Brain MRI findings in acute hepatic encephalopathy in liver transplant recipients

Histopathological examination of characteristic brain MRI findings in acute hyperammonemic encephalopathy: A case report and review of the literature

INTRODUCTION

Acute hyperammonemic encephalopathy is associated with distinct brain MRI findings, namely, hyperintensity in T2-weighted sequences as well as restricted diffusion in diffusion-weighted imaging with accentuation in the insular cortex and cingulate gyrus. The pathophysiology and the histopathological correlates of these characteristic MRI findings are largely unknown.

CASE REPORT

We present a 57-year-old male with a history of chronic alcohol abuse, liver cirrhosis and portal hypertension, and a clinical syndrome (variceal bleeding, depression of consciousness, seizures), elevated plasma ammonia levels, and characteristic brain MRI abnormalities suggestive of acute hyperammonemic encephalopathy. A postmortem histopathological examination revealed extensive hypoxic ischemic encephalopathy without evidence for metabolic encephalopathy. No episodes of prolonged cerebral hypoxemia were documented throughout the course of the disease. We conducted a review of the literature, which exhibited no reports of hyperammonemic encephalopathy in association with characteristic brain MRI findings and a consecutive histopathological examination.

CONCLUSION

This is the first report of a patient with acute hyperammonemic encephalopathy together with characteristic brain MRI findings and a histopathological correlation. Although characteristic MRI findings of acute hyperammonemic encephalopathy were present, a histopathological examination revealed only hypoxic pathology without signs of metabolic encephalopathy.

Altered Mental Status in the Solid-Organ Transplant Recipient

Patients undergoing solid-organ transplantation (SOT) face a tumultuous journey. Prior to transplant, their medical course is characterized by organ dysfunction, diminished quality of life, and reliance on organ support, all of which are endured in hopes of reaching the haven of organ transplantation. Peritransplant altered mental status may indicate neurologic insults acquired during transplant and may have long-lasting consequences. Even years after transplant, these patients are at heightened risk for neurologic dysfunction from a myriad of metabolic, toxic, and infectious causes. This review provides a comprehensive examination of causes, diagnostic approaches, neuroimaging findings, and management strategies for altered mental status in SOT recipients. Given their complexity and the numerous etiologies for neurologic dysfunction, liver transplant patients are a chief focus in this review; however, we also review lesser-known contributors to neurological injury across various transplant types. From hepatic encephalopathy to cerebral edema, seizures, and infections, this review highlights the importance of recognizing and managing pre- and posttransplant neurological complications to optimize patient outcomes.

Neurologic Manifestations of Gastrointestinal and Nutritional Disorders

OBJECTIVE

A tie between nutritional or gastrointestinal and neurologic disease has been recognized for centuries. Many gastrointestinal disorders are associated with neurologic disease through nutritional, immune-mediated, or degenerative pathophysiologies. This article reviews neurologic disorders in patients with gastrointestinal disease and gastrointestinal manifestations in their own neurologic patients.

LATEST DEVELOPMENTS

Development of new gastric and bariatric surgical procedures and the widespread use of over-the-counter gastric acid-reducing medications continue to create vitamin and nutritional deficiencies despite modern diet and supplementation. Some supplements, such as vitamin A, vitamin B6, and selenium, themselves are now found to cause disease. Recent work has shown extraintestinal and neurologic manifestations of inflammatory bowel disease. Chronic brain damage in liver disease has been recognized, and the opportunity to intervene may exist in the covert beginning stages. The characterization of gluten-related neurologic symptoms and differentiation from those of celiac disease is an evolving body of work.

ESSENTIAL POINTS

Gastrointestinal and neurologic diseases related to common immune-mediated, degenerative, or infectious mechanisms are common and can coexist in the same patient. Furthermore, gastrointestinal disease may cause neurologic complications because of nutritional inadequacies, malabsorption, and hepatic dysfunction. In many cases, the complications are treatable but have subtle or protean presentations. Therefore, the consulting neurologist must be current in knowledge of the growing ties between gastrointestinal and neurologic disease.

Pediatric Wilson disease presenting as acute liver failure: Prognostic indices

BACKGROUND

Acute liver failure (ALF) can be a primary presentation of Wilson disease (WD). Mortality rates are high in WD with ALF (WDALF). Predictions of mortality in WDALF vary by model and are sometimes contradictory, perhaps because few patients are studied or WD diagnoses are questionable.

AIM

To determine the outcomes among well-documented WDALF patients and assess mortality model performance in this cohort.

METHODS

We reviewed the medical records of our pediatric WDALF patients (n = 41 over 6-years-old, single-center retrospective study) and compared seven prognostic models (King’s College Hospital Criteria, model for end-stage liver disease/pediatric end-stage liver disease scoring systems, Liver Injury Unit [LIU] using prothrombin time [PT] or international normalized ratio [INR], admission LIU using PT or INR, and Devarbhavi model) with one another.

