Clinical Analysis of Central Pontine Myelinolysis after Liver Transplantation

Zhixin Wang¹, Ruiyao Zhang¹, Kai Qu¹, Yanyan Zhou¹, Wei Chen¹, Xinsen Xu¹, Fandi Meng¹, Jichao Wei¹, Minghui Tai¹, Jingyao Zhang¹, Lingqiang Zhang¹, Yuelang Zhang², Chang Liu¹

¹Department of Hepatobiliary Surgery, The First Affiliated Hospital, Medical School of Xi’an Jiaotong University, Xi’an, China.
²Department of Radiology, The First Affiliated Hospital, Medical School of Xi’an Jiaotong University, Xi’an, China.

DOI: 10.4236/oalib.1100759                

Abstract

Objective: To discuss the etiology, diagnosis and treatment of central pontine myelinolysis (CPM) by analyzing 4 cases of our center and 26 cases reported by others in our country. Methods: We analyzed the clinical feature, diagnosis and treatment of 4 CPM cases and then compared them with 26 CPM cases reported between 2000 and 2010. Results: The average age of our 4 cases (3 men and 1 woman) was 47.5 years old. All cases were diagnosed by MRI scan. The patients all had been diagnosed as liver cirrhosis and most of the CPM related symptoms were observed within 2 weeks after surgery, including neural and psychic symptoms and physical impairment. Rapid correction of hyponatremia during perioperative period and high blood concentration of FK506 may be the main causes. All cases received etiological and symptomatic combination treatment and were continued with neural function training after hospital discharge. A long-term follow-up (29.5 ± 15.0 months) showed an improvement of neural function to different degrees. Conclusion: CPM after liver transplantation is a severe complication, of which the etiology and pathogenesis were not clear. MRI scan is the main method for confirmative diagnosis. Etiological prevention and timely treatment may improve the prognosis.

