Posterior reversible encephalopathy syndrome independently associated with tacrolimus and sirolimus after multivisceral transplantation

Update on Maintenance Immunosuppression in Intestinal Transplantation

Outcomes in intestinal transplantation remain hampered by higher rates of rejection than any other solid organs. However, maintenance immunosuppression regimens have largely remained unchanged despite advances in therapies for induction and treatment of rejection and graft-versus-host disease. Recently, there have been a small number of new maintenance therapies attempted, and older agents have been used in new ways to achieve better outcomes. The authors herein review the traditional maintenance therapies and their mechanisms and then consider updates in new therapies and new ways of using old therapies for maintenance immunosuppression after intestinal transplantation.

Should Calcineurin Inhibitors/Sirolimus Be Ceased Completely In Posterior Reversible Encephalopathy Syndrome?

BACKGROUND

To investigate the relationship between immunosuppressive treatments and posterior reversible encephalopathy syndrome (PRES) in transplant patients.

METHODS

We presented a retrospective study of 4 cases of PRES in transplant patients. Patient records were reviewed to identify potential risk factors, clinical presentations, radiological findings, and immunosuppressive treatments used.

RESULTS

Our analysis revealed a potential association between immunosuppressive treatments and the development of PRES in transplant patients. Specifically, we found that adjusting or switching immunosuppressive treatments can improve outcomes and prevent the recurrence of PRES.

CONCLUSION

Our findings highlight the importance of recognizing PRES as a potential complication of immunosuppressive treatments in transplant patients. Early detection and management, including a review of immunosuppressive treatments, may improve patient outcomes and prevent further complications.

Model-informed Estimation of Acutely Decreased Tacrolimus Clearance and Subsequent Dose Individualization in a Pediatric Renal Transplant Patient with Posterior Reversible Encephalopathy Syndrome

BACKGROUND

Considerable inter-patient and inter-occasion variability has been reported in tacrolimus pharmacokinetics (PK) in the pediatric renal transplant population. The present study investigated tacrolimus PK in a 2-year-old post-renal transplant patient and a known CYP3A5 expresser who developed posterior reversible encephalopathy syndrome (PRES) and had significantly elevated tacrolimus blood concentrations during tacrolimus treatment. A model-informed PK assessment was performed to assist with precision dosing. Tacrolimus clearance was evaluated both before and after the development of PRES on post-transplant day (PTD) 26.

METHODS

A retrospective chart review was conducted to gather dosing data and tacrolimus concentrations, as part of a clinical pharmacology consultation service. Individual PK parameters were estimated by Bayesian estimation using a published pediatric PK model. Oral clearance (CL/F) was estimated for three distinct time periods-before CNS symptoms (PTD 25), during the PRES event (PTD 27-30), and after oral tacrolimus was re-started (PTD 93).

RESULTS

Bayesian estimation showed an estimated CL/F of 15.0 L/h in the days preceding the PRES event, compared to a population mean of 16.3 L/h (95% confidence interval 14.9-17.7 L/h) for CYP3A5 expressers of the same age and weight. Samples collected on PTD 27-30 yielded an estimated CL/F of 3.6 L/h, a reduction of 76%, coinciding with clinical confirmation of PRES and therapy discontinuation. On PTD 93, an additional assessment showed a stable CL/F value of 14.5 L/h one month after re-initiating tacrolimus and was used to recommend a continued maintenance dose.

CONCLUSION

This is the first report to demonstrate acutely decreased tacrolimus clearance in PRES, likely caused by the downregulation of metabolizing enzymes in response to inflammatory cytokines. The results suggest the ability of model-informed Bayesian estimation to characterize an acute decline in oral tacrolimus clearance after the development of PRES, and the role that PK estimation may play in supporting dose selection and individualization.

Posterior reversible encephalopathy syndrome in a pediatric heart transplant recipient with coarctation of aorta

Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiographic syndrome reported in children with hypertension due to renal diseases, immunosuppression after solid organ transplant, cytotoxic agents for chemotherapy, and many others rare instances. We described PRES in a 6-year-old child with hypertension secondary to an incidental postoperative coarctation of the aorta after heart transplantation (HT). Her blood pressure was well controlled with amlodipine during the outpatient visits and home monitoring of blood pressure, but she had hypertension when presented with neurological symptoms. This case's unique feature is that although PRES has been described after pediatric HT, this is the first case report due to a postoperative coarctation of the proximal descending aorta related to scarring from previous multiple sternotomies leading to inadvertent external compression of the aorta with scar tissue. We discussed the risk factors associated with hypertension before PRES and the correlation of brain magnetic resonance imaging findings with clinical outcomes.

