
transplantation. This association has been suggested in a
prior report: a prospective study of 84 patients seen by a
neurologist before and serially after LT found that an
abnormal neurological examination prior to LT was the
strongest predictor of postoperative neurological compli-
cations [12].
There is a strong and coherent rationale for why those
with active HE would be at particularly high risk for
postoperative encephalopathy. It is now clear that liver
failure with even subtle or subclinical HE induces signifi-
cant changes in cerebral function and morphology,
primarily affecting astrocytes [20]. As the site of ammonia
detoxification, astrocytes accumulate the osmotically active
metabolite glutamine in the setting of liver failure. This
promotes intracellular swelling with depletion of the
compensatory organic osmolyte, myo-inositol serving as a
marker, as measured by magnetic resonance spectroscopy
(MRS) studies [21]. Increased astrocyte water content can
disrupt cellular function including maintenance of the
blood–brain barrier and neurotransmitter clearance. As
important constituents of the glio-neuronal network,
changes in astrocyte activity can induce widespread neu-
ronal dysfunction. Increased GABA-ergic tone is also
found in HE, likely mediated through increased production
of neurosteroids as a consequence of astrocyte swelling.
Elevations of extracellular glutamate, which accumulates
in this setting, can activate NMDA receptors and induce
nitric oxide synthesis, cerebral vasodilatation, as well as
seizures [22]. There is also a correlation between grade of
HE and MRI abnormalities before transplantation, with
evidence of subtle brain edema manifested in increased
ADC values even in those with subclinical HE [3]. Ele-
vation in ADC correlated with venous ammonia levels,
while more overt T2-abnormalities were only seen in those
with grade 2 or greater HE.
Even though liver transplantation ultimately improves
the selective cognitive deficits seen in mild HE [23], the
stress of the procedure itself can trigger worsening cerebral
dysfunction. Administration of benzodiazepines, shifts in
osmolality, and cytokine release known to occur after
major surgery, are all well known triggers of HE; their
contributions to postoperative encephalopathy may be
explained by their modulation of astrocyte swelling.
Patients with limited reserves of organic osmolytes,
depleted in attempting to compensate for active preopera-
tive HE, are unable to counteract the increased swelling
precipitated by these additional perioperative stressors and
so are at greater risk for cerebral dysfunction after LT.
Limitations of this study include its retrospective nature.
Extraction of relevant complications depended on adequate
recognition and documentation by the transplant and inten-
sive care services looking after the patients. However, these
patients are followed very closely in the post-transplant
period by a dedicated and trained team; most persistent and
significant changes in neurological status were likely noticed
while subtle symptoms may have been missed. We also
could only classify pre-transplant HE qualitatively into mild
or severe forms in this retrospective series, and did not utilize
the four-stage HE grading scale, which may have allowed a
more refined analysis of the association between degree of
HE and postoperative complications.
A prospective study examining the role of preoperative
HE in the pathogenesis of postoperative neurological
morbidity would allow a more accurate quantification of its
role and impact of its severity; examining interventions to
stabilize neurological status prior to LT and their effects on
the rate of these complications may also be warranted.
Reducing the frequency of these morbid events may reduce
the length of stay after LT and improve the neurological
status of these patients at discharge.
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