Identifying In-Hospital Risk Factors for Post-liver Transplant Seizures

TL;DR

This study identifies risk factors for seizures after liver transplants and creates a predictive model to help clinicians manage patient care.

Contribution

The study introduces a new predictive risk model for post-liver transplant seizures using in-hospital clinical variables.

Findings

10.6% of liver transplant patients experienced seizures within 30 days post-surgery.

A predictive model with an AUC of 0.90 was developed using seven perioperative variables.

The model achieved an accuracy of 0.72 and could help improve neurological outcomes.

Abstract

Background

Liver transplantation (LT) is a life-saving intervention for end-stage liver disease; however, postoperative complications, particularly neurological issues such as seizures, pose significant challenges. This study aims to identify perioperative factors associated with seizures following LT and develop a predictive risk model. By recognizing these in-hospital risk factors, clinicians may tailor perioperative management to mitigate seizure risk and improve neurological outcomes.

Methodology

We conducted a retrospective observational study of adult patients who underwent LT at a tertiary referral center between January 2009 and January 2019. Data were collected for the perioperative period, spanning seven days pre-LT to 30 days post-LT. Variables included demographic, clinical, neurological, and liver-related data. Statistical analyses compared patients with and without seizures using appropriate tests for categorical and continuous variables. A predictive model for seizures was developed using in-hospital factors. It was then internally validated and evaluated for accuracy, sensitivity, specificity, and receiver operating characteristic curve. From this model, a practical clinical risk score was created.

Results

Of 376 patients, 40 (10.6%) experienced seizures within 30 days post-LT. The median age was 54.8 years, and 41% were males. Chronic liver failure was the primary indication for LT, with alcohol abuse, hepatitis C, and hepatitis B being the most common etiologies. Patients’ preoperative conditions included hepatocellular carcinoma (23%), chronic hyponatremia (22.6%), and prior kidney failure (22.1%). Portosystemic encephalopathy (PSE) was present in 46.5% of patients. Patients’ preoperative blood tests revealed low hemoglobin (mean: 10.8 g/dL, SD: 2.2), hyponatremia (mean: 134 mEq/L, SD: 5), elevated international normalized ratio (mean: 2.21, SD: 1.56), high bilirubin (mean: 8.74 mg/dL, SD: 10.23), and creatinine (mean: 1.41 mg/dL, SD: 1.95). Combined liver and kidney transplantation was performed in 9.2% of cases, while 15.4% were emergency procedures. Graft complications occurred in 25% of patients, with functional delay being the most frequent (14.5%). Immunosuppressive regimens included prednisone with tacrolimus or mycophenolate. Seizures typically occurred on post-LT day seven (interquartile range: 5-13) and included uncertain onset (40%), non-convulsive status epilepticus (30%), generalized seizures (22.5%), convulsive status epilepticus (5%), and focal seizures (2.5%). Treatment was administered to 85% of seizure patients, primarily with levetiracetam (75%). Using seven acute perioperative variables, i.e., age at transplantation, history of PSE, pre-LT epilepsy diagnosis, pre-LT hemoglobin, procedure duration, graft cold ischemia time, and intraoperative blood transfusion, we developed a risk score for post-LT seizures. This score achieved an accuracy of 0.72 (95% CI: 0.63-0.80) and an area under the curve (AUC) of 0.90.

Conclusions

This study identifies key in-hospital factors associated with seizures following LT and presents a predictive risk model based on clinical preoperative and surgical variables. With an AUC of 0.90, the model demonstrates strong discriminative ability, suggesting it is a robust tool for predicting seizures in the immediate post-LT period. Further prospective multicenter studies are needed to externally validate the model and risk score, thereby enhancing its clinical applicability.