Is cognitive confusion common after liver transplant?

Question

Hello doctor,

I hope you are doing well. I wanted to share some concerns and seek your guidance.

I am 44 years old and underwent a liver transplant 14 months ago due to end-stage liver disease caused by non-alcoholic fatty liver disease (NAFLD). My recovery had been progressing well until about two months ago, when I began experiencing intermittent episodes of confusion and difficulty concentrating on simple tasks.

My transplant hepatologist ordered tests, and my ammonia level was found to be mildly elevated at 67 µmol/L. She mentioned the possibility of overt hepatic encephalopathy, which came as a surprise to me, as I had assumed that the transplant would resolve these types of complications. I was also unaware that NAFLD could continue to contribute to issues like hepatic encephalopathy after a successful transplant.

Currently, I am on Tacrolimus and Mycophenolate for immunosuppression. My BMI remains at 31, and my triglyceride levels are elevated at 210 mg/dL.

I would greatly appreciate your insight on the following:

Is it common for NAFLD to lead to overt hepatic encephalopathy after a liver transplant, or would this be considered unusual?
Could my immunosuppressive medications be contributing to these episodes of confusion?
Given that my neurologist did not find any abnormalities on MRI, what additional evaluations or investigations would you recommend discussing with my transplant team?

Thank you very much for your time and guidance.

Answer 1

Hi,

Welcome to icliniq.com

After a liver transplant, hepatic encephalopathy usually gets better or goes away. So, it is not normal for someone to get confused at this point, and they should be carefully and thoroughly checked out instead of being told that it is due to recurrent NAFLD (non-alcoholic fatty liver disease).

A little high ammonia level (67 µmol/L) by itself is not likely to cause serious cognitive problems, so it is vital to look into other possible explanations instead of just ammonia.

The meds you are currently taking are very important. People know that Tacrolimus can cause neurotoxic side effects such as disorientation, trouble concentrating, tremors, and mood swings. This is a really typical and significant thing to think about for those who have had a transplant.

NAFLD itself does not directly cause hepatic encephalopathy after a transplant, but metabolic conditions that go along with it, such as being overweight, having high triglycerides, and being insulin resistant, can have an indirect effect on cognitive function.

It is good that your magnetic resonance imaging (MRI) came back normal because it means that there are no serious structural problems in your brain. But metabolic and medication-related issues may still be making your symptoms worse.

You should talk to your transplant team about the following:

Checking Tacrolimus blood levels, since even slightly higher amounts can cause neurological signs.
Checking for infections, thyroid problems, kidney problems, electrolyte imbalances, and changes in blood glucose levels.
Checking for sleep problems, anxiety, or sadness, which are prevalent after a transplant and might look like cognitive problems.
Thinking of doing neuropsychological tests to find little changes in thinking and to assist in keeping track of improvements over time.

Your presentation is not typical of recurrent hepatic encephalopathy in general. A medication-related or metabolic reason is more likely, and these are usually treatable with the right changes and care.

I hope this helps.

Thank you.