Neurological complications of organ transplantation

Nerve regeneration in transplanted organs and tracer imaging studies: A review

The technique of organ transplantation is well established and after transplantation the patient might be faced with the problem of nerve regeneration of the transplanted organ. Transplanted organs are innervated by the sympathetic, parasympathetic, and visceral sensory plexuses, but there is a lack of clarity regarding the neural influences on the heart, liver and kidneys and the mechanisms of their innervation. Although there has been considerable recent work exploring the potential mechanisms of nerve regeneration in organ transplantation, there remains much that is unknown about the heterogeneity and individual variability in the reinnervation of organ transplantation. The widespread availability of radioactive nerve tracers has also made a significant contribution to organ transplantation and has helped to investigate nerve recovery after transplantation, as well as providing a direction for future organ transplantation research. In this review we focused on neural tracer imaging techniques in humans and provide some conceptual insights into theories that can effectively support our choice of radionuclide tracers. This also facilitates the development of nuclear medicine techniques and promotes the development of modern medical technologies and computer tools. We described the knowledge of neural regeneration after heart transplantation, liver transplantation and kidney transplantation and apply them to various imaging techniques to quantify the uptake of radionuclide tracers to assess the prognosis of organ transplantation. We noted that the aim of this review is both to provide clinicians and nuclear medicine researchers with theories and insights into nerve regeneration in organ transplantation and to advance imaging techniques and radiotracers as a major step forward in clinical research. Moreover, we aimed to further promote the clinical and research applications of imaging techniques and provide clinicians and research technology developers with the theory and knowledge of the nerve.

Guillain-Barre Syndrome-A Rare Cause of Quadriparesis after the Bentall Procedure for Type A Aortic Dissection

Neurological complications following aortic surgery are most often cerebrovascular accidents due to embolism, or spinal infarcts resulting in hemiparesis or hemiplegia. Guillain-Barre syndrome is a rare cause of quadriparesis. Here, we report a 49-year old male who presented with acute aortic dissection and underwent the Bentall procedure following which he developed quadriparesis, subsequently diagnosed to be a case of Guillain-Barre syndrome. He was successfully treated with intravenous immunoglobulin.

Renal transplant recipient seizure practical management

Seizures are not uncommon in renal transplant patients. The common aetiologies are metabolic disturbance associated with renal failure, immunosuppression and associated complications and infections. Their management can be challenging because of altered pharmacokinetics of antiepileptic drugs (AEDs) and their removal by dialysis. A practical approach to the management of seizure in renal transplant patients is discussed. This review highlights the guidelines for use of various AEDs in renal transplants.

The Incidence of Perioperative Stroke: Estimate Using State and National Databases and Systematic Review

Background and Purpose

Perioperative stroke remains a devastating complication after surgical procedures, due to hemodynamic and inflammatory changes that increase the risk of strokes within 30 days following surgery. We aimed to assess the incidence of perioperative strokes in patients undergoing various surgical procedures and reach a national estimate.

Methods

A retrospective cohort study was conducted using California State Inpatient Databases, State Emergency Department Databases, State Ambulatory Surgery and Services Databases, and the National Inpatient Sample (NIS) during the period 2008 to 2011 from the Healthcare Cost and Utilization Project. A systematic review was conducted using PubMed, Embase, and Web of Science databases to obtain published articles that reported the incidence of perioperative stroke in various surgical procedures.

Results

Analysis of 3,694,410 surgical encounters from the state of California (mean±standard deviation age: 52.4±21.1 years) yielded an overall rate of perioperative stroke of 0.32% (n=11,759). The incidence of perioperative strokes was highest following neurological (1.25%), vascular (1.07%), and cardiac (0.98%) surgeries. The NIS database contained a total of 48,672,974 weighted hospitalizations and yielded a rate of perioperative stroke of 0.42% (n=204,549). The systematic review completed yielded 187 articles, which had an overall sample size of 184,922 and an incidence of perioperative stroke ranging from 0% to 13.86%. It is estimated that in any given year, there would be approximately 40,000 to 55,000 (0.33% to 0.46%) perioperative strokes nationally.

Conclusions

Our findings support further strategies to identify and stratify patients undergoing surgical procedures with a high incidence of perioperative strokes to improve patient counseling and a future potential treatment plan.

Neurological Complications After Renal Transplantation: A Systematic Review and Meta-Analysis

