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Case Report
Fatal neurological complication after liver transplantation in acute hepatic failure patient with hepatic encephalopathy
Joo-Yun Kim, Hyun-Su Ri, Ji-Uk Yoon, Eun-Ji Choi, Hye-Jin Kim, Ju-Yeon Park
Kosin Medical Journal 2018;33(1):96-104.
Published online: January 21, 2018

Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea

Corresponding Author: Hyun-Su Ri, Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 50612 Mulgeurn-eup, Yangsan-si, Korea Tel: +82-55-360-2129 Fax: +82-55-360-2149 E-mail:
• Received: October 10, 2017   • Accepted: November 16, 2017

Copyright © 2018 Kosin University School of Medicine Proceedings

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Liver transplantation is a current definitive treatment for those with end-stage liver disease. Hepatic encephalopathy is a common complication of hepatic failure, which can be improved and aggravated by various causes. It is important to differentiate hepatic encephalopathy from other diseases causing brain dysfunction such as cerebral hemorrhage, which is also related to high mortality after liver transplant surgery. A 37-year-old patient was presented with acute liver failure and high ammonia levels and seizure-like symptoms. Computed tomography (CT) of his brain showed mild brain atrophy, regarded as a symptom of hepatic encephalopathy, and treated to decrease blood ammonia level. Deceased donor liver transplantation was performed and liver function and ammonia level normalized after surgery, but the patient showed symptoms of involuntary muscle contraction and showed loss of pupil reflex and fixation without recovery of consciousness. Brain CT showed brain edema and bilateral cerebral infarction, and the patient died after a few days. The purpose of this case report is to emphasize the importance of preoperative neurological evaluation, careful transplantation decision, and proper perioperative management of liver transplantation in patients with acute hepatic encephalopathy.
Fig. 1.
Brain CT was performed on the day before surgery when the consciousness was semi-coma. As a results of reading, no specific finding was observed other than mild brain atrophy.
Fig. 2.
On the first day after surgery, brain CT revealed severe cerebral edema and cerebral infarction. At this time, the patient showed bilateral pupil dilatation and fixation without recovery of consciousness.
Table 1.
Perioperative clinical laboratory findings
Preoperative period Pre-anhepatic period Anhepatic period Neohepatic period Postoperativ e day 1
Ammonia (umol/L) 314 240 209 182 108
Total Bilirubin (mg/dL) 15.5 14.1 12.9 9.4 8.2
Prothrombin time (INR) 6.58 8.84 4.20 4.54 1.85
Creatinine (mg/dL) 2.62 3.38 3.22 3.25 2.15

INR: Internationalized ratio

Table 2.
Perioperative vital signs
Pre-operative Pre-anhepatic period Anhepatic period Neo-hepatic period Post-operative (After 2 hours post-operative) Post-operative (After 2 hours post-operative)
Systolic ABP (mmHg) 150-170 80-130 70-100 100-120 140-165 6-65
Diastolic ABP (mmHg) 65-80 40-75 30-55 40-60 60-80 40-45
Mean ABP (mmHg) 70-85 60-75 45-60 60-65 70-85 45-50
HR (bpm) 100-120 70-90 90-100 60-80 65-80 60-70
SPO2 (%) 98-100 97-100 100 100 99-100 88-96
Mental status Semicoma Under general anesthesia sedation coma
BIS 22-46 0-10 0

ABP: Arterial blood pressure; HR: Heart rate; BIS: Bispectral index

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        Fatal neurological complication after liver transplantation in acute hepatic failure patient with hepatic encephalopathy
        Kosin Med J. 2018;33(1):96-104.   Published online January 21, 2018
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