Neurologic complications after liver transplantation

Abstract

Neurologic complications are relatively common after solid organ transplantation and affect 15%-30% of liver transplant recipients. Etiology is often related to immunosuppressant neurotoxicity and opportunistic infections. Most common complications include seizures and encephalopathy, and occurrence of central pontine myelinolysis is relatively specific for liver transplant recipients. Delayed allograft function may precipitate hepatic encephalopathy and neurotoxicity of calcineurin inhibitors typically manifests with tremor, headaches and encephalopathy. Reduction of neurotoxic immunosuppressants or conversion to an alternative medication usually result in clinical improvement. Standard preventive and diagnostic protocols have helped to reduce the prevalence of opportunistic central nervous system (CNS) infections, but viral and fungal CNS infections still affect 1% of liver transplant recipients, and the morbidity and mortality in the affected patients remain fairly high. Critical illness myopathy may also affect up to 7% of liver transplant recipients. Liver insufficiency is also associated with various neurologic disorders which may improve or resolve after successful liver transplantation. Accurate diagnosis and timely intervention are essential to improve outcomes, while advances in clinical management and extended post-transplant survival are increasingly shifting the focus to chronic post-transplant complications which are often encountered in a community hospital and an outpatient setting.

Keywords: Liver transplantation, Neurologic complications, Meningoencephalitis, Seizures, Stroke, Critical illness myopathy

Core tip: Neurologic complications after liver transplantation are still a major source of morbidity and mortality and careful approach to possible immunosuppressant neurotoxicity and opportunistic infections is needed. Most common neurologic complications include encephalopathy, seizures and cerebrovascular complications, but opportunistic central nervous system infections and central pontine myelinolysis may be associated with significant morbidity as well. Accurate diagnosis and timely intervention are essential to improve outcomes, while advances in clinical management of neurologic post-transplant complications and extended post-transplant survival are increasingly shifting the focus to chronic post-transplant complications which are often encountered in a community hospital and an outpatient setting.