The aim of this systematic review and meta-analysis was to evaluate the prevalence of neurological complication after renal transplantation. The searches were conducted by two independent researchers in the international (PubMed, Web of Science, Scopus, and Google Scholar) and national databases (Magiran and SID) to find the relevant studies published in English and Persian languages since the creation of the databases until January 2019 (without time limitations). The keywords used in the search strategy were: neurologic complication, central nervous system, peripheral nervous system, tremor, CVA, encephalopathy, neurological complications, renal transplantation, renal failure, kidney transplantation, immunosuppression, neurotoxicity, opportunistic infections, CNS, cerebrovascular disease, chronic kidney disease, cognitive impairment, and end-stage renal disease, which were combined using the AND, OR, and NOT operators. Finally, a meta-analysis was conducted in STATA14 statistical software. Based on the random effect model, the total prevalence of neurologic complications in 4674 patients who had undergone the renal transplantation surgery was 7.9% (95% confidence interval [CI]:7.2%,8.7%, I² = 90.1%). The prevalence of infectious, non-infectious and treatment associated neurologic complications was 9.5% (95% CI -8.9, 10.2), 91.8% (95% CI -91.3, 92.4) and 97% (95% CI-95.7%,98.4%) of all neurologic complications in renal transplant patients, respectively. And according to the present subgroup analysis, peripheral neuropathy with a prevalence about 30% (29%) (95% CI -27.6%, 30.4%, I² = 99.4%) was the most common neurological disorder in renal transplant patients followed by tremor with a prevalence of 19.5% (CI -17.6%, 21.3%, I² = 97.1%), cerebrovascular events with a prevalence of 15.1% (95% CI -13.9%, 16.4%, I² = 96.5%), encephalopathy with the prevalence of 13% (95% CI -12%, 14%, I² = 99.3%), headache with a prevalence of 8.3% (95% CI -6.8%, 9.8%, I² = 97.3%) and seizure with a prevalence of 7.4% (CI - 6.5%, 8.3%, I² = 94.6%). The results of the present systematic review and meta-analysis, suggests that post-kidney transplantation neurological disorders, with a prevalence rate about 8%, are relatively common; most of them are caused by immunosuppressive drugs and can be treated by decreasing the dose or switching the immunosuppressive drugs. Neurological disorders are associated with increased mortality; thus, differential diagnosis should be conducted for each individual patient with neurological symptoms after transplantation. It is important for all health care providers to become familiar with the symptoms of neurological disorders that may occur after organ transplants. Recognizing and monitoring these symptoms can reduce the risk of death in kidney transplant recipients. Further research is needed to help the transplant community to identify these issues and problems better in order to achieve the ultimate goal of helping renal patients and sending them back into their normal lives.

Cardiovascular and Neurologic Complications in Kidney Transplant Recipients: A Focused Appraisal of Symptoms

BACKGROUND AND OBJECTIVE

After a kidney transplantation, all efforts are focused on graft function. However, cardiovascular and neurologic complications might lead to decreased quality of life and shortened life expectancy. Early recognition of related symptoms might be critical to successfully manage these complications.

METHODS AND PATIENTS

We retrospectively reviewed the medical records of patients who had undergone kidney transplantation in a tertiary center between January 2014 and December 2017. Demographic data and past medical history were systematically gathered. Symptoms related to cardiac or neurologic disorders and final diagnoses were recorded.

RESULTS

One hundred eighty-six patients were evaluated by a cardiologist or a neurologist in the early post-operative period or long-term follow-up. Chest pain (n = 17; 9.1%) and palpitations (n = 13; 7.0%) were the most prevalent symptoms. Coronary artery disease was diagnosed in 70.6% (n = 12) of the patients presenting with chest pain. All of the patients were treated successfully, with either antianginal drugs or percutaneous angioplasty. Atrial fibrillation was diagnosed in 53.9% (n = 7) of the patients presenting with palpitations. Headache was the most prevalent chronic neurologic symptom (n = 16; 8.6%). Transient ischemic attack occured in 7 patients (3.8%) and 5 (2.7%) patients experienced ischemic stroke.

CONCLUSION

Kidney transplantation is associated with short- and long-term cardiac and neurologic complications. Our findings underscore the crucial role of questioning symptoms that might be related to severe disorders. Asymptomatic patients with high risk factors must also be under scope. Attending physicians should have a low threshold for referring these patients to cardiologists and neurologists.

Complications of Solid Organ Transplantation: Cardiovascular, Neurologic, Renal, and Gastrointestinal

Despite improvements in overall graft function and patient survival rates after solid organ transplantation, complications can lead to significant morbidity and mortality. Cardiovascular complications include heart failure, arrhythmias leading to sudden death, hypertension, left ventricular hypertrophy, and allograft vasculopathy in heart transplantation. Neurologic complications include stroke, posterior reversible encephalopathy syndrome, infections, neuromuscular disease, seizure disorders, and neoplastic disease. Acute kidney injury occurs from immunosuppression with calcineurin inhibitors or as a result of graft failure after kidney transplantation. Gastrointestinal complications include infections, malignancy, mucosal ulceration, perforation, biliary tract disease, pancreatitis, and diverticular disease. Immunosuppression can predispose to infections and malignancy.

Neurodevelopmental Outcomes in Children With Liver Diseases: a Systematic Review

OBJECTIVE

The aim of the study was to determine the neurodevelopmental outcomes of children with liver diseases based on a systematical review of the literature.

METHOD

A literature search according to the PRISMA statement was conducted using predefined search terms in PubMed, Cochrane Library, and PsycINFO. The inclusion criterion was studies published from 2000 onwards that reported on the neurodevelopmental outcomes of term-born children with liver diseases. A narrative synthesis was done to appraise the studies.

RESULTS

Twenty-five studies were included (1913 children), 19 of which described children after liver transplantation (LTx; 1372 children). Sixty-seven percentage of the studies on children with liver diseases who survived with their native livers showed low-average or abnormal scores on specific subscales of cognitive and behavioral measures. In studies on children after LTx, this was 82%. After LTx, 83% of studies demonstrated impaired outcomes on behavior, whereas 42% of children received special education. Motor development was impaired in 82% of studies in children with native liver and after LTx.

LIMITATIONS

Studies were heterogenic because of sample sizes, etiology of liver disease and type of assessment tools used.

CONCLUSIONS

More than two-third of included studies showed neurodevelopmental deficits in children with liver diseases, affecting all neurodevelopmental areas. Knowledge on risk factors for impaired neurodevelopment is limited and lack of long-term follow-up is worrying, especially considering the increasing survival rates, resulting in more at-risk patients. Studying early predictors and risk factors of abnormal developmental trajectories of children with liver diseases is indicated to assess strategies to improve their long-term neurodevelopmental outcomes.

Influence of early neurological complications on clinical outcome following lung transplant

Background

Neurological complications after lung transplantation are common. The full spectrum of neurological complications and their impact on clinical outcomes has not been extensively studied.

