Encephalopathy and neuropathy in end-stage liver disease before and after liver transplantation

Status Epilepticus in Post-Transplantation Hyperammonemia Involves Careful Metabolic Management

Hyperammonemia is a condition that may result after solid organ transplantation, particularly lung transplantation. However, it is very uncommon for this presentation to occur more than 30 days post-transplantation. Hyperammonemia and the resulting encephalopathy typically manifest with altered sensorium, a clinical situation which is not often included in the differential diagnosis of presumed nonconvulsive status epilepticus (NCSE). Seizures are common among this subset of patients with hyperammonemia and may be refractory to traditional treatments. Evidence of elevated intracranial pressure by invasive monitoring and neuroimaging findings of diffuse cerebral edema are commonly reported. Here we examine the therapeutic importance of identifying the specific cause of hyperammonemic encephalopathy, a condition which may result in status epilepticus and ultimately cerebral edema or even brain death.

Hepatic Encephalopathy and Liver Transplantation: The Past, Present, and Future Toward Equitable Access

Cirrhosis is a debilitating chronic disease with high morbidity and mortality, with the only real cure being liver transplantation (LT). Currently, we allocate organs for transplantation based on the Model for End-Stage Liver Disease-Sodium (MELD-Na) score that does not account for hepatic encephalopathy (HE). HE affects patients, families, and the health care system because of high rates of recurrence and major readmission burden. Moreover, HE casts a long shadow even after LT. Accounting for HE and incorporating it into the current allocation system has many proponents, but the framework to do this is currently lacking because of differences in consensus or in operationalization parameters. We review the latest evidence of the burden of HE, management of HE before and after LT, and evaluate pros and cons of several methods of diagnosing HE objectively to ensure early and equitable access to LT in this underserved population.

The influence of HE history, HE status and neuropsychological test type on learning ability in patients with cirrhosis

BACKGROUND & AIMS

Learning ability may be impaired in patients with a history of overt hepatic encephalopathy (OHE). The aim of this study was to compare performance on the first/second attempt at a series of tests.

METHODS

Two hundred and fourteen patients with cirrhosis were enrolled. On the day of study, 41% were classed as unimpaired, 38% as having minimal HE and 21% as having mild OHE; 58% had a history of OHE. Performance was compared between two versions of the trail-making test A (TMT-A), and between the first/second half of a simple/choice reaction time (sRT and cRT), and a working memory test (ScanRT).

RESULTS

Both patients with and without OHE history improved in TMT-A, sRT and ScanRT. Only patients with no OHE history improved in cRT. All patients, regardless of their HE status on the day of study, improved in TMT-A and sRT. Only patients with mild OHE on the day of study improved in cRT. Only unimpaired patients improved in ScanRT. When OHE history and HE status on the day of study were tested together, only HE status had an effect. The same held true when age, the Model for End Stage Liver Disease (MELD) and educational attainment were adjusted for.

CONCLUSIONS

HE status on the day of study and the type of neuropsychological test had an effect on learning ability in a well-characterized group of patients with cirrhosis.

Neurological Complications Occurring After Liver Transplantation: Role of Risk Factors, Hepatic Encephalopathy, and Acute (on Chronic) Brain Injury

Orthotopic liver transplantation (LT) remains the only way to definitively cure patients with the most severe liver diseases. Because the survival rate is now fairly high, important questions about neurological sequelae or quality of life after LT have emerged. Indeed, LT represents a peculiar situation because up to 30% of patients present with neurological symptoms after LT compared with only 4% after cardiac transplant and 0.5% after renal transplant. These postoperative neurological symptoms have long been interpreted as sequelae of hepatic encephalopathy (HE). However, postoperative decompensation of an unknown cerebral condition due to the pathophysiology of cirrhosis or undiagnosed neurodegenerative disorders or aging constitute other possibilities that are underrecognized. Some patients who undergo LT for acute liver failure and patients with cirrhosis without episodes of HE and without any previous cerebral alteration also display post-LT neurological symptoms. This latter situation speaks in favor of a direct adverse effect of either general anesthesia, the surgical procedure, or factors related to the postoperative intensive care unit (ICU) environment. The role of inflammation, which has been described in the ICU setting, could also be a crucial determinant. In this review, we will discuss the neurological complications associated with LT, the neurocognitive complications after LT, and how to assess the LT-related neurological or neurocognitive complications. Furthermore, we will review the various hypotheses surrounding post-LT neurocognitive impairment and will conclude with recommendations for future directions.

Patients with manifest hepatic encephalopathy can reveal impaired thermal perception

OBJECTIVES

Previous evoked potential studies indicated central impairments of somatosensory function in patients suffering from hepatic encephalopathy (HE). The aim of this study was to quantify the somatosensory perception in patients with minimal and overt HE.

