Chapter 30: Neurologic Events after Liver Transplantation

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

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

  • Chronic alcohol consumption

  • Hyponatremia

• Posttransplant factors:

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