Methods

We investigated the neurological incidence of complications, categorized according to whether they affected the central, peripheral or autonomic nervous systems, in a series of 109 patients undergoing lung transplantation at our center between January 1 2013 and December 31 2014.

Results

Fifty-one patients (46.8%) presented at least one neurological complication. Critical illness polyneuropathy-myopathy (31 cases) and phrenic nerve injury (26 cases) were the two most prevalent complications. These two neuromuscular complications lengthened hospital stays by a median period of 35.5 and 32.5 days respectively. However, neurological complications did not affect patients’ survival.

Conclusions

The real incidence of neurological complications among lung transplant recipients is probably underestimated. They usually appear in the first two months after surgery. Despite not affecting mortality, they do affect the mean length of hospital stay, and especially the time spent in the Intensive Care Unit. We found no risk factor for neurological complications except for long operating times, ischemic time and need for transfusion. It is necessary to develop programs for the prevention and early recognition of these complications, and the prevention of their precipitant and risk factors.

Guillain-Barré syndrome after allogeneic bone marrow transplantation: Case report and literature review

A 50-year-old man with acute myelogenous leukemia underwent allogeneic bone-marrow transplantation (BMT). He presented with severe diarrhoea 86 days post BMT and was diagnosed with graft-versus-host disease (GVHD) based on skin and rectal biopsies. He complained of numbness and weakness in the distal extremities at 114 days after BMT. His symptoms rapidly deteriorated and he required mechanical ventilation for respiratory failure. His clinical course and the findings of a nerve conduction study fulfilled the criteria for diagnosis of Guillain-Barré syndrome (GBS). Sural nerve biopsy revealed active demyelination and infiltration of macrophages and CD8⁺ T-cells. After three cycles of intravenous immunoglobulin therapy, his symptoms gradually improved, and he could eventually walk unassisted. Although GBS has been known to develop after allogeneic BMT, the pathogenesis remains unclear, and specific treatment regimens have not been well established. Here, we report a case of GBS, caused by an immune-mediated mechanism related to GVHD, which was successfully treated using intravenous immunoglobulin therapy.

Neurologic complications following pediatric renal transplantation

We reviewed neurologic complications after renal transplantation in children over a 20-year period. Neurologic complications were classified as early (within 3 months) and delayed (beyond 3 months). Of 115 children, 10 (8.7%) had complications. Early complications were found in 4.35% of patients: seizures in 4 (posterior reversible leukoencephalopathy syndrome due to immunosuppressant toxicity, sepsis/presumed meningitis, and indeterminate) and headaches in 1. One patient with seizures received levetiracetam for 6 months and 1 with headaches received amitriptyline prophylaxis. Late complications were noted in 4.35% of patients: seizures in 3 (posterior reversible leukoencephalopathy syndrome due to hypertension, hypertensive encephalopathy), headaches in 2, and tremors in 1. Two patients with seizures were treated with anti-epilepsy medications; 1 with migraine received cyproheptadine prophylaxis. Neurologic complications develop in children after renal transplantation. Seizures due to posterior reversible leukoencephalopathy syndrome were the commonest complication. Early detection and appropriate management of these complications is important.

Overview of the effect and epidemiology of parasitic central nervous system infections in African children

Infections of the central nervous system are a significant cause of neurologic dysfunction in resource-limited countries, especially in Africa. The prevalence is not known and is most likely underestimated because of the lack of access to accurate diagnostic screens. For children, the legacy of subsequent neurodisability, which affects those who survive, is a major cause of the burden of disease in Africa. Of the parasitic infections with unique effect in Africa, cerebral malaria, neurocysticercosis, human African trypanosomiasis, toxoplasmosis, and schistosomiasis are largely preventable conditions, which are rarely seen in resource-equipped settings. This article reviews the current understandings of these parasitic and other rarer infections, highlighting the specific challenges in relation to prevention, diagnosis, treatment, and the complications of coinfection.

An uncommon cause of acutely altered mental status in a renal transplant recipient

INTRODUCTION

Neurological complications are quite frequent in patients after solid organ transplantation presenting with focal or generalized neurologic symptoms as well as altered mental status. Posterior reversible encephalopathy syndrome is a rare cliniconeuroradiological entity characterized by headache, altered mental status, cortical blindness, seizures, and other focal neurological signs and a diagnostic magnetic resonance imaging.

CASE REPORT

We present a case of a 57-year-old woman with one episode of seizures and sudden onset of altered mental status (time and person perception) accompanied with headache at the thirtieth postoperative day after renal transplantation.

CONCLUSION

Posterior reversible encephalopathy syndrome, although an uncommon post-renal transplantation complication, should be considered in these patients, as several factors surrounding the setting of transplantation have been implicated in its development. Thus, physicians should be aware of this condition in order to establish the diagnosis and offer appropriate treatment.

Neurologic aspects of multiple organ transplantation

Complex multiorgan failure may require simultaneous transplantation of several organs, including heart-lung, kidney-pancreas, or multivisceral transplantation. Solid organ transplantation can also be combined with hematopoietic stem cell transplantation to modulate immunologic response to a solid organ allograft. Combined multiorgan transplantation may offer a lower rate of allograft rejection and lower immunosuppression needs. In recent years, intestinal and multivisceral transplantations became viable as a rescue treatment for patients with irreversible intestinal failure who can no longer tolerate total parenteral nutrition with 70% survival after 5 years which is comparable to other types of solid organ allografts. Post-transplant neurologic complications were reported in up to 86% of allograft recipients and greatly overlap in intestinal and multivisceral allograft recipients, without a significant effect on the outcome of transplantation. Other common organ combinations in multiorgan transplantation include kidney-pancreas, which is mostly used for patients with renal failure and uncontrolled diabetes, and heart-lung for patients with congenital heart disease and idiopathic pulmonary arterial hypertension. Kidney-pancreas transplantation frequently results in an improvement of diabetic complications, including diabetic neuropathy. Heart-lung allograft recipients have very similar clinical course and spectrum of neurologic complications to lung transplant recipients. At this time there are no reports of an increased risk of graft-versus-host disease with combined transplantation of solid organ allograft and hematopoietic stem cells. Chronic immunosuppression and complex toxic-metabolic disturbances after multiorgan transplantation create a permissive environment for development of a wide spectrum of neurologic complications which largely resemble complications after transplantations of individual components of complex multiorgan allografts.