MATERIALS AND METHODS

Forty-two patients with liver cirrhosis and HE up to grade 2 and 12 age-matched healthy controls underwent a comprehensive graduation of HE including the West Haven criteria, the critical flicker frequency (CFF), and neuropsychometric testing. Quantitative sensory testing, standardized by the German Research Network on Neuropathic Pain, was performed on both hands.

RESULTS

Pain and mechanical detection thresholds were unchanged in HE. Tests of thermal processing revealed that patients with HE of grade 2 perceive cold at lower temperatures (cold detection threshold) and need a higher temperature difference to distinguish between warm and cold (thermal sensory limen). These impairments correlated with the CFF. A correction for attention deficits by performing partial correlations using neuropsychometric test results canceled these correlations.

CONCLUSIONS

The present findings demonstrate an impairment of temperature perception in HE. The extent of this impairment correlates with HE severity as quantified by the CFF. The attenuation of the correlations after correction for attention deficits suggests a strong role of attention deficits for the impaired thermal perception. Thus, it provides initial evidence for a central impairment of thermal processing in HE due to alterations in high-level processes rather than due to peripheral neuropathic processes, which are a frequent complication in patients with liver cirrhosis.

New-onset cognitive dysfunction impairs the quality of life in patients after liver transplantation

Patients after orthotopic liver transplantation (OLT) may show cognitive dysfunction. To date, it has not been clear whether this dysfunction is due to residual hepatic encephalopathy (HE) or new-onset cognitive disturbances. Just as little is known about the course and clinical significance. In this prospective, observational study, 50 patients on the waiting list for OLT were examined in an outpatient setting before OLT and 6 and 12 months after OLT with the Psychometric Hepatic Encephalopathy Score, the Inhibitory Control Test, and the critical flicker frequency for the diagnosis of HE; in addition, the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was used as a tool for the measurement of global cognitive function. The Short Form 36 health survey was used to assess health-related quality of life. Twelve months after OLT, cognitive dysfunction characteristic of HE had resolved, but a secondary cognitive decline became apparent and had features different from those known with HE. Approximately 70% of the patients deteriorated in at least 1 cognitive domain of RBANS. This cognitive decline was related to neither a history of HE nor a history of alcohol abuse, but it was accompanied by a decline in the quality of life. In conclusion, OLT improves HE but is frequently followed by new-onset cognitive dysfunction, which can interfere with the quality of life.

Impact of preoperative overt hepatic encephalopathy on neurocognitive function after liver transplantation

In the current Model for End-Stage Liver Disease allocation system, patients are at risk of suffering repeated episodes of hepatic encephalopathy (HE) while waiting for an orthotopic liver transplantation (OLT); the posttransplantation impact of these episodes has not been well explored. We evaluated the cognitive function and quality of life in a group of OLT recipients (n = 25) who had suffered from overt HE prior to their procedure (HE-PreLT group) and compared their performance to that of a similar group of patients (n = 14) without overt HE (No HE-PreLT group) as well as to controls. Patients were selected from a cohort of 280 patients who underwent OLT during this period; the presence of clinical confounders excluded many of the remaining subjects. Demographic and clinical characteristics were balanced among groups. At an average of 18 months after OLT, we administered 2 neuropsychological batteries [Psychometric Hepatic Encephalopathy Score (PHES) test battery and Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)]; a pyschophysiological test (critical flicker frequency); and the SF-36 quality of life score. The HE-PreLT group scored below controls in 5 of 6 cognitive domains tested by RBANS, 3 of 6 PHES subtests, as well as the critical flicker frequency test. The No HE-PreLT group scored below the controls in 1 of the 6 cognitive domains tested by RBANS. The more severe neurocognitive abnormalities seen in the HE-PreLT group did not appear to affect quality of life, as lower values than normative data were only found in 1 of the 8 SF-36 scales. In conclusion, neurocognitive abnormalities were more severe in liver transplant recipients that had suffered from overt HE prior to OLT. Prospective studies of neurocognitive function pre-OLT and post-OLT are needed to fully determine the impact of such abnormalities.

Detection of HBV core promoter and precore mutations helps distinguish flares of chronic hepatitis from acute hepatitis B

BACKGROUND AND AIM

Acute exacerbation of chronic hepatitis B has to be distinguished from acute hepatitis, because treatment strategies differ between them.

METHODS

Mutations in the core promoter and precore region of hepatitis B virus (HBV) were determined in 36 patients with acute exacerbation of chronic hepatitis B, in whom alanine aminotransferase (ALT) increased above 500 IU/L, as well as the 36 patients with acute hepatitis.

RESULTS

Mutations in the core promoter (A1762T/G1764A) and precore region (G1896A) were more frequent in patients with acute exacerbation of chronic hepatitis than acute hepatitis (81% vs 19%; P < 0.0001 and 58% vs 6%; P < 0.0001, respectively). Of the 19 patients with mutations in both the core promoter and precore region, 17 (89%) had acute exacerbation of chronic hepatitis. In contrast, among the 32 patients with the wild-type for both the core promoter and precore region, 29 (89%) developed acute hepatitis. By multivariate analysis, the double mutation in the core promoter was predictive of acute exacerbation in chronic hepatitis with the highest odds ratio at 26.4.