RESULTS

Among the 41 Han Chinese patients with ALF, WD was established by demonstrating ATP7B variants in 36. In 5 others, Kayser-Fleischer rings and Coombs-negative hemolytic anemia permitted diagnosis. Three died during hospitalization and three underwent liver transplantation (LT) within 1 mo of presentation and survived (7.3% each); 35 (85.4%) survived without LT when given enteral D-penicillamine and zinc-salt therapy with or without urgent plasmapheresis. Parameters significantly correlated with mortality included encephalopathy, coagulopathy, and gamma-glutamyl transpeptidase activity, bilirubin, ammonia, and serum sodium levels. Area under the receiver operating curves varied among seven prognostic models from 0.981 to 0.748 with positive predictive values from 0.214 to 0.429.

CONCLUSION

WDALF children can survive and recover without LT when given D-penicillamine and Zn with or without plasmapheresis, even after enlisting for LT.

By downregulating PBX3, miR-526b suppresses the epithelial-mesenchymal transition process in cervical cancer cells

Aim: Research on novel mutant genes may develop the treatment of cervical cancer (CC). The role of miRNA-526b in epithelial-mesenchymal transition (EMT) of CC was investigated. Methods: The role and the molecular mechanism of miRNA-526b in CC and its effect on EMT were analyzed in clinical specimens and oncology experiments. Results: miRNA-526b was proved to be decreased in CC and associated with malignant clinicopathological characters. The character of miRNA-526b in EMT was also inspected in CC cells and tumor models. miRNA-526b was found to be able to inhibit the EMT property of CC cells by directly targeting PBX3. Conclusion: miRNA-526b restoration may be deliberated as a new treatment strategy of CC.

miR-431-5p alters the epithelial-to-mesenchymal transition markers by targeting UROC28 in hepatoma cells

OBJECTIVE

MicroRNA (miR)-431 plays an essential role in various human cancer types, particularly in the process of invasion. However, the function and mechanism of miR-431-5p in the invasion of hepatocellular carcinoma (HCC) remain undefined.

METHODS

The expression levels of miR-431-5p and its potential target protein UROC28 in hepatocellular carcinoma cells and tissues were detected, and the levels of EMT markers in vivo and in vitro were also detected.

RESULTS

MiR-431-5p was downregulated in HCC cell lines and tissues and associated with vascular invasion and tumor encapsulation. Furthermore, miR-431-5p was able to influence the epithelialto-mesenchymal transition (EMT) process in HCCLM3 and HUH7 cells. Mechanistically, it was discovered that miR-431-5p repressed invasion by targeting UROC28. Furthermore, miR-431-5p influenced the EMT markers in HCCLM3 and HUH7 cells by downregulating UROC28 expression. Similarly, in vivo assays confirmed that miR-431-5p upregulation in HCC cells remarkably inhibited tumor proliferation and influenced the EMT markers.

CONCLUSION

The current study has demonstrated that the miR-431-5p/UROC28 axis acts possible influence on the EMT in HCC. Upregulation of miR-431-5p could be an original approach for inhibiting tumor invasion.

Predictive Value of Serum Creatinine, Blood Urea Nitrogen, Uric Acid, and β2-Microglobulin in the Evaluation of Acute Kidney Injury after Orthotopic Liver Transplantation

Background

As a major complication after orthotopic liver transplantation (OLT), the occurrence of acute kidney injury (AKI) is frequently defined by serum creatinine (Cr); however, the accuracy of commonly used blood urea nitrogen (BUN), uric acid (UA), and β₂-microglobulin (β₂-MG) remains to be explored. This retrospective study compared the accuracy of these parameters for post-OLT AKI evaluation.

Methods

Patients who underwent OLT in three centers between July 2003 and December 2013 were enrolled. The postoperative AKI group was diagnosed by the Kidney Disease Improving Global Outcomes (KDIGO) criteria and classified by stage. Measurement data were analyzed using the t-test or Wilcoxon rank-sum test; enumerated data were analyzed using the Chi-square test or Fisher's exact test. Diagnostic reliability and predictive accuracy were evaluated using receiver operating characteristic (ROC) curve analysis.

Results

This study excluded 976 cases and analyzed 697 patients (578 men and 119 women); the post-OLT AKI incidence was 0.409. Compared with the no-AKI group, the AKI group showed very significant differences in Model for End-stage Liver Disease score (14.74 ± 9.91 vs. 11.07 ± 9.54, Z = 5.404; P < 0.001), hepatic encephalopathy (45 [15.8%] vs. 30 [7.3%], χ² = 12.699; P < 0.001), hemofiltration (28 [9.8%] vs. 0 [0.0%], χ² = 42.171; P < 0.001), and 28-day mortality (23 [8.1%] vs. 9 [2.2%], χ² = 13.323; P <0.001). Moreover, mean values of Cr, BUN, UA, and β₂-MG in the AKI group differed significantly at postoperative days 1, 3, and 7 (all P < 0.001). ROC curve area was 0.847 of Cr for the detection of AKI Stage 1 (sensitivity 80.1%, specificity 75.7%, cutoff value 88.23 μmol/L), 0.916 for Stage 2 (sensitivity 87.6%, specificity 82.6%, cutoff value 99.9 μmol/L), and 0.972 for Stage 3 (sensitivity 94.1%, specificity 88.2%, cutoff value 122.90 μmol/L).

Conclusion

The sensitivity and specificity of serum Cr might be a high-value indicator for the diagnosis and grading of post-OLT AKI.