Neurologic complications of pancreas and small bowel transplantation

In the past decade, substantial improvements in patient and graft survival for pancreas and small bowel transplants have been achieved. Despite this progress, many patients still develop neurologic complications in the course of their illness. Small bowel transplants produce more neurologic complications because of the complex metabolic environment in which the procedure is performed and because of the intense immune suppression necessitated by the greater immunogenicity of the intestinal mucosa. Pancreas transplants stabilize and/or improve the signs and symptoms of diabetic neuropathy over time. Because transplantation of the pancreas is often coupled with a kidney transplant and small intestine with liver, neurologic complications in these patients sometimes reflect problems involving the organ partner or both organs. The spectrum of neurologic complications for pancreas and small bowel transplant recipients is similar to other organ transplants but their frequency varies depending on the type of transplant performed.

Neurocognitive outcomes at kindergarten entry after liver transplantation at <3 yr of age

This prospective inception cohort study determines kindergarten-entry neurocognitive abilities and explores their predictors following liver transplantation at age <3 yr. Of 52 children transplanted (1999-2008), 33 (89.2%) of 37 eligible survivors had psychological assessment at age 54.7 (8.4) months: 21 with biliary atresia, seven chronic cholestasis, and five acute liver failure. Neurocognitive scores (mean [s.d.], 100 [15]) as tested by a pediatric-experienced psychologist did not differ in relation to age group at transplant (≤12 months and >12 months): FSIQ, 93.9 (17.1); verbal (VIQ), 95.3 (16.5); performance (PIQ), 94.3 (18.1); and VMI, 90.5 (15.9), with >70% having scores ≥85, average or above. Adverse predictors from the pretransplant, transplant, and post-transplant (30 days) periods using univariate linear regressions for FSIQ were post-transplant use of inotropes, p = 0.029; longer transplant warm ischemia time, p = 0.035; and post-transplant highest serum creatinine, (p = 0.04). For PIQ, they were pretransplant encephalopathy, p = 0.027; post-transplant highest serum creatinine, p = 0.034; and post-transplant inotrope use, p = 0.037. For VMI, they were number of post-transplant infections, p = 0.019; post-transplant highest serum creatinine, p = 0.025; and lower family socioeconomic index, p = 0.039. Changes in care addressing modifiable predictors, including reducing acute post-transplant illness, pretransplant encephalopathy, transplant warm ischemia times, and preserving renal function, may improve neurocognitive outcomes.

Enhancing brain lesions in a renal transplant patient

Neurologists should be familiar with the spectrum of central nervous system (CNS) pathology that renal transplants patients are prone to. We are presenting a case of posttransplant lymphoproliferative disorder of the CNS to highlight less commonly described imaging findings and review this disease entity.

Chronic immune-mediated axonal polyneuropathy following umbilical cord blood transplant for childhood-onset cerebral adrenoleukodystrophy

Peripheral polyneuropathy is an unusual complication after organ transplantation and HSCT. The present study describes the case of an eight-yr-old boy diagnosed with ALD who underwent HLA-matched UCBT under a reduced-intensity conditioning regimen and developed progressive walking difficulty and hand clumsiness 11 months after transplantation. These symptoms were associated with cGVHD, identified as immune-mediated axonopathy by electrophysiological examination and sural nerve biopsy. Peripheral polyneuropathy should be kept in mind as a complication of GVHD.

Factors influencing outcome and incidence of late complications in children who underwent allogeneic hematopoietic stem cell transplantation for hemoglobinopathy

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) remains the only potentially curative treatment for severe hemoglobinopathy (HGP). Late complications (LCs) are all events occurring beyond two years post-HSCT. We retrospectively analyzed prevalence, factors influencing occurrence, and prognosis of LCs post-HSCT for HGP.

PATIENTS AND METHODS

Between 2000 and 2011, 47 patients (21 males, 26 females; 43 with beta thalassemia major, four with sickle cell disease) who had survived more than two years post-HSCT for HGP were retrospectively reviewed. Mean age at HSCT was 7.7 years (1.1-32 years); mean follow-up was 7.1 years (2-11.6 years); 11 patients were splenectomized; mean ferritin level was 3022 ng/mL (350-10900); and seven patients underwent a second HSCT.

RESULTS

Endocrinological complications were observed with primary gonadal failure in 16/20 mature females and 4/11 mature males, in five patients with primary hypothyroidism and in four with insulin-dependent diabetes mellitus (DM). Skeletal complications were observed in 10 with secondary osteoporosis; 22 patients had elevated transaminase levels; two had hepatitis B reactivation. Neurological, cardiac and ocular manifestations were relatively rare. A higher incidence of LCs was observed in splenectomized than in nonsplenectomized patients: cGVHD -64% versus 13% (P = .003); endocrine abnormalities -91% versus 30.5%, (P = .001); elevated transaminase levels -73% versus 33% (P = .043); mortality -18% versus 2.7% (NS).