CONCLUSIONS

In patients with hepatitis B having ALT levels >500 IU/L, mutations in the core promoter and precore region are useful in distinguishing acute exacerbation of chronic from acute HBV infection. Detection of these mutations would be useful for commencing prompt antiviral treatments on patients with acute exacerbation of chronic hepatitis for a better prognosis.

Quality of life after liver transplantation. A systematic review

BACKGROUND/AIMS

Although many studies have reported significant improvements in quality of life (QOL) after liver transplantation (LT), consistent data on areas of improvement are lacking. To perform a systematic review on medical literature of QOL after LT paying particular attention to studies that utilized the most commonly adopted study instrument, Short Form-36 (SF-36).

METHODS

To collect studies focused on QOL in adult LT recipients, from 1963 to 2007, cited in Pub Med, Embase or Cochrane databases. From an initial identification of 613 articles, we selected 44 longitudinal studies with pre- and post-LT data that we assessed using a sign test, and 19 used SF-36, which we analyzed separately.

RESULTS

Longitudinal data showed remarkable improvement of common domains of QOL comparing pre- and post-transplant items. However, analysis of 16 SF-36 cross-sectional studies comparing post-LT patient domains with control population showed significantly higher ratings for controls in six while no differences were found in two.

CONCLUSIONS

This review suggests that whereas general QOL improves after LT, when compared with healthy controls, LT recipients have significant deficits in QOL. Consequently, the previously reported QOL benefits after LT may have been overstated.

Minimal hepatic encephalopathy

Minimal hepatic encephalopathy (MHE), formerly known as subclinical hepatic encephalopathy, is the mild cognitive impairment commonly seen in patients who have cirrhosis. Current understanding suggests that MHE forms part of the spectrum of hepatic encephalopathy, although this remains to be proven. Although traditionally viewed as having negligible clinical significance, MHE has a significant impact on quality of life. MHE often goes undiagnosed because in many patients there is no evidence of clinically overt signs of impaired cognition. In addition, the diagnostic criteria for MHE have not been standardized, which means that the exact characteristics of MHE remain in question. This Review focuses on the pathogenesis and neuropsychological findings (incorporating neuroimaging) of MHE, as well as the effect of MHE on quality of life and survival, and developments in treatment.

Neuronal cell death in hepatic encephalopathy

It is generally assumed that neuronal cell death is minimal in liver failure and is insufficient to account for the neuropsychiatric symptoms characteristic of hepatic encephalopathy. However, contrary to this assumption, neuronal cell damage and death are well documented in liver failure patients, taking the form of several distinct clinical entities namely acquired (non-Wilsonian) hepatocerebral degeneration, cirrhosis-related Parkinsonism, post-shunt myelopathy and cerebellar degeneration. In addition, there is evidence to suggest that liver failure contributes to the severity of neuronal loss in Wernicke's encephalopathy. The long-standing nature of the thalamic and cerebellar lesions, over 80% of which are missed by routine clinical evaluation, together with the probability that they are nutritional in origin, underscores the need for careful nutritional management (adequate dietary protein, Vitamin B(1)) in liver failure patients. Mechanisms identified with the potential to cause neuronal cell death in liver failure include NMDA receptor-mediated excitotoxicity, lactic acidosis, oxidative/nitrosative stress and the presence of pro-inflammatory cytokines. The extent of neuronal damage in liver failure may be attenuated by compensatory mechanisms that include down-regulation of NMDA receptors, hypothermia and the presence of neuroprotective steroids such as allopregnanolone. These findings suggest that some of the purported "sequelae" of liver transplantation (gait ataxia, memory loss, confusion) could reflect preexisting neuropathology.

Association of core promoter/precore mutations and viral load in e antigen-negative chronic hepatitis B patients

Apart from core promoter A1762T/G1764A and precore G1896A mutations, other hepatitis B virus (HBV) mutants are detected in hepatitis B e antigen (HBeAg)-negative chronic hepatitis B (CHB). The aim of this study was to determine the effects of those mutants on clinical manifestation and viral loads of genotypes B and C HBV. Seventy-nine HBeAg-negative CHB patients with hepatitis flare were enrolled in this study and their HBV precore/core region were sequenced. Serial biochemical profiles and viral loads were assessed and compared. Fifty-three patients (67%) were infected by genotype B HBV and 26 (33%) were infected by genotype C HBV. The clinical manifestation and HBV viral loads were comparable between the two groups. However, genotype B was significantly associated with precore G1896A mutation (92.5%), and more mutations within nucleotide 1809-1817 were detected in patients infected by genotype B as compared with those infected by genotype C (18.9%vs 3.8%). Most of the cases had mutations at the -2, -3 or -5 position from the precore AUG initiation codon. Triple core promoter mutations T1753C/A1762T/G1764A [corrected] appeared to be linked to genotype C rather than genotype B HBV (19.2%vs 1.9%; P = 0.013). In multivariate analysis, the presence of either triple core promoter 1753/1762/1764 mutation or nucleotide 1809-1817 mutation was the only factor associated with lower HBV viral load (<70 Meq/mL) (odds ratio = 9.01; 95% CI 1.11-71.43; P = 0.04). In conclusion, minor HBV variants with mutations in the core promoter and precore region were detectable in genotypes B and C. Such HBV variants are genotype specific and related to viraemia levels.