Keywords

Liver Transplantation, Central Pontine Myelinolysis, Clinical Analysis

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Yang, X.H., Zhang, J.W. and Qi, B.K. (2003) Retrospective Analysis of Central Pontine Myelinolysis. Journal of Qiqihar Medical College, 24, 742-743.
[2]	Yu, J., Zheng, S., Liang, T.B., et al. (2004) Possible Causes of Central Pontine Myelinolysis after Liver Transplantation. World Journal of Gastroenterology, 10, 2540-2543.
[3]	Liang, T.B., Ke, Q.H., Zheng, S.S., et al. (2005) Central Pontine Myelinolysis after Liver Transplantation: Report of Three Cases. Chinese Journal of Organ Transplantation, 26, 292-293.
[4]	Wu, J.W. (2005) MRI Findings after Liver Transplantation the Pons Central Myelinolysis. Chinese Journal of Medical Imaging, 13, 452-454.
[5]	Cheng, Y. and Li, C.Y. (2006) One Cases of the Postoperative Central Pontine Myelinolysis Liver Transplant. Stroke and Nervous Diseases, 13, 186-186.
[6]	Guo, Y., Sun, Wei, Q., B.A., et al. (2007) MRI Findings after Liver Transplant Center of the Pontine Myelinolysis. Chinese Journal of Medical Imaging, 15, 389-391.
[7]	Cai, C.J., Lu, M.Q., An, Y.L., et al. (2007) Diagnosis and Treatment of Postoperative Liver Transplantation Pons Central Myelinolysis Disease. Journal of Southern Medical University, 27, 849-851.
[8]	Hui, B. (2008) Diagnosis and Treatment of Central Pontine Myelinolysis after Liver Transplantation: A Report of Five cases. Shandong University, Jinan.
[9]	Ma, Y., Tai Q., He, X.-S., et al. (2009) Prophylaxis and Management of Neuropsychiatric Complications after Liver Transplantation. Chinese Journal of Practical Surgery, 29.
[10]	Zhang, H.B., Zhang, M.Y. and Cao Y.Y. (2009) Cause Analysis for Central Pontine Myelinolysis after Liver Transplantation. The Journal of Clinical Anesthesiology, 25.
[11]	Zhang, S.F., Cui, L.L., Yan, S.M., et al. (2009) Central Pontine Myelinolysis after Liver Transplantation: 5 Cases Report. Chinese Journal of Difficult and Complicated Cases, 8, 587-590.
[12]	Zhang, Z.W., Kang, Y., Deng, L.J., et al. (2009) Therapy of Central Pontine Myelinolysis Following Living Donor Liver Transplantation: Report of Three Cases. World Journal of Gastroenterology, 15, 3960. http://dx.doi.org/10.3748/wjg.15.3960
[13]	Mu, X.T. and Wang, H. (2009) MR and DWI Imaging of Central Pontine Myelinolysis after Liver Transplantation. Chinese Medical Equipment Journal, 30, 73-73.
[14]	Yi, S.H., Li, M.R., Yi, H.M., et al. (2010) Central Pontine Myelinolysis Following Liver Transplantation: Five Cases Report. Organ Transplantation, 1, 77-80.
[15]	Sun, L.Y., Xu, W.T., Zhu, Z.J., et al. (2010) Cases Analysis of Our Cases of Central Pontine Myelinolysis after Liver Transplantation. Tianjin Medical Journal, 5, 044.
[16]	Bonham, C.A., Dominguez, E.A., Fukui, M.B., et al. (1998) Central Nervous System Lesions in Liver Transplant Recipients: Prospective Assessment of Indications for Biopsy and Implications for Management. Transplantation, 66, 1596-1604. http://dx.doi.org/10.1097/00007890-199812270-00005
[17]	Martin, R.J. (2004) Central Pontine and Extrapontine Myelinolysis: The Osmotic Demyelination Syndromes. Journal of Neurology, Neurosurgery & Psychiatry, 75, iii22-iii28. http://dx.doi.org/10.1136/jnnp.2004.045906
[18]	Laureno, R. (2004) Central Pontine Myelinolysis Following Rapid Correction of Hyponatremia. Annals of Neurology, 13, 232-242. http://dx.doi.org/10.1002/ana.410130303
[19]	Jun, Y., Liang, T.-B. and Zheng, S.-S. (2004) Progress in Etiology, Diagnosis and Treatment of Central Pontine Myelinolysis after Liver Transplantation. National Medical Journal of China, 84, 1052-1054.
[20]	Luo, Y.-Q., Guo W.-Y. and Fu Z.-R. (2010) Demyelinative Diseases after Liver Transplantation: The Etiology. Academic Journal of Second Military Medical University, 1, 104-107.
[21]	Abbasoglu, O., Goldstein, R., Vodapally, M., et al. (1998) Liver Transplantation in Hyponatremic Cases with Emphasis on Central Pontine Myelinolysis. Clinical Transplantation, 12, 263.
[22]	Bronster, D.J., Emre, S., Boccagni, P., et al. (2001) Central Nervous System Complications in Liver Transplant Recipients—Incidence, Timing, and Long-Term Follow-Up. Clinical Transplantation, 14, 1-7. http://dx.doi.org/10.1034/j.1399-0012.2000.140101.x
[23]	Shi, Y.H., Fan, J., Wu Z.Q., et al. (2004) Retrospective Analysis of Neuropsychiatric Complications of Liver Transplantation. Journal of Surgery Concepts & Practice, 8, 451-453.
[24]	Schwartz, R., Bravo, S., Klufas, R., et al. (1995) Cyclosporine Neurotoxicity and Its Relationship to Hypertensive Encephalopathy: CT and MR Findings in 16 Cases. American Journal of Roentgenology, 165, 627-631. http://dx.doi.org/10.2214/ajr.165.3.7645483
[25]	Bekersky, I., Dressler, D. and Mekki, Q. (2001) Effect of Time of Meal Consumption on Bioavailability of a Single Oral 5 mg Tacrolimus Dose. The Journal of Clinical Pharmacology, 41, 289-297. http://dx.doi.org/10.1177/00912700122010104
[26]	Yuan, C.H. and Liu, Y.F. (2004) Central Nervous System Toxicity Induced by Tacrolimus after Liver or Renal Transplantation. Journal of Chinese Clinical Medicine, 5, 10-11.
[27]	Yi, S.H., Li, H., Yang, Y., et al. (2007) Major Neurological Complications Following Liver Transplantation and Their Management. Journal of Southern Medical University, 27, 1310-1313.
[28]	Saner, F.H., Koeppen, S., Meyer, M., et al. (2008) Treatment of Central Pontine Myelinolysis with Plasmapheresis and Immunoglobulins in Liver Transplant Patient. Transplant International, 21, 390-391. http://dx.doi.org/10.1111/j.1432-2277.2007.00608.x
[29]	Ramia, J.M., Villar, J., Castaão, J., et al. (2006) Mielinólisis Central Pontina tras Trasplante Hepático. Cirugía Espaãola, 80, 411-412. http://dx.doi.org/10.1016/S0009-739X(06)70999-X
[30]	Kim, B.S., Lee, S.G., Hwang, S., et al. (2007) Neurologic Complications in Adult Living Donor Liver Transplant Recipients. Clinical transplantation, 21, 544-547. http://dx.doi.org/10.1111/j.1399-0012.2007.00687.x
[31]	Yuan, H. and Qi, J. (2008) Progress in MRI Diagnosis of the Center of the Pontine Myelinolysis. Shandong Medical Journal, 48, 107-108.
[32]	Murase, T., Sugimura, Y., Takefuji, S., et al. (2006) Mechanisms and Therapy of Osmotic Demyelination. The American Journal of Medicine, 119, S69-S73. http://dx.doi.org/10.1016/j.amjmed.2006.05.010
[33]	Ellison, G.W. and Myers, LW. (1980) Immunosuppressive Drugs in Multiple Sclerosis Pro and Con. Neurology, 30, 28-32. http://dx.doi.org/10.1212/WNL.30.7_Part_2.28
[34]	Yoon, K., Fong, K., Koh, D., et al. (2000) Central Pontine Myelinolysis a Rare Manifestation of CNS Sjogren’s Syndrome. Lupus, 9, 471-473. http://dx.doi.org/10.1191/096120300678828550
[35]	Chemaly, R., Halaby, G., Mohasseb, G., et al. (1998) Extrapontine Myelinolysis: Treatment with TRH. Revue Neurologique, 154, 163-165.
[36]	Zhang, L.-J., Huang, X.-N., Wang, M. and Zhang, J.-J. (1995) A Case of Hyperbaric Oxygen Treatment of Central Pontine Myelinolysis. Chinese Journal of Nautical Medicine and Hyperbaric Medicine, 270, 333-313.
[37]	Liu, Y., Dong, W.W., Liu, Y., et al. (2001) Central Pontine Myelinolysis: A Report of 5 Cases with Autopsy Pathological Analysis. Chinese Journal of Neurology, 34, 326-328.