology other than critical illness. ICU-AW is uncommon in patients undergoing orthotopic liver transplantation (OLT). Our report sheds light on the highest number of ICU-AW cases observed in a single center on OLT patients with early allograft dysfunction. Out of 282 patients who underwent OLT from January 2015 to June 2023, 7 (2.5%) developed generalized muscle weakness in the ICU and underwent neurophysiological investigations. The neurologic examination showed preserved extraocular, flaccid quadriplegia with the absence of deep tendon reflexes in all patients. Neurophysiological studies, including electromyography and nerve conduction studies, showed abnormalities with fibrillation potentials and the rapid recruitment of small polyphasic motor units in the examined muscles, as well as a reduced amplitude of the compound muscle action potential and sensory nerve action potential, with an absence of demyelinating features. Pre-transplant clinical status was critical in all patients. During ICU stay, early allograft dysfunction, acute kidney injury, prolonged mechanical ventilation, sepsis, hyperglycemia, and high blood transfusions were observed in all patients. Two patients were retransplanted. Five patients were alive at 90 days; two patients died. In non-cooperative OLT patients, neurophysiological investigations are essential for the diagnosis of ICU-AW. In this setting, the high number of red blood cell transfusions is a potential risk factor for ICU-AW.

Beatmung bei neuromuskulären Erkrankungen

Neuromuskuläre Erkrankungen betreffen das erste und zweite Motoneuron, die peripheren Nerven, die neuromuskulären Übertragung und die Muskelzelle. Es handelt sich um eine heterogene Gruppe von erblichen, degenerativen und autoimmunen Erkrankungen. Eine korrekte diagnostische Einordnung ist erforderlich, da zentralnervöse, kardiale, endokrine und weitere Begleitsymptome vorliegen können und für einige Erkrankungen bereits medikamentöse Therapien zur Verfügung stehen. Neuromuskuläre Erkrankungen haben eine große Bedeutung in der neuromuskulären Beatmungsmedizin. Die respiratorische Symptomatik resultiert in der Regel aus Paresen der am Atmen, Schlucken oder Husten beteiligten Muskulatur mit konsekutiver ventilatorischer Insuffienz, Dysphagie bis hin zur Speichelaspiration und Sekretretention. Mittels eines strukturierte Sekretmanagements und einer effektive nichtinvasive oder invasive Beatmungstherapie können neuromuskuläre Patienten viele Jahre mit guter Lebensqualität überleben. Themen dieses Kapitels sind ein Überblick über die neuromuskulären Erkrankungen, die Indikationen und Strategien der nichtinvasiven und der invasiven Beatmung und eine ausführliche Darstellung beatmungsmedizinisch besonders relevanter neuromuskulärer Erkrankungen wie der amyotrophe Lateralsklerose, des Guillain-Barré-Syndroms, der Myasthenia gravis und der Critical-Illness-Polyneuropathie/-Myopathie.

Diagnosis of Critical Illness Myopathy After Liver Transplantation and Muscle Condition Monitoring: A Case Report

BACKGROUND

Intensive care unit-acquired weakness (ICUAW) can occur after liver transplantation. Early diagnosis of ICUAW and monitoring of muscle condition during rehabilitation are helpful in improving functional recovery.

METHODS AND MATERIALS

A 47-year-old man with liver cirrhosis developed limb weakness after liver transplantation. The patient had a Medical Research Council sum score of 2 weeks post-liver transplantation with marked proximal limb weakness. Direct muscle stimulation was performed on the right tibialis anterior muscle; the nerve-to-muscle ratio of compound muscle action potentials was 0.96, which indicated critical illness myopathy. Fatigue analysis using surface electromyography was performed 4 times after liver transplantation.

RESULTS AND CONCLUSIONS

The maximal voluntary contraction tended to increase during rehabilitation, whereas the percentage of maximal voluntary contraction tended to decrease, indicating that muscle strength was increased. The fatigue index gradually decreased, showing that muscle endurance had improved along with strength. Muscle fatigue can be evaluated during rehabilitation using surface electromyography to prevent damage of the impaired muscle and to control exercise intensity. Early diagnosis of ICUAW and evaluation of muscle fatigue during rehabilitation will ensure a better prognosis for patients with ICUAW.

Efficacy of early passive tilting in minimizing ICU-acquired weakness: A randomized controlled trial

Purpose

To investigate whether passive tilting added to a standardized rehabilitation therapy improved strength at Intensive Care Unit (ICU) discharge.

Material and methods

This single-center trial included patients admitted to an adult surgical ICU and ventilated for at least 3 days. Patients were randomized to daily standardized rehabilitation therapy alone or with tilting on a table for at least 1 h. The primary outcome was the Medical Research Council (MRC) sum score at ICU discharge. Muscular recovery was a secondary outcome.

Results

Of 145 included patients, 125 received mobilization, 65 in the Tilt group and 60 in the Control group. Total mobilization duration (median [25th–75th percentiles]) in the Tilt group was 1020 [580–1695] versus 1340 [536–2775] minutes in the Control group (p = 0.313). MRC sum scores at ICU discharge were not significantly different between groups (Tilt, 50 [45–56] versus 48 [45–54]; p = 0.555). However, the number of patients with weakness was higher in the Tilt group at baseline (Tilt: 60/65 versus 48/60, p = 0.045) and muscular recovery was better in the Tilt group (p = 0.004).