CONCLUSIONS

LCs post-HSCT for HGP are common and heterogeneous. Etiology is multifactorial with iron overload (IO), class, splenectomy, age, chronic GVHD, and corticosteroid (CS) treatment. Our data may help build follow-up guidelines to limit, detect, and treat any LCs and improve quality of life.

Nocardia brain abscess in a liver transplant recipient

Nocardia brain abscess is rare. We report on a unique case of N. farcinica brain abscess in a liver transplant recipient, following Aspergillus fumigatus pneumonia. A 43-year-old liver transplant recipient presented with altered mentality at 2 months after A. fumigates pneumonia. He was successfully treated with surgical removal and antibiotic therapy with trimethoprim-sulfamethoxazole and ceftriaxone.

Therapeutic window analysis of the neuroprotective effects of cyclosporine A after traumatic brain injury

Mitochondrial dysfunction plays a pivotal role in secondary cell death mechanisms following traumatic brain injury (TBI). Several reports have demonstrated that inhibition of the mitochondrial permeability transition pore with the immunosuppressant drug cyclosporine A (CsA) is efficacious. Accordingly, CsA is being moved forward into late-stage clinical trials for the treatment of moderate and severe TBI. However, several unknowns exist concerning the optimal therapeutic window for administering CsA at the proposed dosages to be used in human studies. The present study utilized a moderate (1.75 mm) unilateral controlled cortical impact model of TBI to determine the most efficacious therapeutic window for initiating CsA therapy. Rats were administered an IP dose of CsA (20 mg/kg) or vehicle at 1, 3, 4, 5, 6, and 8 h post-injury. Immediately following the initial IP dose, osmotic mini-pumps were implanted at these time points to deliver 10 mg/kg/d of CsA or vehicle. Seventy-two hours following the initiation of treatment the pumps were removed to stop CsA administration. Quantitative analysis of cortical tissue sparing 7 days post-injury revealed that CsA treatment initiated at any of the post-injury initiation times out to 8 h resulted in significantly less cortical damage compared to animals receiving vehicle treatment. However, earlier treatment begun in the first 3 h was significantly more protective than that begun at 4 and 8 h. Treatment initiated at 1 h post-injury (∼68% decrease) was not significantly different than that seen at 3 h (∼46% decrease), but resulted in significantly greater cortical tissue sparing compared to CsA treatment initiated at least 4 h post-injury (28% decrease). Together these results illustrate the importance of initiating therapeutic interventions such as CsA as soon as possible following TBI, preferably within 4 h post-injury, to achieve the best possible neuroprotective effect. However, the drug appears to retain some protective efficacy even when initiated as late as 8 h post-injury.

Diagnosis and treatment of status epilepticus in a pediatric renal recipient

We elaborate on the retrospective analysis of clinical data on a patient afflicted with grand mal seizures following a kidney transplant. The 16-year-old female patient was hospitalized for chronic glomerulonephritis. She experienced an epileptic seizure and was treated with carbamazepine. Renal transplantation was performed; the function of the transplant kidney was normal. However, grand mal seizures, which required intravenous and luminal intramuscular diazepam injections for control, began on the fourth postoperative day and lasted for 3 days, occurring approximately 10 to 20 times per day. On the sixth day, the patient fell into a deep comatose state and developed the inability to move the right side of her body, hypomyotonia, type 1 respiratory failure, and a pulmonary infection. She was given a breathing machine to assist with respiration. At the same time, she was given protection from infection, tranquilization, treatment for dehydration and diuresis, supportive therapy for the right side of her body, and adjustment of her immunosuppressants. On the 12th postoperative day, the patient's consciousness gradually returned; on the 15th day, the breathing machine was removed with recovery of myodynamia; on the 27th day, she was fully cured with no neurological sequelae.

Neurocognitive-neurological complications of liver transplantation: a review

Neurological complications are common after liver transplantation (LT) and they are associated with a significant morbidity. Long-term effects of LT on cognitive and psychological outcomes are not clear. The objective of this study was to summarize the present knowledge on the neurological and cognitive complications of LT, resulting from a systematic review of the literature in the last 10 years. Several studies have investigated the incidence and the pathophysiology of neurological complications; in contrast, the knowledge of cognitive and psychological status after LT is poor. Currently, the effect of LT on mental performance is debated. Some studies have shown an improvement of cognitive function after OLTX and, at the same time, a persistence of different cognitive deficits. In addition, the quality of life (QoL) and the psychological status after LT seem to improve but LT recipients have significant deficiencies in most QoL domains. Consequently, future studies are necessary in order to investigate cognitive alterations and QoL in LT recipients.

Neurologic manifestations of transplant complications

Neurologic complications affect posttransplant recovery of more than 20% of transplant recipients. Etiology is usually related to surgical procedure of transplantation, primary disorders causing failure of transplanted organ, opportunistic infections, and neurotoxicity of immunosuppressive medications. Risk of opportunistic infections and immunosuppressant neurotoxicity is greatest within the first six months, but it persists along with long-term maintenance immunosuppression required to prevent graft rejection. Neurotoxicity may require alteration of immunosuppressive regimen, and prompt therapy of opportunistic infections improves outcomes.

Neurologic complications in non-neurological intensive care units

BACKGROUND

Neurologists are frequently called to evaluate patients in the intensive care units who are not waking up. This often poses a diagnostic and prognostic dilemma.

REVIEW SUMMARY

The initial evaluation starts with abstracting the prehospital and in-hospital history, followed by bedside clinical and neurologic examination to establish a differential diagnosis. The subsequent work-up is based on clinical suspicion where reversible life-threatening causes should be immediately identified. After confirming the diagnosis and implementation of the appropriate medical management, a prompt family meeting and counseling is recommended. The role of neurologists in clinical diagnosis and prognostication of the coma patient, as well as diagnosing brain death is instrumental.