Quantitative EEG analysis before and after liver transplantation

Quantitative EEG has been shown to be effective for the assessment of hepatic encephalopathy. Initial quantitative EEG studies of patients who had undergone liver transplantation demonstrated improvement of frequency and the alpha-theta power ratio in the occipital area. This study involved the assessment of comprehensive quantitative EEG variables over the entire cortex following transplantation. Fourteen subjects underwent EEG recording prior to transplantation. Eight (6 without complications and 2 having problems with rejection) underwent the same recording between 3 and 6 months following transplantation. For all subjects, EEG variables showing significant changes from pre- to post-transplantation included posterior alpha frequency (increase, p < or = .03), central theta absolute power (decrease, p < or = .03), theta relative power over anterior, central, and posterior regions (decrease, p < or = .02, p < or = .01, p < or = .03, respectively), posterior beta absolute power (increase, p < or = .01), and central and posterior beta relative power (increase, p < or = .04, p < or = .04, respectively). When the two subjects with complications were removed from the analyses, these variables and also anterior alpha absolute power (increase, p < or = .02), alpha relative power over anterior, central, and posterior regions (increase, p < or = .05, p < or = .03, p < or = .04, respectively), and anterior and central theta absolute power (decrease, p < or = .05, p < or = .04, respectively) showed significant pre- to post-transplant changes. In conclusion, a combination of quantitative EEG parameters which are most affected by liver transplantation might provide an effective assessment tool for determining and quantitatively monitoring the cerebral status of post-transplant patients.

Infectious source factors affecting the severity of sexually transmitted acute hepatitis due to hepatitis B virus genotype C

OBJECTIVE

The aim of this study was to identify clinical features and virological aspects of infectious sources that are related to the severity of sexually transmitted acute hepatitis B virus (HBV) infection in patients, especially in cases of genotype C.

METHODS

Nineteen patients with acute HBV infection, 10 classified with severe acute hepatitis (SH) (prothrombin time; PT <40%) and 9 with typical acute hepatitis (AH) (PT >40%), and their infectious sources (all were sexual partners) were studied. Infectious source factors were analyzed in relation to the severity of hepatitis in the patients' partners.

RESULTS

The nucleotide homology of HBV-DNA between each pair was >/=98.9%. Sixteen were infected with HBV genotype C. Among the 16 infectious sources, age, numbers with elevated alanine aminotransferase (ALT, 7/9 vs. 1/7), anti-HBe positivity (8/9 vs. 1/7) and core promoter mutations at nt 1762 (7/9 vs. 1/7), nt 1764 (8/9 vs. 1/7) and precore mutation at nt 1896 (8/9 vs. 1/7) were significantly higher in the sources of SH than in those of AH.

CONCLUSION

Higher age, elevated ALT, anti-HBe positivity and core promoter/precore mutations were possible risk factors for an infectious source of the severe form of sexually transmitted acute hepatitis due to HBV genotype C.

The pharmacokinetics of ropivacaine in hepatic and renal insufficiency

In patients with chronic end-stage liver disease, the peak plasma concentrations of ropivacaine after a single intravenous ropivacaine dose are similar to those in healthy subjects. However, patients with end-stage liver disease have about a 60% lower mean ropivacaine clearance than healthy subjects and are thus expected to have over two-fold higher steady-state ropivacaine plasma concentrations during a continuous ropivacaine infusion. The peak plasma concentrations of ropivacaine after an axillary plexus block in uraemic patients are considerably higher than those in non-uraemic patients. However, uraemic patients have significantly higher alpha-1-acid glycoprotein plasma concentrations than non-uraemic patients, and the peak plasma concentrations of free ropivacaine (related to toxicity) are similar in both groups. The pharmacokinetics of intravenously administered ropivacaine in patients with renal insufficiency and the possibility of clinically significant (S)-2',6'-pipecoloxylidide metabolite accumulation during continuous or repeated ropivacaine administration in these patients remain to be clarified.