Conclusions

Passive tilting added to a standardized rehabilitation therapy did not improve muscle strength at ICU discharge in surgical patients even if a faster recovery with tilting is suggested.

Tacrolimus-related polyneuropathy: case report and review of the literature

Patients, in particular recipients of orthotopic liver transplants, receiving the immunosuppressant tacrolimus (FK-506), are at risk for developing central neurotoxic adverse events. We report the occurrence of a tacrolimus-induced peripheral neurotoxic event, i.e. pure motor axonal polyneuropathy of the lower limbs in a 44-year-old woman, 9 days after combined orthotopic liver and pancreas transplantation. She was treated for 5 days with intravenous immunoglobulins. Partial recovery followed over months to years. An overview of all 11 reported FK506-associated polyneuropathies is given.

[Neuromuscular complications in transplant recipients]

Neuromuscular complications in transplant recipients are common and contribute to morbidity and mortality. Complications such as acute and chronic inflammatory demyelinating polyneuropathies and toxic myopathies are related to the changes in immune modulation that occur after transplantation or result from immunosuppressive treatment toxicity. Alternatively, other complications such as myositis, myasthenia gravis, and mononeuropathy multiplex may result from a dysimmune systemic disorder such as post-transplant lymphoproliferative disorder, graft-versus-host disease or hepatitis C virus or hepatitis B virus chronic infection. Lastly, some of these complications, e.g., compression or stretch of individual nerves or plexus, are commonly seen in a postoperative setting and are not specific of patients with organ transplantation. This review focuses on the characteristic features, management, prognosis and pathophysiology of common and immune-related neuromuscular complications in organ transplant recipients.

EFNS guidelines on management of neurological problems in liver transplantation

Neurological impairment after orthotopic liver transplantation (OLT) is common and represents a major source of morbidity and mortality. The diagnosis and management of neurological problems occurring after OLT are difficult and evidence-based guidelines for this task are currently lacking. A Task Force was set up under the auspices of the European Federation of Neurological Societies to devise guidelines to prevent and manage neurological problems in OLT. We selected six major neurological problems and approached them combining an evidence-based scientific literature analysis with a search of consensus by means of a Delphi process. Search results were translated into a series of recommendations constituting a basis for better care of patients with neurological complications after OLT.

Polyradiculonévrite chronique chez des patients avec une greffe d’organe solide : une étude clinique, neurophysiologique et neuropathologique de 4 cas

INTRODUCTION

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) rarely develops in patients with solid organ transplantation.

PATIENTS AND METHOD

We describe the clinical, biological, electrophysiological and neuropathological features of 4 patients with solid organ transplantation who developed CIDP. Two patients had liver transplantation, one had kidney transplantation and one had lung transplantation.

RESULTS

All 4 patients developed in the months following transplantation a syndrome that fulfilled criteria for definite CIDP. All patients had immunosuppressive therapy, with ciclosporin + prednisolone in 2 cases, tacrolimus in 1 case and azathioprine + prednisolone + ciclosporin in one case. One patient had chronic HCV and HBV infection. Treatment with intravenous immune globulin (IVIG) and/or a change in immunosuppressive therapy improved the neuropathy in all cases.

CONCLUSION

CIDP is a rare and potentially treatable condition that should be considered in all patients with solid organ transplantation who develop a rapidly disabling sensorimotor polyneuropathy.

Acute quadriplegia complicating critical illness polyneuropathy in a patient with infective endocarditis: a case report

A 75-year-old woman with infective endocarditis developed critical illness polyneuropathy (CIP) with quadriplegia after cardiac surgery. The quadriplegia resolved gradually after aggressive treatment of the underlying infection and with rehabilitation. However, a MEDLINE search of the English-language literature failed to yield results matching quadriplegia and infective endocarditis. CIP is a complication of septic syndrome and sepsis. This complication has been largely unrecognized in intensive care units owing to difficulties in performing a clinical examination or electrophysiologic studies. Difficulty in weaning from the ventilator is an important early manifestation of CIP. Electroneuromyography (ENMG) should be routinely performed to establish the diagnosis. We suggest that any septic patients with unexplained muscle weakness, paralysis, or difficulty in weaning from the ventilator should be evaluated for CIP.

Chronic inflammatory demyelinating polyradiculoneuropathy in patients with liver transplantation

We report two patients with orthotopic liver transplantation (OLT) who developed a syndrome that fulfilled criteria for definite chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). One patient had OLT because of alcoholic cirrhosis and one following hepatitis C-induced hepatic failure. Both had immunosuppressive therapy, with cyclosporine and prednisolone in one case and tacrolimus in the other case. Treatment with intravenous immune globulin (IVIG) significantly improved the neuropathy in both patients. In patients with OLT developing disabling sensorimotor neuropathies, CIDP should be considered as should the use of potentially beneficial immunosuppressive treatment.