The effect of liver transplantation on autonomic dysfunction in patients with end-stage liver disease

Abstract

Autonomic dysfunction is a recognized complication of end-stage liver disease (ESLD), but there is little information on how liver transplantation (LT) affects this problem. We sought to prospectively evaluate autonomic function in patients with ESLD before and after LT. Autonomic reflex screen (ARS) was performed on 30 patients with ESLD prior to transplantation. A 10-point composite autonomic score (CAS) was calculated from these data. ARS was repeated after LT, and these scores were compared with the pre-LT ARS. Thirty patients (25 male, 5 female) with cirrhosis that were listed for LT were enrolled in the study and underwent ARS prior to LT. The average age was 55.4 Ϯ 9.1 years. Indications for LT included hepatitis C virus (14), cryptogenic cirrhosis (5), alcoholic cirrhosis (4), and other (7). The mean native Model for End-Stage Liver Disease (MELD) score at ARS was 17.0 Ϯ 5.0. Prior to LT, 86.7% of patients had evidence of autonomic dysfunction. Mean CAS was 2.7 Ϯ 2.2. Sudomotor function was disturbed in 66%, parasympathetic function was disturbed in 57%, and adrenergic function was disturbed in 37%. There was no relationship between pre-LT CAS and age, gender, diabetes, etiology of liver disease, or MELD score. Twenty-one patients (17 male, 4 female) had repeat ARS a mean of 9 Ϯ 6.2 months after LT. The mean native MELD score at the time of ARS testing was 18.1 Ϯ 4.3. Mean pre-LT CAS in this group was 3.0 Ϯ 2.4. Pretransplant CAS was not related to age, gender, diabetes, or MELD score. Autonomic dysfunction improved after LT (CAS pre-LT, 3.0, versus CAS post-LT, 1.9, P ϭ 0.02). There was no relationship between post-LT CAS and age, gender, diabetes, etiology of liver disease, immunosuppression, or type of transplant. In conclusion, autonomic dysfunction is common in patients with ESLD, with over 86% having abnormal testing. Sixty-three percent of patients with cirrhosis with autonomic dysfunction show improvement after LT. Liver Transpl 14:235-239, 2008 Autonomic neuropathy is recognized in up to 68%-80% of patients with cirrhosis.

The heart: Pathophysiology and clinical implications of cirrhotic cardiomyopathy

“…44,45 About two-thirds of the patients with cirrhosis have an autonomic dysfunction before liver transplantation. 41,44,46 The prolonged QT interval reverses in about half of the patients after liver transplantation, probably as a result of diminished portosystemic shunting. 43,47,48 But in a minority of the patients, the QT interval may worsen after liver transplantation.…”

“…43,47,48 But in a minority of the patients, the QT interval may worsen after liver transplantation. 46 In conclusion, liver transplantation is the ultimate treatment for patients with end-stage liver disease, but perioperatively it exerts a considerable stress on the cirrhotic heart. However, proper identification of patient at risk of developing cardiac failure is difficult.…”

Functional status and heart rate variability in end-stage liver disease patients: Association with nutritional status

“…was assigned to them [10]. The remaining two patients chose not to perform the 6mwt, and they were excluded from the gait speed analysis.…”

“…Some studies have already indicated that the six minutes walking test (6mwt) is an adequate predictor of mortality in liver transplantation candidates [10,11] and hospital readmission in chronic heart failure [12]. Therefore, the possibility for using this approach to predict cardiac events in advanced liver disease should be considered as it is not neither expensive nor complicated to be carried out.…”

Autonomic dysfunction in chronic liver disease

“…39 The degree of dysautonomia improves after liver transplantation in 63% of patients at 6-7 months; however in a very small number it gets worse despite successful grafting, 39 and in patients whose allograft function is impaired, dysautonomia persists. 40 Although the aforementioned studies had relatively short follow-up studies of spontaneous baroreflex sensitivity have shown improvements which remain at 18 months.…”