Carlo Poci

Cognitive impairment and electroencephalographic alterations before and after liver transplantation: What is reversible?

The influence of liver transplantation (LT) on mental performance is debated, as is the role of pretransplant overt hepatic encephalopathy (OHE). The aim of this study was to evaluate the time course of the neuropsychological and electroencephalogram (EEG) features of patients with cirrhosis before and after LT with respect to prior OHE. The study population included 65 patients with cirrhosis on the transplant waiting list; 23 had a history of OHE. Each patient underwent an extensive psychometric assessment (10 tests, including paper and pencil tests and a computerized test) and an EEG before and 9 to 12 months after LT. For a subgroup of 11 patients, the assessment was also performed 3 and 6 months after LT. EEGs were analyzed spectrally, and the mean dominant frequencies were obtained. Both psychometric tests and EEGs improved 9 to 12 months after LT. Patients with a history of OHE before LT had worse cognitive performances (P < 0.001) and EEG performances in comparison with their counterparts with a negative history. They also showed greater cognitive improvement after LT (P < 0.01); however, their global cognitive performance remained slightly impaired (P < 0.01). After LT, EEGs normalized for 98% of the patients (P < 0.01), regardless of any history of OHE. In the subgroup of patients evaluated every 3 months, psychometric and EEG findings showed deterioration at 3 months and subsequently steady improvements from 6 months onward. In conclusion, both neuropsychological and EEG performances had significantly improved 1 year after LT. Patients with a history of OHE showed greater improvements after LT than patients with a negative history, but their global cognitive function remained slightly worse; in contrast, EEGs normalized in both groups. Liver Transpl 20:977‐986, 2014.

Split-brain syndrome after hepatic transplantation: a tacrolimus-related vasculitis?

An unusual case of inter-haemispheric disconnection syndrome occurring in a patient who had undergone hepatic transplantation is presented. The underlying disorder, at first wrongly interpreted as encephalitis, was found to be severe, diffuse cerebral vasculitis. The hypothesis that treatment with tacrolimus might have caused, or at least favoured the vascular damage is discussed.

461 INCOMPLETE REVERSAL OF COGNITIVE DYSFUNCTION AFTER LIVER TRANSPLANTATION IN INDIVIDUALS WHO HAD HAD OVERT HEPATIC ENCEPHALOPATHY BEFORE LIVER TRANSPLANTATION

Results: The MTHFR C677T homozygote mutation (TT) was found in 28 (21%) patients, while the remaining 107 (79%) were wild types or heterozygotes (C/*). TT as compared to C/* patients had significantly higher DMELD-score (0.329±0.093 vs 0.146±0.096 means±SE, respectively; p < 0.01) before LT. At multivariate analysis, TT genotype was independently associated with MELD-score worsening during the waiting list (OR 5.21, lower 95% C.L 1.33, upper 95% C.L 20.31, p = 0.018), after adjustment for patient age, PL-MELD score, sex, portal vein thrombosis and cirrhosis aetiology. Post-transplant patient survival was significantly (Log-Rank test p = 0.007) lower in TT (median follow-up 27 months; range 0.1–85 months) than in C/* (median follow-up 33 months; range 0.1– 102 months) recipients. At Cox regression analysis, recipient TT genotype was independently associated with post-transplant patient survival (OR 2.44, lower 95% C.L 1.22, upper 95% C.L 4.84, p = 0.011), after adjustment for recipient age, LT-MELD score, sex, HCV status, and donor risk index. Conclusions: Cirrhotic patients with the MTHFR C677T homozygous mutation have faster disease progression before LT and worse survival after LT.