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BACKGROUND

  • Neurologic complications after orthotopic liver transplantation are common, at rates reported between 9% and 42% higher than for other solid organ transplants.1

  • Although the principal risk factors for development of these events is the immunosuppressive neurotoxicity (mainly calcineurin inhibitors [CNIs]), other causes of this higher rate among liver transplant patients remains unknown.

  • Mostly occur within the first 6 months (early) after transplant.

  • Attempts in order to avoid these events are mandatory, mainly because they represent a major source of morbidity and mortality after liver transplantation.

THE TRANSPLANT EVALUATION TEAM

  • Neurologic events posttransplantation should be evaluated by a skilled multidisciplinary team, including the neurology team.

  • Risks, benefits, and the process from preoperative evaluation to postoperative evaluation and long-term follow-up should be reviewed with the patient (when appropriate) and the family/caregivers in each step in order to determine whether to proceed based on an informed decision.

CLASSIFICATION OF NEUROLOGIC EVENTS AFTER LIVER TRANSPLANTATION

  • Major neurologic events:

    • Confusional syndrome, encephalopathy

    • Depress level of consciousness

    • Akinetic mutism

    • Seizures (see Figs. 30-1 and 30-2A-D)

    • Speech disorders

    • Visual disturbances

    • Sensory or motor deficits.

    • Posterior reversible encephalopathy syndrome (PRES) (see Fig. 30-3)

  • Minor neurologic events:

    • Tremor

    • Headache

    • Insomnia

    • Paresthesia

FIGURE 30-1

A 20-year-old male received a transplant after acute liver failure. He presented with a major neurologic event (seizures) on day 6 postop. On EEG, the study showed normal results.

FIGURE 30-2

(A-D) MRI CNS scan—normal results. A 20-year-old male received a transplant after acute liver failure. He presented with a major neurologic event (seizures) on day 6 postop.

FIGURE 30-3

Posterior reversible leukoencephalopathy syndrome. CNS MRI scan—multiple areas of leukoencephalopathy are observed. A 59-year-old male cirrhotic patient received a transplant after acute on chronic liver failure. No immediate surgical complications were observed other than confusional syndrome. T2 FLAIR hyperintensities can be observed in the posterior circulation, mostly in the occipital lobes. The other lobes can also be involved, but to a lesser degree.

PATHOGENIC CAUSES OF NEUROLOGIC EVENTS

  • CNIs (tacrolimus, cyclosporine)

  • Surgical procedure complexity. Surgical ischemic times

  • Structural central nervous system (CNS) changes during the pretransplant period (e.g., chronic portosystemic encephalopathy)

  • Hypocholesterolemia before liver transplant related to liver insufficiency

  • Severe ascites

  • Chronic alcohol consumption

  • Metabolic disturbances before liver transplant (e.g., hyponatremia)

  • Differences between serum sodium levels immediately before liver transplant and up to 72 hours after liver transplant (defined as delta sodium) of ≥12 mEq/L

  • Hypomagnesemia and hypocalcemia after transplantation.

  • Other neurotoxic drugs

PREDICTIVE RISK FACTORS ASSOCIATED WITH NEUROLOGIC EVENTS

  • Pretransplant factors:

    • Recipient’s age

    • Hypocholesterolemia

    • Severe ascites

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