Chronic parkinsonism associated with liver cirrhosis

Liver Transplantation Improves Symptoms in Patients With Cirrhosis-Related Parkinsonism: Presented at EFNS
By Jenny Powers

GENEVA -- September 28, 2010 -- Patients with cirrhosis-related parkinsonism have improved overall symptoms after liver transplantation, according to preliminary data from a study presented here at the 14th Congress of the European Federation of Neurological Societies (EFNS).

A form of chronic parkinsonism associated with liver cirrhosis is rapidly evolving and involves symmetrical akinetic-rigid syndrome, gait and postural impairment, and focal dystonia. Unlike classic Parkinson's disease, resting tremor is notably minimal or absent in this form of parkinsonism, but postural tremor is prominent.

Diana Apetauerova, MD, Lahey Clinic, Burlington, Massachusetts, presented the findings on September 26. The researchers are conducting an ongoing trial to determine the relationship between the neuroradiological and biological aspects of parkinsonism and liver cirrhosis severity.

Cirrhosis-related parkinsonism is seen in acquired hepatocerebral degeneration, but its prevalence and post-transplant natural history have not been determined. This prospective study will enrol up to 120 patients with liver cirrhosis who were treated at the Lahey Clinic liver-transplant facility.

Parkinsonism is being evaluated by use of the United Parkinson's Disease Rating Scale (UPDRS), brain magnetic resonance imaging, Mini-Mental State Examination, and videotaping. Patients are also undergoing standard liver transplant evaluation and repeat testing at 6 weeks and 3 and 12 months after transplantation.

The researchers examined the possible correlations between the severity of liver disease, determined by the Model for End-Stage Liver Disease (MELD) scale, and the stage of parkinsonism, determined by the motor part of UPDRS.

Of the patients with cirrhotic liver disease, 46% (38 of 81) exhibited parkinsonism. No association was seen between the severity of MELD and motor UPDRS (P = .74) or increased copper, ammonia, manganese, or iron levels. Abnormal signal in the basal ganglia was seen in all of the patients with parkinsonism.

Seven parkinsonian patients underwent liver transplantation. At 3 months after surgery, statistically significant improvement was seen in several aspects of parkinsonism, specifically gait (P = .02), total motor UPDRS (P = .03), and activities of daily living (P = .06).

Dr. Apetauerova concluded that this study identified a high incidence of parkinsonism in patients with liver cirrhosis. Although no correlations were found between the severity of liver cirrhosis and the severity of symptoms, a statistically significant improvement was observed in symptoms after liver transplantation.

The ongoing study has accumulated substantial data that have yet to be analysed, Dr. Apetauerova said. One aspect that will be retrospectively investigated is the effect of portal systemic shunting.

[Presentation title: Chronic Parkinsonism Associated With Liver Cirrhosis. Abstract P1671]

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