Resolution of alcoholic neuropathy following liver transplantation

Between 10 and 20% of adult liver transplants are performed for end-stage alcoholic liver disease. Severe extrahepatic end-organ damage from alcoholism (cardiomyopathy, pancreatitis, central nervous system injury, and neuropathy) is widely regarded as an absolute contraindication to liver transplantation, despite a lack of data on the effect of transplantation on these complications. We describe such a patient who presented with decompensated alcoholic liver disease and moderately severe peripheral neuropathy. Both his liver failure and neuropathy progressed despite 9 months abstinence and intensive nutritional support. By 12 months post-transplant, however, this patient had regained almost normal muscle strength, with associated recovery in sensory and motor conduction velocities. Direct alcohol toxicity, nutritional and vitamin deficiencies, and liver failure were all likely etiologic factors in this patient's neuropathy. In conclusion, this case suggests that peripheral neuropathy in a patient with alcoholic cirrhosis may resolve following liver transplantation and should not constitute a contraindication to transplantation, even when it is disabling.

Postural hand tremor before and following liver transplantation and immunosuppression with cyclosporine or tacrolimus in patients without clinical signs of hepatic encephalopathy

OBJECTIVE

To assess tremor characteristics and severity in patients with severe liver disease without hepatic encephalopathy and following orthotopic liver transplantation (LTX) and immunosuppression (IS) with cyclosporin A (CsA) or tacrolimus (FK 506).

METHODS

A total of 35 consecutive patients were included into the prospective study and serum levels of CsA (n = 29) or FK 506 (n = 6) were monitored following LTX. Tremor characteristics and severity were assessed by two-blinded raters before and following LTX. In addition, accelerometric recordings were taken before and after LTX, and compared with 16 normal controls without tremor and without clinical signs of hepatic encephalopathy or liver disease. Accelerometry was performed while sitting in a comfortable chair with the forearms supported and included rest and postural condition with and without weight load (500 g) on each hand. Kolmogorov-Smirnov test, paired t-test and t-test for independent samples were used for statistical analysis.

RESULTS

The clinical rating revealed no rest but a mild postural hand tremor before LTX with a significant increase following LTX (p < 0.001). After LTX the mean score of postural tremor was significantly (p < 0.05) higher in patients with plasma levels of >850 ng CsA/ml compared with patients with lower levels. Patients and normal controls showed comparable mean peak frequencies of rest and postural hand tremor. The mean amplitude of postural hand tremor was significantly higher in patients before and after LTX compared with controls. In the majority of patients (89%) and controls (88%), the dominant tremor frequency decreased significantly (>1.5 Hz) when applying a weight load on each hand.

CONCLUSION

The present study is the first to describe hand tremor characteristics in patients with severe liver disease without clinical signs of hepatic encephalopathy and in patients following LTX and IS. Compared with normal controls the patients showed a significant postural hand tremor prior and post-LTX and an increase of mean tremor amplitude following LTX and CsA/FK 506 treatment. The decrease of the dominant tremor frequency with weight load and an increase of tremor amplitude with higher plasma levels of CsA are both indicative of an enhanced physiological or toxic tremor.

Autonomic and peripheral neuropathy in endstage liver disease and following liver transplantation

Severe chronic liver disease may be associated with a peripheral somatic and an autonomic neuropathy. There are only a limited number of reports on the incidence and features of these neuropathies. In addition the effects of liver transplantation on these neuropathies have not been well studied. We examined peripheral somatic and autonomic nerve function in 42 patients with endstage liver disease prior to transplantation and also examined the effect of liver transplantation on these neuropathies in 14 patients. Peripheral somatic neuropathy (93%) and autonomic neuropathy (50%) were common in patients with endstage liver disease and were more frequent than previously reported. Abnormalities improved in some patients after liver transplantation, particularly if there was return of normal hepatic function.

Clinical significance of basal ganglia alterations at brain MRI and 1H MRS in cirrhosis and role in the pathogenesis of hepatic encephalopathy

In hepatic encephalopathy, a progressive and diffuse impairment in brain function is associated with gradual alterations that can be detected by magnetic resonance imaging (MRI) and proton magnetic resonance spectroscopy (1H MRS). In some patients, a variety of movement disorders suggestive of extrapyramidal impairment points toward basal ganglia (BG) alterations. Accordingly, (i) hyperintensities at MRI predominant in the pallidum, an important region of BG involved in the motor control, (ii) redistribution of cerebral blood flow from cortical areas to BG structures observed using positron emission tomography studies, and (iii) the preferential pallidal location of Alzheimer astrocytosis, all support this hypothesis. In most clinical studies, little if any correlations have been found between cerebral hyperintensities and neurological manifestations. The application of a test designed to evaluate patients with Parkinson's disease (where extrapyramidal signs are typical) showed significant clinical correlations both with pallidal hyperintensity and with choline/creatine ratio at 1H MRS in BG structures. Because of complex neuronal connections between BG and many cortical areas, BG dysfunction may influence the neurocognitive manifestations of hepatic encephalopathy. Similarities between chronic Mn intoxication and cirrhosis suggest common pathophysiological mechanisms including altered dopaminergic neurotransmission, although information in chronic liver failure is limited. Clinical observations are presented regarding the evolution of parkinsonian signs in various situations.

