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Identifying Risk Factors for Central Pontine and Extrapontine Myelinolysis After Liver Transplantation: A Case–Control Study

Neurocritical Care volume 20, pages 287–295 (2014)Cite this article

Abstract

Background

Central pontine and extrapontine myelinolysis (CPEPM) is a rare but potentially fatal complication after orthotopic liver transplantation (OLT). The aim of this study was to identify risk factors for development of CPEPM after OLT and to assess patient outcome.

Methods

We reviewed the clinical data of 1,378 patients who underwent OLT between 1987 and 2009 in Geneva, Switzerland and Edmonton, Canada. Nineteen patients (1.4 %) developed CPEPM. We compared their characteristics with control patients, matched by age, gender, date of OLT, and MELD score.

Results

The 19 patients with CPEPM (7F, mean age 52.1 ± 2 years) had a mean MELD score of 26 ± 2.2. Before OLT, patients who develop CPEPM presented more frequently low (<130 mmol/l; p < 0.04) and very low (<125 mmol/l; p < 0.009) sodium than controls. In patients developing CPEPM, the number of platelet units and fresh frozen plasma transfused during surgery was higher (p = 0.05 and 0.047), hemorrhagic complications were more frequent after OLT (p = 0.049), and variations of sodium before and after OLT were higher (p = 0.023). The association of >2 of these conditions were strongly associated with CPEPM (p = 0.00015). Mortality at 1 year of patients developing CPEPM was higher (63 vs. 13 %, p < 0.0001).

Conclusions

High MELD score patients undergoing OLT, receiving massive perfusions of Na-rich products, experiencing surgery-related hemorrhagic complication and important fluctuations of Na are at risk of developing CPEPM. Therefore careful monitoring of natremia in the perioperative period and use of water-free perfusion in case of massive blood-products transfusion are critical points of this patient management.

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Acknowledgments

Christian Toso was supported by the Swiss National Science Foundation (SCORE Grant 3232230-126233).

Conflict of interest

Isabelle Morard, Yvan Gasche, Mark Kneteman, Christian Toso, Ariane Mentha, Glenda Meeberg, Gilles Mentha, Norman Kneteman, and Emiliano Giostra declare that they have no conflict of interest.

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Author notes

  1. Isabelle Morard & Emiliano Giostra

    Present address: Department of Gastroenterology and Hepatology, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland

  2. Yvan Gasche

    Present address: Division of Critical Care Medicine, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland

  3. Mark Kneteman, Glenda Meeberg & Norman Kneteman

    Present address: Department of Surgery, University of Alberta, Edmonton, AB, Canada

  4. Christian Toso, Ariane Mentha & Gilles Mentha

    Present address: Department of Visceral Surgery, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland

Affiliations

  1. Department of Transplantation, Geneva University Hospital, Geneva, Switzerland

    Isabelle Morard, Christian Toso, Ariane Mentha, Gilles Mentha & Emiliano Giostra

  2. Geneva Neuroscience Center, Geneva University, Geneva, Switzerland

    Yvan Gasche

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  1. Isabelle Morard
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Correspondence to Isabelle Morard.

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Morard, I., Gasche, Y., Kneteman, M. et al. Identifying Risk Factors for Central Pontine and Extrapontine Myelinolysis After Liver Transplantation: A Case–Control Study. Neurocrit Care 20, 287–295 (2014). https://doi.org/10.1007/s12028-013-9928-9

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Keywords

  • Orthotopic liver transplantation
  • MELD
  • Neurological complications
  • Central pontine and extrapontine myelinolysis
  • Hyponatremia
  • Hemorrhagic complications
  • Mortality