CONCLUSIONS

In this review, we explore a practical systematic approach to patients with decreased level of consciousness. The most common causes of impaired alertness in different non-neurologic critical care units and commonly used prognostication tools are presented. Finally a brief introduction of hypothermia, a novel therapeutic approach is also discussed.

Incidence and risk factors for seizures after heart transplantation

Neurological complications can occur after heart transplantation and present with seizures. We examined the incidence of seizures from a population of adult patients who had received heart transplants over a period of 3 years. Brain MRI and clinical data were analysed to identify the risk factors for the seizures. Eight of the 166 post-transplant patients presented seizures (4.8%). The first seizures occurred with a mean of 30 days after the transplantation. For seven patients, the mean delay was 8 days, and for one, it was longer, 172 days. The analysis of brain MRI showed two main epileptogenic factors in the early post-transplant seizures: posterior reversible encephalopathy syndrome (PRES) due to cyclosporine treatment (n = 4) and cortical ischemic stroke (n = 5). In two patients, we identified multiple epileptogenic factors, including notably the association of PRES and cortical stroke. Since treatment of seizures in patients in the intensive care unit (ICU) after heart transplantation depends on identifying and correcting the causes, FLAIR and diffusion MRI sequences are needed, even if the patients have a previous history of epilepsy. Seizures were easy to control. In patients with PRES, imaging and clinical abnormalities improved when cyclosporine was replaced by another immunosuppressive treatment. Death of three patients was not related to seizures, but to infectious or malignant complications of immunosuppressive treatments (n = 2) or to post-stroke neurological deficit (n = 1). Mortality was similar among patients presenting seizures and those who did not.

Headache in kidney transplantation

The aim of this retrospective study was to determine the relevance of the symptom “headache” in kidney transplanted patients, since few studies have considered headache as a clinically significant complication in this condition. A total of 83 consecutive kidney transplant patients underwent to neurological examination and a detailed headache history was taken. The headache history considered the period before kidney disease, during renal failure, during dialysis treatment and after transplantation. Diagnosis was made according to International Headache Criteria (ICDH-II) (2004). Our results reveal an occurrence of headache after kidney transplantation in 44.5% of the patients, which is higher than rates reported for the general population and in the only specific comparable study on liver transplant patients. These data suggest the need for prospective studies to explore the causal mechanisms by which headache develops with frequency in kidney transplant patients, and in particular to determine the role of immunosuppressive therapy.

Neurological complications of hematopoietic stem cell transplantation (HSCT): a retrospective study in a HSCT center in Brazil

We present the neurological complications evaluated in a series of 1000 patients who underwent hematopoietic stem cell transplantation (HSCT). Central nervous system (CNS) neurological complications, particularly brain hemorrhages, were the most common, followed by seizures and CNS infections. An unusual neurological complication was Wernicke's encephalopathy. Less frequent neurological complications were metabolic encephalopathy, neuroleptic malignant syndrome, reversible posterior leukoencephalopathy syndrome, brain infarct and movement disorders. The most common neurological complication of the peripheral nervous system was herpes zoster radiculopathy, while peripheral neuropathies, inflammatory myopathy and myotonia were very rarely found.

Neuromuscular diseases after cardiac transplantation

BACKGROUND

Cardiac transplantation is a therapeutic option in end-stage heart failure. Peripheral nervous system (PNS) disease is known to occur in cardiac transplant recipients but has not been fully characterized.

METHODS

This retrospective cohort review reports the PNS-related concerns of 313 cardiac transplant recipients (28% women, 8% children) over an 18-year period at a single institution.

RESULTS

Thirty percent of patients (95 of 313) reported a PNS-related concern in the post-transplant period, but only 5% had a concern in the first 6 weeks after transplant. The relative frequency of PNS-related complaints was as follows: polyneuropathy, 33%; muscle disease, 26%; mononeuropathy, 17%; radiculopathy, 13%; small-fiber polyneuropathy, 4%; plexopathy, 3%; and other (e.g., herpes zoster), 4%.

CONCLUSIONS

Etiology of these concerns can be divided into four broad categories: (1) immediate post-operative complications (e.g., brachial plexus stretch injury); (2) concerns related to the underlying disease prompting transplantation (e.g., polyneuropathy secondary to amyloidosis); (3) concerns related to necessary medications (e.g., steroid-associated myopathy); and (4) concerns reflective of aging in a post-transplant population with enhanced survival (e.g., degenerative joint disease-related radiculopathy).

[Infections of the central nervous system in the immuno-compromised]

Infections of the central nervous system (CNS) can be caused by a variety of pathogens, depending on whether the number and function of T-cells or monocytes are impaired (as in HIV patients) or whether the number and function of polymorphonuclear granulocytes are reduced or impaired, as typically seen in patients on immunosuppressive therapy, post transplantation, etc.. The first part of the chapter deals with CNS infections associated with reduced or abnormal T-cell (or monocytic) function and number, mainly seen in HIV patients, such as cerebral toxoplasmosis, CNS cryptococcosis, cytomegalovirus encephalitis, and progressive multifocal leukoencephalopathy. The clinical presentation, diagnostic procedures, as well as therapeutic and prophylactic management of these diseases are described in detail. The second part of the chapter deals with diseases usually seen in patients with impaired or reduced number and function of polymorphonuclear granulocytes. Such CNS infections are frequently caused by viral, bacterial, or fungal pathogens and are described in their clinical presentation, their diagnostic procedures and the best possible therapeutic and prophylactic management.