Nerve conduction study on patients with severe liver syndrome and its change after transplantation

This study is to investigate the character of peripheral neuropathy associated with end stage liver disease and the effect of liver transplantation on peripheral neuropathy. Twenty-five patients admitted for a liver transplantation were involved in this study. All patients underwent neural conduction study before liver transplantation and 6 months after liver transplantation. Based on results of this study, motor amplitude score, motor velocity score (MVS), sensory amplitude score (SAS), and sensory velocity score were calculated. The changes between before and after liver transplantation were evaluated. The SAS and MVS substantially increased after transplantation. Nerve conduction study showed the improvement in sensory and motor nerve after liver transplantation.

Delayed neuropsychologic dysfunction after liver transplantation for acute liver failure: a matched, case-controlled study

Although several studies have identified posttransplant neurologic sequelae in patients with acute liver failure (ALF), the effects of these sequelae on neuropsychologic functioning after transplant is unknown. This study compared neuropsychologic functioning of ALF patients with chronic liver disease patients after liver transplantation. After liver transplantation, seven ALF patients were compared with a matched control group of patients who had been transplanted for chronic liver disease. The patients were matched by gender, age (within 5 years), and time since transplantation (within 2 years). Patients completed a 2-hour battery of tests, which included measures of attention, memory, motor performance, abstract conceptualization, and visuospatial perception. There were no significant differences between the groups on measures of socioeconomic status or education. Significant differences were found on three separate tests: WAIS-III Vocabulary, WAIS-III Similarities, and WMS-III Paired Associate Learning II. Although these tests measure distinct functions (vocabulary knowledge, abstract conceptualization, and delayed verbal recall), they may be influenced by broader verbal functions, such as verbal fluency, conceptualization, and the ability to articulate ideas. When patients were asked what functions had noticeably deteriorated since transplantation, nearly all complained of memory difficulties, and there was no difference between groups. However, more ALF than chronic liver disease (CLD) patients complained of concentration difficulties. The results of this study suggest that ALF patients may experience more neuropsychologic dysfunction after transplant. Further studies are required to expand on these initial observations with the potential to improve patient care and referral to appropriate rehabilitative services.

Rapid improvement of autonomic and peripheral neuropathy after liver transplantation: a single case report

Peripheral and autonomic neuropathies are known but often unrecognized associations of cirrhosis from any cause. The pathogenesis of these effects are ill understood. Liver transplantation has been shown to reverse autonomic manifestations, but little evidence exists for an effect on peripheral neuropathy. This case report documents improvement in peripheral and autonomic neuropathy in a 40-year-old man with hepatitis B virus--related cirrhosis. A return to normal neurophysiological function was seen within 9 months of successful liver transplantation, suggesting a metabolic, rather than a structural, cause of such changes in the peripheral nervous system.

Chronic liver disease: relaxometry in the brain after liver transplantation

Relaxometry revealed changes in the basal ganglia in T(1) and T(2) relaxation times due to liver disease. Manganese is probably responsible for T(1) and T(2) shortening (as the concentration is known to be higher in both the liver and blood due to hepatic cirrhosis). The aim of this study was to follow possible recovery after liver transplantation by MR relaxometry. Together with a group of 20 healthy volunteers we scanned 53 patients before and after liver transplantation (some of them repeatedly). Both T(1) and T(2) values were evaluated in the basal ganglia, thalamus, and frontal white matter. T(1) relaxation time was shortened by approx. 20-25% compared to the control group, probably the result of manganese deposition in the brain caused by hepatic cirrhosis. After liver transplantation the relaxation time recovered gradually with almost normal values reached approx. 2 years after surgery. T(1) recovery was observed in all evaluated structures. Similar results were observed with T(2) relaxation in the basal ganglia and thalamus. In the white matter T(2) remained low even 2 years after surgery.

Employment and alcohol use after liver transplantation for alcoholic and nonalcoholic liver disease: a systematic review

The purpose of the study is to evaluate patterns of employment and alcohol use among liver transplant recipients with alcoholic (ALD) and nonalcoholic liver disease (non-ALD). MEDLINE, EMBASE, and bibliographic searches identified 5,505 potentially relevant articles published between January 1966 and October 1998. Eighty-two studies reporting data on 5,020 transplant recipients met our inclusion criteria. Pre-orthotopic liver transplantation (OLT), 29% of transplant recipients with ALD and 59% of those with non-ALD worked versus 33% and 80% at 3 years for transplant recipients with ALD and non-ALD, respectively (P <.00001 for each interval). We found no difference in the proportion of transplant recipients with ALD and non-ALD reporting early alcohol use post-OLT: 4% versus 5% at 6 months and 17% versus 16% at 12 months. However, among post-OLT drinkers, transplant recipients with non-ALD were more likely to drink moderately and those with ALD to drink excessively. At 7 years post-OLT, 32% of the patients with ALD reported using alcohol. The odds ratio for alcohol use among patients who maintained abstinence for fewer than 6 months pre-OLT versus those who maintained abstinence for greater than 6 months was 7.8 (95% confidence interval, 4.0 to 15.3). Before OLT and at long-term follow-up, substantially more transplant recipients with non-ALD than ALD were employed. The proportions of transplant recipients with ALD and non-ALD reporting alcohol use did not differ, although those with ALD tended to consume greater quantities.

