Neurologic Problems in Renal Transplant Recipients

Characteristics and Prognosis of Stroke in Living Donor Renal Transplant Recipients

Aims: We aimed to determine the characteristics and vascular outcomes of stroke in renal transplant (RT) recipients and compare them with those in patients on hemodialysis (HD) and those with no renal replacement therapy (RRT).

Methods: In this prospective observational study, 717 patients (mean age, 70.8 years; male, 60.5%) with acute ischemic stroke within one week of onset were consecutively enrolled and followed for one year. The patients were classified into three groups: (1) living donor RT recipients (n=27); (2) patients on maintenance HD before the index stroke (n=39); and (3) those with no history of RRT (n=651). The primary outcome was a composite of major adverse cardiovascular events (MACE).

Results: Diabetic nephropathy was the most common reason for RRT in both RT and HD patients. RT patients were more likely to have embolic stroke of undetermined source (33.3%) than others, whereas HD patients more often had cardioembolism (51.3%). No difference was observed in the MACE risk between the patients in RT and non-RRT groups (annual rate, 11.3% vs. 13.1%; log-rankP=0.82; hazard ratio [95% confidence interval], 0.92 [0.29-2.98]). In contrast, HD patients had a greater risk of MACE than those with no RRT (annual rate, 28.2% vs. 13.1%; log-rankP=0.019; hazard ratio [95% confidence interval], 2.24 [1.16-4.3]).

Conclusions: The underlying etiologies of stroke differed in RT and HD patients. The one-year risk of MACE for stroke patients who had received an RT was lower than that for patients undergoing HD and comparable with that of patients with no RRT.

Cerebral abscess and calvarial osteomyelitis caused by Burkholderia pseudomallei in a renal transplant recipient

Melioidosis is an infection of humans caused by the saprophytic bacterium Burkholderia (previously Pseudomonas) pseudomallei. We present a patient of cerebral abscess and calvarial osteomyelitis caused by B. pseudomallei in a renal transplant recipient. We treated the patient with ceftazidime for 3 weeks, followed by trimethoprim-sulfamethoxazole (TMP-SMX) for 6 months. The superficial abscess reduced in size at the end of first month and subsided gradually. A repeat MRI showed reduction in intracranial abscess. The patient had no neurological deficit.

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.

Influence of Tacrolimus on Depressive-Like Behavior in Diabetic Rats Through Brain-Derived Neurotrophic Factor Regulation in the Hippocampus

The neurotoxicity of immunosuppressive agents and diabetes mellitus are known risk factors of neurological complications in kidney transplant recipients. The aim of the present study was to investigate the influence of tacrolimus on brain-derived neurotrophic factor (BDNF), the critical protein for maintenance of neuronal functions, in the hippocampus in a diabetic condition. A diabetic rat model was established by a single streptozotocin injection (60 mg/kg). Control and diabetic rats then received daily tacrolimus (1.5 mg/kg per day) injections for 6 weeks. BDNF expression in the hippocampus was examined in the dentate gyrus (DG) and CA3 region using immunohistochemistry. There was a significant decrease of BDNF expression in the DG and CA3 region in tacrolimus-treated and diabetic rats compared with that of the control group injected with vehicle only. However, there was no difference in BDNF expression between the two experimental groups. Tacrolimus treatment in diabetic rats further decreased the BDNF expression level in the DG and CA3 region. Interestingly, mossy fiber sprouting, demonstrated by prominent punctate immunolabeling of BDNF with synaptoporin, was observed in the diabetic group treated with tacrolimus, which localized at the stratum oriens of the CA3 region. These data suggest that tacrolimus treatment or a diabetic condition decreases BDNF expression in the hippocampus, and that tacrolimus treatment in the diabetic condition further injures the CA3 region of the hippocampus. In addition to BDNF expression, decreased locomotor activity and evident depressive behavior were observed in tacrolimus-treated diabetic rats. Moreover, there were significant decreases of the mRNA levels of γ-aminobutyric acid and serotonin receptors in the diabetic hippocampus with tacrolimus treatment. This finding suggests that tacrolimus treatment may cause further psychiatric and neurological complications for patients with diabetes, and should thus be used with caution.

Multiple cerebral abscesses in a renal transplant recipient: Two swords in one scabbard!