Assessment of psychoeducational outcomes after pediatric liver transplant

Outcomes research in pediatric liver transplant (LT) has focused on mortality and morbidity but there is a need to also evaluate functional outcomes. Standardized cognitive testing was administered to a cohort of children with infantile chronic liver disease who were transplanted at the University of Alberta during their preschool years. Thirty children had comprehensive assessments with the Bayley Scales of Infant Development or Wechsler testing. Patient variables potentially associated with cognitive delay were analyzed with multiple regression analysis. The mean DQ/IQ score (developmental quotient/intelligence quotient) was 81 +/- 17. Delay (DQ/IQ score < 70), and borderline delay (DQ/IQ 70-84) were each present in 27% of the cohort, with only 46% demonstrating normal cognition. Regression analysis demonstrated that the decreased IQ was associated with pretransplant growth retardation and elevated calcineurin inhibitor levels. Performance IQ had strong correlation with pretransplant growth retardation and elevated serum ammonia, R(2)= 45%, compared to verbal IQ that was associated was elevated calcineurin inhibitor levels, R(2)= 23%. Children post-LT are at high risk for cognitive delay or borderline delay. This is the first study to demonstrate the association calcineurin inhibitors with impaired IQ and also the unique finding of different variables predictive of impaired verbal intelligence quotient (VIQ) versus performance intelligence quotient (PIQ).

Neurologic complications after solid organ transplantation

Neurologic complications are common after solid organ transplantation and are associated with significant morbidity. Approximately one-third of transplant recipients experiences neurologic alterations with incidence ranging from 10% to 59%. The complications can be divided into such of those common to all types of transplant and others of those specific to transplanted organ. The most common complication seen with all types of transplanted organ is neurotoxicity attributable to immunosuppressive drugs, followed by seizures, opportunistic central nervous system (CNS) infections, cardiovascular events, encephalopathy and de novo CNS neoplasms. Amongst immunosuppressants, calcineurin inhibitors are the main drugs involved in neurotoxicity, leading to complications which ranges from mild symptoms, such as tremors and paresthesia to severe symptoms, such as disabling pain syndrome and leukoencephalopathy. Neurologic complications of liver transplantation are more common than that of other solid organ transplants (13-47%); encephalopathy is the most common CNS complication, followed by seizures; however, central pontine myelinolysis can appear in 1-8% of the patients leading to permanent disabilities or death. In kidney transplanted patients, stroke is the most common neurologic complication, whereas cerebral infarction and bleeding are more typical after heart transplantation. Metabolic, electrolyte and infectious anomalies represent common risk factors; however, identification of specific causes and early diagnosis are still difficult, because of patient's poor clinical status and concomitant systemic and metabolic disorders, which may obscure symptoms.

Complications of pediatric live-donor kidney transplantation: a single center's experience in Egypt

Our objective was to study the complications of chronic renal failure (CRF) among pediatric live-donor kidney transplant recipients. Between March 1976 and December 2005, 1,785 live-donor kidney transplantations were carried out at our center. Of the recipients, 292 were 20 years old or younger (mean age 12.8 years, ranging from 4 years to 20 years). Clinical and laboratory parameters of these 292 patients were analyzed retrospectively. They were 182 boys and 110 girls. Patients who had received transplants before 1988 were treated with prednisolone and azathioprine as combined therapy. From 1988 to 1998, a triple regimen comprising prednisolone, azathioprine and cyclosporine A (CsA) was administered. Tacrolimus and mycophenolate mofetil (MMF) were introduced as primary therapy in 1998. Growth, anemia, infections, and surgical, cardiac, neurologic, bone and other medical complications were assessed. Triple-drug immunosuppression (prednisone + CsA + azathioprine) was used in 68.2% of transplants. Acute rejection rate was 47.6%; chronic rejection rate was 31%. Hypertension (62%) was the commonest complication. Anemia was diagnosed in 61%. A substantial proportion of patients (48%) were short, with height standard deviation scores (SDSs) of less than -1.88. The overall infection rate was high, and the majority (54%) was bacterial. Malignancy was diagnosed in eight (3%) patients. The incidence of urological complications was 14%, and that of vascular complications was 1%. Cardiac complications included left ventricular hypertrophy (LVH) in 47.9% of patients, left atrial enlargement (31.5%) and left ventricular dilatation and systolic dysfunction (13.7% for each). Neuropathic changes were found in 19% of our cases, with the distal muscles of lower limbs more affected. Other complications included avascular bone necrosis in 8% (all of them in the hip joint) and bone loss in 60% of patients. We concluded that, despite the long-term success of pediatric renal transplantation in a developing country, there is a risk of significant morbidity.

Metabolische Störungen

Bei fortgeschrittenem Organversagen von Niere, Herz, Leber oder Lunge stellt eine Organtransplantation meist das einzige kurative Therapieverfahren dar. Auch eine Knochenmarktransplantation wird bei sonst unheilbaren Leukämien oder Lymphomen eingesetzt. Nach Organtransplantation treten bei 30–60% der Patienten neurologische Komplikationen auf. Differenzialdiagnostisch müssen vorbestehende, durch die Grunderkrankung bedingte, Störungen von intraoperativen Komplikationen, von metabolisch bedingten neurologischen Störungen und von Nebenwirkungen der notwendigen immunsuppressiven Medikation abgegrenzt werden. Immunsuppressiva können dabei sowohl eine direkte Neurotoxizität als auch indirekt vermehrt Infektionen des Zentralnervensystems (ZNS) und sekundäre ZNS-Malignome verursachen. Während metabolische Enzephalopathien oder opportunistische ZNS-Infektionen bei allen Patienten nach Transplantation etwa gleich häufig auftreten können, sind andere neurologische Syndrome für bestimmte Organtransplantationen typisch.