Long-term care of the liver transplant recipient

Many liver transplant recipients are now reaching survival beyond 5 years from the liver transplant procedure, and many others are alive more than a decade from acquiring their new liver. Orthotopic liver transplant recipients enjoy the benefits of normal liver function, but a variety of metabolic and other medical problems often develop that require diagnosis and adequate management. These problems include hyperlipidemia, obesity, diabetes mellitus, renal disfunction, arterial hypertension, bone disease and neuropsychiatric syndromes. The gastroenterologist, internist, or local family physician is frequently called on to identify and treat these postoperative complications in conjunction with physicians at the transplant center.

[Neurologic disorders in patients submitted to liver transplantation: analysis of 30 consecutive cases]

Neurologic complications are important source of morbi-mortality, in liver transplantation. They result from previous factors, alterations during the surgical procedure, effects from immunosuppressor drugs, coagulopathy and infections. We analyzed, retrospectively, the chronology, causes, and frequencies of neurologic alterations in thirty adult patients submitted to liver transplantation, and our results differ slightly from those registered in other series.

Health-related quality of life after liver transplantation: a meta-analysis

The goal of this study is to assess health-related quality of life (HRQL) after orthotopic liver transplantation (OLT). Structured MEDLINE and Embase literature searches identified 5473 potentially relevant articles. Thirty-two additional references were collected from the bibliographies. Of the 5505 identified articles, 49 studies reporting data on 3576 transplant recipients met our inclusion criteria, which were an assessment of quality of life (QOL) in adult patients reported as either pretransplantation and posttransplantation data or with a comparison group and written in English. We combined posttransplantation QOL scores from 15 studies that reported data from the same QOL scales to assess the magnitude of the effect of OLT on QOL scales. We also performed a sign test on the 49 studies to evaluate the direction (positive or negative) of the effect of transplantation on QOL. Transplantation resulted in an improvement of 32% in Karnofsky scores, 11% in Sickness Impact Profile scores, and 20% to 50% in the domains of the Nottingham Health Profile. The sign test showed significant improvement in posttransplantation physical health (P <.0004), sexual functioning (P <.008), daily activities (P <.02), general HRQL (P <.02), and social functioning (P <.05), but not psychological health (P <.08). In general, the HRQL of the 3576 patients was impaired pretransplantation and improved posttransplantation. Transplant recipients reported large gains in those aspects of QOL most affected by physical health and smaller improvements in areas affected by psychological functioning.

Evidence of transmission of hepatitis B virus to spouses from sequence analysis of the viral genome

Heterosexual contact is one of the common routes of transmission for hepatitis B virus (HBV) among adults in Taiwan, but only a few studies have provided direct evidence at the level of the HBV genome of infected couples with acute non-fulminant hepatitis to document a common source. By cloning and sequencing polymerase chain reaction-amplified HBV-DNA, we analysed the sequences of the conserved region of the surface gene (nucleotide (n.t.) 305-513, representing 6.5% of the viral genome) of HBV in five HBV-infected index patients, their spouses and four randomly selected HBV carriers as controls. Risk factors associated with acute HBV infection in index cases were sexual contact with their spouses within 3 months before the onset of hepatitis. For all five couples, the HBV-infected index patient and the spouse shared a 100% sequence homology of HBV-DNA. In contrast, there was significantly more variation (mean heterogeneity 6.1%, range 1-13.9%) in the amplified region between the five couples and between each couple and the controls (P<0.001). This study demonstrated that sequence analyses can correlate well with epidemiological findings and confirm the value of the molecular approach for linked infections of HBV through heterosexual contact between spouses. Susceptible adults should receive vaccination.

Regional cerebral blood flow changes in patients with cirrhosis assessed with 99mTc-HM-PAO single-photon emission computed tomography: effect of liver transplantation

BACKGROUND/AIMS

Previous studies showed contrasting results with regard to alterations of regional cerebral blood flow/metabolism in subjects with liver cirrhosis. The aim of the study was to extend these findings in a larger series of patients. In addition, we wanted to determine whether such alterations are reversed by successful liver transplantation.

METHODS

The study group comprised 23 patients with liver cirrhosis and 13 normal controls. At entry to the study, all subjects underwent a complete neurological examination, EEG recordings and SPECT scanning. The severity of liver disease was determined according to the Child-Pugh score. Fourteen patients underwent a second SPECT examination 1 year after liver transplantation.