Although rare, both Cladophialophora bantiana (C. bantiana) and Toxoplasma gondii have been known to be associated with brain abscess in renal transplant recipients (RTRs), however co-infection has never been reported till date. In the present case, 40 years old renal transplant recipient on curtailed immunosuppressive therapy presented with progressive headache and altered sensorium. The computed tomography of head showed multiple ring-enhancing discrete lesions in the left frontal lobe, with moderate perilesional oedema. Left frontal craniotomy and aspiration revealed thick yellowish brown pus, which on culture showed the growth of dematiaceous fungal hyphae “C. bantiana” and co-infection with “Toxoplasma” was confirmed by PCR as well as serology (both IgM and IgG – Toxoplasma) positivity. Stereotactic aspiration/open craniotomy and drainage is imperative to arrive at microbiological diagnosis and provide timely therapy to the patient.

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.

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.

Piperacillin/tazobactam in treatment of brain abscess

Central nervous system (CNS) infection is a common complication following renal transplantation. Successful management of a brain abscess usually requires a combination of antibiotics and surgical drainage for both diagnostic and therapeutic purposes. We report the successful treatment of a patient with multiple brain abscesses with piperacillin/tazobactam without surgical intervention.

Evaluation of neurologic complications by brain MRI in kidney and liver transplant recipients

The aim of this study was to retrospectively analyze brain magnetic resonance imaging (MRI) findings in patients who developed neurologic complications after liver and kidney transplantation. The results in 216 organ transplant recipients, who had brain MRI were evaluated retrospectively. We performed 187 brain MRI on kidney recipients and 29 liver recipients. Neuroradiologic findings were classified in three groups: group 1 findings were related to transplantation; group 2 findings, to chronic parenchymal disease; and group 3 to neither transplantation nor chronic parenchymal disease. In group 1, six patients (20.6%) after liver and three (1.6%) after kidney transplantation had posterior reversible encephalopathy syndrome; two patients (1.1%) after renal and one (3.4%) after liver transplantation had tuberculosis granulomas; one patient (0.5%) after renal transplantation had osmotic demyelination syndrome; one patient (0.5%) had a Nocardia abcess and one (0.5%) focal cerebritis after renal transplantation. Among group 2, 38 patients (20.3%) had brain atrophy; 37 (20%), white matter changes; 3 (1.6%), sinus thrombosis; 8 (4.3%), lacunar infarct; 1 (0.5%), had renal osteodystrophy in the cranial bones; and 4 (2.2%), had intracranial hemorrhage secondary to end-stage renal disease. Brain atrophy in nine patients (31%), hyperintensity in the globus pallidus on T1-weighted MR images owing to manganese deposits in nine patients (31%), hyperintensity in basal ganglia on T2-weighted MR images owing to copper depositions in one patient (3.4%) were seen secondary to chronic liver disease. In group 3, three patients (1.6%) had intracranial lipomas; one (0.5%), mesial temporal sclerosis; and one (0.5%), an anterior cerebral artery aneurysm in renal transplant patients. Periventricular and subcortical white matter hyperintensities were observed on T2-weighted MR images in six liver transplant patients (20.7%). Neurologic complications after organ transplantation may be secondary to transplantation itself, to chronic parenchymal disease, or to neither transplantation nor chronic parenchymal disease.

Neurological complications in renal failure: a review

Neurological complications whether due to the uremic state or its treatment, contribute largely to the morbidity and mortality in patients with renal failure. Despite continuous therapeutic advances, many neurological complications of uremia, like uremic encephalopathy, atherosclerosis, neuropathy and myopathy fail to fully respond to dialysis. Moreover, dialytic therapy or kidney transplantation may even induce neurological complications. Dialysis can directly or indirectly be associated with dialysis dementia, dysequilibrium syndrome, aggravation of atherosclerosis, cerebrovascular accidents due to ultrafiltration-related arterial hypotension, hypertensive encephalopathy, Wernicke's encephalopathy, hemorrhagic stroke, subdural hematoma, osmotic myelinolysis, opportunistic infections, intracranial hypertension and mononeuropathy. Renal transplantation itself can give rise to acute femoral neuropathy, rejection encephalopathy and neuropathy in graft versus host disease. The use of immunosuppressive drugs after renal transplantation can cause encephalopathy, movement disorders, opportunistic infections, neoplasms, myopathy and progression of atherosclerosis. We address the clinical, pathophysiological and therapeutical aspects of both central and peripheral nervous system complications in uremia.

Stroke in renal transplant recipients: epidemiology, predictive risk factors and outcome

BACKGROUND

Cerebrovascular and cardiovascular diseases are the most important causes of increased morbidity and mortality in patients with end-stage renal disease. Stroke has been widely reported in chronic dialysis patients, but there is scarce information about stroke in renal transplant recipients (RTR), although cerebrovascular events are the most common and potentially life-threatening neurological complications in them. Our aim is to analyze the prevalence, risk factors, etiopathogenia, clinical aspects and outcome of stroke in RTR.