Neuroimaging and neurologic complications after organ transplantation

Neurologic complications are common after transplantation and affect 30-60% of transplant recipients. The etiology of most of the posttransplant neurologic disorders is related to the opportunistic infections, both systemic and involving central nervous system (CNS), toxicity of immunosuppressive medications, and the metabolic insult created by the underlying primary disease and the transplant procedure. Neuroimaging studies are one of the key tools in the evaluation and enable early diagnosis of neurologic complications in transplant patients, especially posterior reversible leukoencephalopathy syndrome, central pontine myelinolysis, intracerebral hemorrhage, and fungal and bacterial abscesses. Magnetic resonance imaging (MRI) is the preferred technique, but each of the available neuroimaging techniques offers a unique insight into the pathophysiologic mechanisms underlying neurologic complications of transplantation. The role of neuroimaging in this population includes early detection of calcineurin inhibitor neurotoxicity, opportunistic infections, neoplasia, metabolic disorders, or cerebrovascular diseases. In addition, we can monitor longitudinal progression of disease and treatment response.

The Blood?Brain Barrier and Epilepsy

During the past several years, there has been increasing interest in the role of the blood-brain barrier (BBB) in epilepsy. Advances in neuroradiology have enhanced our ability to image and study the human cerebrovasculature, and further developments in the research of metabolic deficiencies linked to seizure disorders (e.g., GLUT1 deficiency), neuroinflammation, and multiple drug resistance to antiepileptic drugs (AEDs) have amplified the significance of the BBB's relationship to epilepsy. Prior to 1986, BBB research in epilepsy focused on three main areas: ultrastructural studies, brain glucose availability and transport, and clinical uses of AEDs. However, contrast-based imaging techniques and medical procedures such as BBB disruption provided a framework that demonstrated that the BBB could be reversibly disrupted by pathologic or iatrogenic manipulations, with important implications in terms of CNS drug delivery to "multiple drug resistant" brain. This concept of BBB breakdown for therapeutic purposes has also unveiled a previously unrecognized role for BBB failure as a possible etiologic mechanism in epileptogenesis. Finally, a growing body of evidence has shown that inflammatory mechanisms may participate in the pathological changes observed in epileptic brain, with increasing awareness that blood-borne cells or signals may participate in epileptogenesis by virtue of a leaky BBB. In this article we will review the relationships between BBB function and epilepsy. In particular, we will illustrate consensus and divergence between clinical reality and animal studies.

Critical care considerations of hematopoietic stem cell transplantation

OBJECTIVE

To review the available clinical data on the critical care complications of hematopoietic stem cell transplantation (HSCT).

DATA SOURCE

The MEDLINE database and references from the identified articles related to the critical care in HSCT.

CONCLUSION

HSCT is an important treatment for a variety of malignant and nonmalignant conditions. The procedure is, however, limited by significant complications that may involve every organ of the body. Up to 40% of HSCT recipients are admitted to the intensive care unit as a result of severe complications related to the transplantation. The outcome of those critically ill patients has been traditionally poor. However, recent advances in the transplantation procedure, diagnostic studies, antimicrobial prophylaxis and therapy, and intensive care unit care have improved the outcome of these patients. The increasing number of HSCTs performed annually, the unique complications that develop in these patients, and the improvement in the intensive care unit outcome make knowledge about the critical care aspect of HSCT an essential part of the current practice of critical care medicine.

Granulomatous amebic encephalitis in a multivisceral transplant recipient

A 40-year-old man with multivisceral allograft developed acutely right-sided numbness 9 months after transplantation. Cranial magnetic resonance imaging (MRI) showed a small left parietal lesion, and cerebrospinal fluid analysis was unremarkable. Stereotactic brain biopsy was non-diagnostic. The patient continued to deteriorate, developed cerebral edema and died at 13 days after the onset of symptoms. Unexpectedly, autopsy demonstrated acanthamebic encephalitis. This case highlights diagnostic difficulties encountered with amebic encephalitis and expands the spectrum of opportunistic central nervous system (CNS) infections in solid and visceral organ transplant recipients.

Neurophysiologic changes in live related kidney transplant children and adolescents

Uremic neuropathy is one of the most debilitating symptoms associated with end stage renal disease. In adults the only potential cure for uremic neuropathy is renal transplantation. No studies have investigated the neurophysiologic abnormalities among pediatric renal transplant recipients. The objective of this study is to describe the incidence, nature and factors affecting neurophysiologic abnormalities in young renal transplant recipients. Neurophysiologic study was performed for 31 of our live related pediatric renal transplant recipients; they were 21 males and 10 females. The mean age at transplantation was 13.2 +/- 3.1 yr. The neurophysiologic studies were performed at different time points after transplantation (range 12-60 months), with a mean period of follow-up after transplantation 3.2 +/- 1.1 yr. Electromyography of the following muscles was tested: abductor pollicis brevis of the thenar eminence, biceps brachii, extensor digitorum brevis and rectus femoris. The median and lateral popliteal nerves were tested for estimating the motor conduction velocity. Neuropathic changes were found in 19% of our cases with more affection of the distal muscles of lower limbs. Motor conduction velocities were reduced, distal latencies were lengthened, and motor unit action potentials were reduced or dispersed. The predictors for development of neuropathy by multivariate analysis were the cumulative steroid dose and graft dysfunction. These results suggest that neuropathy is prevalent among young pediatric renal transplants. The independent predictors for development of neuropathy are graft dysfunction and anemia. It is unclear how significant these findings are in view of absent clinical signs and symptoms. This may represent an early stage of a disease that is still silent.