Comprehensive risk assessment for early neurologic complications after liver transplantation

Table 1 Baseline characteristics of the 288 consecutive liver transplantation patients

Recipient variables
Demographics
Age (yr)	52.3 ± 9.81
Gender (M/F)	213/75
BMI (kg/m2)	24.4 ± 3.72
Primary diagnosis, n (%)
Hepatitis B	175 (60.8)
Hepatitis C	73 (25.3)
Alcoholic liver disease	77 (26.7)
HCC	138 (47.9)
Severity of liver disease
Child-Pugh score	10.0 ± 2.49
MELD score	15.0 ± 9.01
Complication, n (%)
Hepatic encephalopathy	132 (45.8)
Ascites	189 (65.6)
Variceal bleeding	114 (39.6)
Comorbidities, n (%)
Diabetes mellitus	103 (35.7)
Hypertension	52 (18.1)
Uremia	14 (4.9)
Mental disorders	99 (34.4)
Blood test before transplant
Glucose (mg/dL)	129 ± 76.07
Albumin (g/dL)	3.08 ± 0.66
Creatinine (mg/dL)	1.22 ± 1.53
INR	1.62 ± 0.99
T. bilirubin (mg/dL)	7.78 ± 11.19
Platelet (× 103/μL)	85.4 ± 53.85
Ammonia (μg/dL)	138.0 ± 97.05
Perioperative variables
Blood loss (mL)	2896 ± 3409
Operation time (min)	575 ± 122.7
Splenectomy, n (%)	87 (30.2)
Complex vascularity, n (%)	75 (26.0)
Postoperative variables
Tacrolimus dose (mg/d)	3.4 ± 1.67
Basiliximab, n (%)	51 (18)
Serum level - Day 7
Tacrolimus level (ng/mL)	7.4 ± 6.24
Ammonia (μg/dL)	69.6 ± 130.8
Sodium (mmol/L)	136 ± 4.92
Magnesium (mEq/L)	1.73 ± 0.34
Donor variables
Age (yr)	33 ± 11.21
Male gender, n (%)	171 (59.4)
Graft weight (g)	872 ± 357.88
Graft type	95/47/142/4
(whole/left/right/S67), n (%)	(33.0/16.3/49.3/1.4)
Donor-recipient matching
GRWR (%)	1.34 ± 0.57
ABO incompatible, n (%)	9 (3.1)
Gender match (MM/MF/FM/FF), n (%)	128/44/86/30 (44.4/15.3/29.9/10.4)
Surgeon variables
Surgeon A/B/C, n (%)	234/51/3 (81/18/1)
Sequence of transplantation	1-288

BMI: Body mass index; HCC: Hepatocellular carcinoma; MELD: Model for end-stage liver disease; GRWR: Graft-recipient weight ratio.

Table 2 Type of complication after liver transplantation n (%)

	Event	Minor/major
Neurologic complications	145 (100)	97 (67)/48 (33)
Encephalopathy	106 (73)	88 (83)/18 (17)
Delirium	75 (52)	64 (85)/11 (15)
Psychosis	5 (4)	4 (80)/1 (20)
Change in consciousness	26 (18)	20 (77)/6 (23)
Seizures	10 (7)	0 (0)/10 (100)
Cerebrovascular events	5 (4)	0 (0)/5 (100)
Drug neurotoxicity	10 (7)	5 (50)/5 (50)
Locked-in syndrome	12 (8)	4 (33)/8 (67)
Central pontine myelinolysis	2 (1)	0 (0)/2 (100)
Other complications
Acute kidney injury	1
Intra-abdominal infection	9
Graft failure	2
Reoperation	31
Acute rejection	61
Hepatitis B recurrence	10
Tuberculosis infection	8
Cytomegalovirus infection	7
Total complications	85

Table 3 Comparison of variables from multiple perspectives between the neurologic complications and control groups

	NC	No NC	P value
	(n = 142)	(n =146)
Recipient variables
Preoperative
Age (yr)	51.75 ± 10.51	52.77 ± 9.09	0.567
Gender (M/F)	109/33	104/42	0.347
BMI (kg/m2)	24.65 ± 4.25	24.26 ± 3.11	0.617
Hepatitis B	86	89	1.000
Hepatitis C	30	43	0.136
Alcoholic liver disease	50	27	0.001
HCC	51	87	< 0.0001
Child-Pugh score	10.26 ± 2.26	8.27 ± 2.32	< 0.0001
MELD score	20.3 ± 9.4	14.0 ± 7.4	< 0.0001
Hepatic encephalopathy	91	41	< 0.0001
Variceal bleeding	51	63	0.229
Ascites	106	83	0.002
Mental disorder	66	33	< 0.0001
Serum Albumin (g/dL)	2.95 ± 0.57	3.21 ± 0.72	0.01
Serum T. bilirubin (mg/dL)	10.91 ± 13.16	4.74 ± 7.79	< 0.0001
Perioperative
Blood loss (mL)	3329 ± 3953	2474 ± 2728	0.081
Operation time (min)	558.98 ± 99.63	579.9 ± 127.0	0.160
Complex vascularity	45	30	0.033
Postoperative
Day 7 tacrolimus level (ng/mL)	8.23 ± 7.42	6.54 ± 4.69	0.023
Acute rejection	38	23	0.030
Intra-abdominal infection	32	12	< 0.0001
Kidney injury requiring dialysis	18	7	0.021
Donor variables
Donor age (yr)	32.5 ± 11.4	33.6 ± 11.0	0.234
Donor gender (M/F)	89/53	82/64	0.282
Graft type (whole/left/right/S67)	45/21/74/2	50/26/68/2	0.827
Donor-recipient matching
GRWR	1.33 ± 0.56	1.35 ± 0.57	0.726
Surgeon variables
Surgeon A/B/C	116/25/1	118/26/2	0.855
Sequence of transplantation	95.35 ± 69.66	108.12 ± 74.41	0.186

NCs: Neurologic complications; HCC: Hepatocellular carcinoma; MELD: Model for end-stage liver disease; GRWR: Graft-recipient weight ratio; BMI: Body mass index.

Table 4 Multiple logistic regression model for neurologic complications

	OR	95%CI	P value
Recipient variables
Preoperative
Age < 29 or ≥ 60 yr	2.071	1.024-4.272	0.045
BMI < 21.6 or > 27.6 kg/m2	1.877	1.007-3.552	0.049
Child-Pugh score > 9 (Class C)	1.509	1.288-1.790	< 0.001
Hepatic encephalopathy	2.432	1.232-4.860	0.011
Variceal bleeding	0.431	0.221-0.821	0.012
Mental disorder	2.517	1.279-5.064	0.008
Postoperative
Day 7 tacrolimus level > 8.9 ng/mL	1.131	1.068-1.205	< 0.001
Intra-abdominal infection	5.193	2.114-13.67	< 0.001
Donor variable
Donor age < 22 or ≥ 40 yr	2.245	1.207-4.271	0.012
Donor-recipient matching
Male to male gender match	2.36	1.266-4.506	0.008
0.9% < GRWR < 1.9%	1.95	1.069-3.624	0.032
Surgeon variable
31 ≤ Sequence of transplantation < 174	2.773	1.479-5.363	0.002

NCs: Neurologic complications; BMI: Body mass index; MELD: Model for end-stage liver disease; GRWR: Graft-recipient weight ratio.