title: Pretransplant neurological presentation and severe posttransplant brain injury in patients with acute liver failure.
abstract: BACKGROUND
  Alterations in the central nervous system in patients with acute liver failure (ALF) present unique challenges in the perioperative period. In this retrospective study, we examined pretransplant neurological presentation and the incidence, clinical presentation, and risk factors associated with severe posttransplant brain injury (BI) in ALF patients undergoing orthotopic liver transplantation (OLT).
  
  
  METHODS
  After institutional review board approval, ALF patients who underwent OLT between 2004 and 2010 at our center were reviewed. Pretransplant neurological presentation and severe posttransplant BI were examined. Risk factors for the latter were identified.
  
  
  RESULTS
  During the study period, 90 (67 adults and 23 children) ALF patients underwent primary OLT. Preoperatively, all patients developed encephalopathy, 6 had seizure activity, 32 had radiological evidence of cerebral edema, and 11 had severe cerebral edema. After OLT, 7 patients developed severe posttransplant BI. Of these 7 patients, 4 had brain death, and 3 had irreversible injury that precluded them from living independently. Severe pretransplant cerebral edema and a higher posttransplant international normalized ratio (odds ratios and 95% confidence intervals: 50.2, 5.8-433.5 [P<0.001] and 3.1, 1.1-8.8 [P=0.031], respectively) were risk factors associated with severe posttransplant BI.
  
  
  CONCLUSIONS
  Pretransplant neurological complications were prevalent, and severe posttransplant BI occurred at a rate of 7.8% and was significantly associated with severe pretransplant cerebral edema and postoperative international normalized ratio. Our findings support the use of pretransplant computed tomography. If severe pretransplant cerebral edema is confirmed, efforts should be made to aggressively control intracranial pressure and select a proper donor to minimize the risk of severe posttransplant BI and futile transplantation.
authors.affiliation: Department of Anesthesiology, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
authors.forename: Wen-Fei
authors.initials: WF
authors.lastname: Tan
authors.forename: Randolph H
authors.initials: RH
authors.lastname: Steadman
authors.forename: Douglas G
authors.initials: DG
authors.lastname: Farmer
authors.forename: Johnny C
authors.initials: JC
authors.lastname: Hong
authors.forename: Ronald W
authors.initials: RW
authors.lastname: Busuttil
authors.forename: Worapot
authors.initials: W
authors.lastname: Apinyachon
authors.forename: Victor W
authors.initials: VW
authors.lastname: Xia
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001926:Brain Death; D001929:Brain Edema / Q000453:epidemiology; D001930:Brain Injuries / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality; D002493:Central Nervous System Diseases / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality; D016009:Chi-Square Distribution; D002648:Child; D002675:Child, Preschool; D005260:Female; D006501:Hepatic Encephalopathy / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D007223:Infant; D017114:Liver Failure, Acute / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*; D016031:Liver Transplantation / Q000009:adverse effects* / Q000401:mortality; D016015:Logistic Models; D015141:Los Angeles / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012640:Seizures / Q000453:epidemiology; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D055815:Young Adult