RESULTS

Significant rCBF reductions, ranging from 6% to 7%, were found in the majority of the cortical regions of the whole group of patients with cirrhosis, as compared to controls. These reductions were more diffuse in patients with alcoholic liver disease, comprising almost all the assayed regions. Liver transplantation normalized cortical rCBF deficits so that postoperative perfusion indexes were superimposable on control values. However, the frontal cortex remained significantly more impaired in patients with alcoholic cirrhosis than in those with non-alcoholic cirrhosis. The differences in frontal rCBF between the two groups of patients ranged from 6 to 11%.

CONCLUSIONS

Liver cirrhosis was associated with rCBF defects that depend upon the etiology of liver disease and that subsided after successful liver transplantation. The frontal defects in alcoholic cirrhosis either before or after surgery may imply a neurotoxic, possibly irreversible, action of ethanol.

Low-dose recombinant interferon therapy in anti-HBe-positive chronic hepatitis B in Asian Indians

Approximately 15% of Indian patients with hepatitis B virus (HBV)-related chronic liver disease (CLD) have infection with precore mutant forms. These patients are likely to have an aggressive course. There are equivocal reports of success with interferon therapy of mutant infection in the West. This therapy has not been evaluated in precore mutant-related CLD in Asian Indians. Eighteen patients (mean age 38.2 +/- 12 years, M:F: 17:1) with biopsy proven CLD and precore mutant HBV infection (hepatitis B surface antige (HBsAg) positive, hepatitis B e antigen (HBeAg) negative, anti-HBe positive, HBV-DNA positive) were included. Interferon alpha 2b was given at 3 mIU on alternate days for 4 months. Serology, determination of HBV-DNA (both by dot-blot hybridization and polymerase chain reaction) and liver biopsy were repeated after completion of the therapy. Response to interferon therapy was defined as loss of HBV-DNA by dot-blot hybridization. Thirteen (72.2%) patients responded to the treatment (responders). Mean alanine aminotransferase levels (83 +/- 12 vs 55 +/- 29 IU/L, P < 0.01) and the histological activity index (15 +/- 1.4 vs 12 +/- 1.3, P < 0.01) significantly decreased in the responders compared with initial values. Serum albumin levels also improved at the end of the therapy (3.5 +/- 0.4 g/dL vs 3.8 +/- 0.4 g/dL, P = 0.07). During follow up, seven of the 13 (54%) responders relapsed; cirrhotics relapsed more often than chronic hepatitis patients (P < 0.05). All 18 patients, however, continued to be HBV-DNA positive at the end of follow up. This study concluded that: 1. Interferon therapy is beneficial, albeit to a limited extent, in HBV precore mutant-related chronic liver disease in Asian Indians. 2. It is ineffective in eliminating the mutant HBV infection, which explains the high relapse rate. 3. Prolonged low-dose interferon therapy alone or in combination with newer nucleoside analogues should be evaluated in these patients.

Whole genome analysis of hepatitis B virus from four cases of fulminant hepatitis: genetic variability and its potential role in disease pathogenicity

The precore stop-codon variant of hepatitis B virus (HBV) has been associated with fulminant hepatitis but is also found in patients with persistent infection and chronic hepatitis. We have examined the possibility that the severe outcome of infection in patients with fulminant disease may be a result of additional genomic variation. We sequenced the entire HBV genome from three patients of Greek and one patient of Chinese origin with fulminant hepatitis, and from two patients with hepatitis B e antigen (HBeAg) positive chronic infection from the same regions, using direct sequencing of amplified viral DNA. Three of the fulminant cases were infected with the precore stop-codon variant HBeAg negative) and the fourth with the wild-type (HBeAg) positive virus. We compared sequences from our four fulminant isolates, and an additional fulminant isolate reported by others, with HBeAg positive carriers from the same regions and 12 published HBV genomes. There was a higher number of nucleotide and amino-acid substitutions throughout the HBV genome in the precore variant fulminant sequences than in the wild type. A cluster of mutations previously identified in the X region (126-132) in sequences reported in Japanese patients and encompassing the Enhancer II-Core Promoter region (1751-1768), were not found in our patients. We conclude that although there are no changes common to all sequences of HBV isolates from fulminant cases, some of these changes are in recognized cis-acting regulatory elements, whilst others are in the immediate vicinity of such elements. The effect of these mutations on viral genome transcription must now be determined.

Psychiatric aspects of liver transplantation

Psychiatry plays an essential role in the selection and preoperative care of liver transplant patients. Unique to liver transplantation are the preponderance of candidates with alcoholic end-stage organ failure and also the reversibility of encephalopathy with postoperative normalization of hepatic function. The expense of liver transplantation necessitates documentation of quality of life among recipients. It can also be postulated that a "ripple effect" does occur, in which favorable operative outcomes provide a meaningful and beneficial effect on social networks of transplant candidates and on society in general.