METHODS

We analyzed 403 patients who received one or more renal grafts between 1979 and 2000: group A = patients who had stroke (n = 19); group B = those who did not (n = 384). Medical records and pertinent data were compiled. The risk of stroke was studied using univariate and multivariate Cox regression models.

RESULTS

prevalence of stroke in RTR was 7.97% at 10 yr. Time elapsed between renal transplantation (RT) and stroke: 49.3 months. Possible risk factors based on the univariate analyses were: diabetic nephropathy (DN) (p < 0.001) and autosomal-dominant-polycystic-kidney-disease (p = 0.049) as original nephropathies, peripheral vascular disease (PVD) (p < 0.001), diabetes mellitus prior to RT (p = 0.005), age older than 40 yr (p = 0.037) and hypertension (p = 0.049). Other analysed risk factors such as gender, renal function, cytomegalovirus infection, hyperlipidemia, hyperuricemia, erythrocytosis or hypertensive donor failed to show any significant predictive value for stroke in these patients. When multivariate analyses were carried out, we found that DN (OR = 4.8; p = 0.010), PVD (OR = 8.2; p < 0.001) and age > 40 yr (OR = 3.3; p = 0.019) were predictive risk factors for stroke. For group A, hypertension was present in all patients, 68.4% had hyperlipidemia and 42.1% reported previous stroke. Cerebral hemorrhage occurred in seven of 19 (36.84%) of the stroke patients, but no subarachnoid hemorrhage occurred in them. Seven of 12 ischemic strokes were atherotrombotic. Considering all strokes, basal ganglia was the predominant localization. The outcome was poor, as nearly half of the patients died in the 3 months following stroke.

CONCLUSIONS

Prevalence of stroke in our RTR population was 7.97%. Cerebral hemorrhage appears to be more prevalent in RTR than in general population. More than that, the cerebral hemorrhage rate we found is higher than that reported elsewhere in RTR. The main predictors of stroke were DN, PVD and age. No patient with interstitial nephropathy suffered stroke. Mortality is high in RTR with stroke.

Neurologic complications of transplantation

BACKGROUND

Organ transplantation is one of the most dynamic fields in medicine and has evolved into a life-saving option for thousands of patients with previously fatal conditions. The posttransplantation clinical course is frequently associated with neurologic complications that are usually related to pretransplant morbidity, the surgical procedure of transplantation, immunosuppression, and opportunistic infection.

REVIEW SUMMARY

Neurologic complications of organ transplantation may be divided into complications common to all types of allografts and complications that are specific for a particular type of organ transplantation. The most common complications include seizures, opportunistic central nervous system (CNS) infection, metabolic encephalopathy, stroke, intracranial hemorrhage, and drug-related adverse events. Opportunistic CNS infection may have a subtle presentation and should not be overlooked, as the consequences of delayed treatment may be grave. Neurotoxicity of immunosuppressive agents is also a frequent cause of neurologic complications and may occur in the setting of normal serum drug levels. The clinical course of transplant patients is frequently complex, requiring close cooperation between the transplant team and specialty consultants. Prolonged survival of transplant patients will shift the focus of neurologic complications from acute, perioperative to chronic complications of immunosuppression.

CONCLUSIONS

Neurologic complications of organ transplantation are commonly related to opportunistic infection or neurotoxicity of immunosuppressive agents, requiring careful titration of immunosuppression. Timely diagnosis of CNS infection or other causes of neurologic dysfunction may significantly improve recovery and outcome in these patients.

Central nervous system complications in renal transplant recipients in a tropical environment

Renal transplant recipients are at risk of developing various infectious and non-infectious complications affecting the central nervous system (CNS). There is paucity of data regarding the spectrum of CNS complications and the epidemiology of infective agents varies according to geographical location. We retrospectively studied the spectrum of CNS complications seen in 792 renal allograft recipients followed up at this tertiary care centre in north India over a 19-year period. Autopsy findings of 78 allograft recipients who died in the hospital were also reviewed and included. The brain was examined in 22 of these patients. Overall, 79 (10%) patients developed some form of CNS dysfunction with a mortality rate of 60.8%. CNS infections occurred in 31 renal allograft recipients (3.9% of total) and accounted for the largest group (39.2%). Fungi were the commonest etiological agents (21 patients) and were associated with a 70% mortality, with cryptococcal meningitis occurring in 12, mucormycosis in six, aspergillosis in one, and other unusual fungal infections in the remaining two patients. All patients with mucormycosis had a fatal outcome. The second largest group comprised of patients with non-uremic encephalopathies (23 patients, 29.1%) with metabolic encephalopathy occurring in 13, toxic encephalopathy in nine and hypertensive encephalopathy in one patient) and was associated with an overall mortality rate of 60.9%. Cerebrovascular accidents occurred in 12 patients (15.2%) and were associated with a mortality of 91.7%. Other CNS complications included treatment related complications in four (5.1%), primary CNS lymphomas in three (3.8%), and miscellaneous complications in six patients (7.6%). Patients with non-cryptococcal fungal infections of the CNS, hepatic and toxic encephalopathy and those with cerebrovascular accidents had the worst outcome. There was no relationship between the development of infection or stroke and the type of maintenance immunosuppression used. We conclude that complications involving the CNS occur in 10% of all renal transplant recipients and are associated a with high mortality, warranting early diagnosis and aggressive treatment.

Brain abscess in renal transplant recipients: report of three cases

BACKGROUND

Neurologic complications occur in about 30% of renal transplant patients, infections being the most common. We encountered three such patients and present our experience in the management of such cases.

CLINICAL MATERIAL

Three cases of brain abscess in renal transplant recipients are reported. These patients presented from 9-60 months after the transplant. One patient had a pyogenic abscess; in the second the organism identified was Nocardia asteroides; in the third, a fungal infection was responsible. In two patients excision of the abscess was done, while in one repeated aspirations with intracavitary antibiotics were used. All received systemic antimicrobial therapy.

CONCLUSIONS

Central nervous system (CNS) complications, specifically infections, are quite common in renal transplant recipients, but reports of brain abscesses in these patients are very rare. The treatment options for such patients are discussed.

Outcome of renal transplant recipients in the ICU

OBJECTIVE

To determine the outcome of renal transplant recipients in an intensive care unit (ICU).

DESIGN

Prospective, cohort study.

SETTING

Surgical ICU in a tertiary care hospital.

PATIENTS

Consecutive adult renal transplant recipients admitted to an ICU.

MEASUREMENTS AND MAIN RESULTS

Demographic data, underlying diseases, indications for admission to the ICU, number of prior kidney transplantations, duration of immunosuppression, duration of mechanical ventilation, length of stay in ICU and hospital, and ICU and hospital mortality were recorded. Seventy-one patients were included in the study. Twenty-seven patients were admitted to the surgical ICU immediately after renal transplantation surgery for postoperative monitoring (group 1). One patient died in this group. The remaining 44 patients were renal transplant recipients admitted to the surgical ICU with various complications (group 2). The mean posttransplant time in group 2 was 23 +/- 30 months. Seven patients died in group 2. The overall ICU mortality in this study was 11% and hospital mortality was 14%. The hospital mortality for postoperative patients (3.7% in group 1) was below the rate predicted based on the acute physiology and chronic health evaluation (APACHE II) score (15%). APACHE II score, duration of mechanical ventilation, and ICU length of stay were significantly higher among nonsurvivors. The ICU mortality among renal transplant recipients was higher than that of other patients (6%) admitted to the surgical ICU during the study period.

CONCLUSION

The ICU mortality of renal transplant recipients was twice that of general surgical ICU patients. The hospital mortality rate for recipients admitted immediately postoperatively to the ICU (group 1) was less than predicted by APACHE II.

Neurological complications of organ transplantation

Over the last thirty years, organ transplantation has become a practical treatment option for many otherwise fatal diseases. New immunosuppressive agents, advances in tissue matching, and improvements in surgical technique have increased both the number and type of transplants performed. Kidney, bone marrow, heart, lung, liver, and pancreas transplants are now used regularly in the treatment of end-stage disease. However, these advances have come at a price. Transplant recipients are subject to numerous complications, many of which involve the nervous system. Depending on the type of organ transplanted, 30 to 60% of transplant recipients experience neurological problems. Most neurological complications, especially those related to immunosuppression, are common to all transplant types; other complications are associated predominantly with specific transplant types. This report reviews the general categories of neurological complications as well as the specific problems associated with each kind of transplant.

Late pseudo-exacerbation of myasthenia gravis due to ectopic thymoma invading lower cranial nerves

Dysarthria, dysphagia and repeated aspiration in a 54-year-old woman diagnosed and treated for myasthenia gravis 7 years earlier were initially thought to represent a late exacerbation of myasthenia. A cervical mass invading the jugular foramen and causing multiple lower cranial nerve palsies was biopsied and found to represent invasive ectopic thymoma.