Late presentation of posterior reversible encephalopathy syndrome following liver transplantation in the setting of tacrolimus and cannabis use

A 45-year-old female presented to hospital with confusion and visual disturbances. She had undergone a liver transplant 3 years prior for cirrhosis secondary to primary biliary cholangitis. Computed tomography and magnetic resonance imaging of the brain showed features consistent with posterior reversible encephalopathy syndrome. Her medications included tacrolimus, sirolimus, and prednisone. She reported smoking 4 grams of cannabis per day. Following cessation of tacrolimus, the patient's encephalopathy and visual disturbances resolved. To our knowledge, this case represents the longest time elapsed from liver transplantation to the development of tacrolimus-associated posterior reversible encephalopathy syndrome in the literature. This case highlights the potential danger of cannabis use in transplant recipients who are on immunosuppressants such as tacrolimus. Clinicians should have a high index of suspicion for posterior reversible encephalopathy syndrome in post-transplant patients presenting with altered mental status, even years after liver transplantation, and be familiar with potential interactions between cannabis and immunosuppressants.

Posterior Reversible Encephalopathy Syndrome Associated with Tacrolimus in Cardiac Transplantation

Background

Neurological complications occur between 50 and 70% of patients with heart transplantation, including cerebrovascular events, infections, seizures, encephalopathy, and neurotoxicity due to pharmacological immunosuppression. Mortality associated with cerebrovascular complications is 7.5% in the first 30 days and up to 5.3% after the first month and up to the first year after transplantation. Case Reports. Three heart-transplanted patients (2 men and 1 woman) treated with tacrolimus were identified. They presented with posterior reversible encephalopathy syndrome on days 5, 6, and 58 posttransplantation, respectively. In these reported cases, no sequelae were observed at 6 months follow-up.

Conclusions

Posterior reversible encephalopathy syndrome as a neurological complication in patients with HT occurred early after the procedure. Early diagnosis and treatment might reduce the risk of serious complications and mortality.

Erdheim-Chester disease: a comprehensive review from the ophthalmologic perspective

Erdheim-Chester disease (ECD) is a rare clonal histiocytic neoplasm with less than 1200 documented cases to date. The disease is life-threatening and difficult to recognize, although increasing awareness as well as the integration of clinical, imaging, pathology information , and genetic studies have led to a recent exponential increase in new reported cases. ECD affects multiple organs and systems, including skeletal, neurologic, and cardiovascular. Pulmonary, retroperitoneal, and cutaneous lesions have also been reported in various combinations. Until the discovery that more than half of ECD patients harbor the BRAF-V600E mutation or other mutations in the mitogen-activated protein kinase (MAPK) and RAS pathways, Interferon-a was the first-line treatment. Nowadays BRAF and MEK-inhibitors targeted therapies are the mainstay of treatment. Ophthalmologic involvement occurs in 25% -30% of ECD cases, usually in the form of orbital involvement presenting with exophthalmos and ophthalmoplegia. Other ophthalmologic manifestations include palpebral xanthelasmas, anterior uveitis and vitritis, optic disk edema, choroidal infiltration, recurrent serous retinal detachment, retinal drusen-like deposits and retinal pigment epithelial changes. ECD patients can also present with ocular symptoms as a result of adverse effects of the treatment regimens. In some cases with smoldering or protean symptoms, the emergence of eye manifestations triggered the diagnosis. Ophthalmologists have to be aware of the disease, recognize the constellation of ECD symptoms, and contribute to the diagnosis, treatment, and follow-up of ECD patients.

Severe hypertension is an independent risk factor for posterior reversible encephalopathy syndrome post-hematopoietic cell transplantation in children with thalassemia major

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is an increasingly recognized serious complication of cyclosporine A (CSA) and tacrolimus (TAC) use in hematopoietic cell transplantation (HCT) recipients.

PROCEDURE

A retrospective study was carried out, including 84 cases of HCT for TM from January 2012 to January 2017. Eleven cases were diagnosed with PRES.

RESULTS

The cumulative incidence of PRES was 13.4% (95% confidence interval (CI) 9.7%-17.2%). The median onset time of the symptoms was 63 [20, 143] days after transplantation. Lumber puncture found that CSF was normal. Univariate analysis showed that patients who received methylprednisolone (MP) (OR = 10.629 95% CI, 1.360-83.071, P = 0.024), female patients (OR = 4.275, 95% CI, 1.154-15.843, P = 0.032), patients who had severe hypertension (OR = 5.162, 95% CI, 1.042 to 25.559, P = 0.029) had significantly higher risks of PRES. Multivariate analysis showed that severe hypertension (hazard ratio [HR], 12.793; 95% CI, 1.477 to 110.813; P  = 0.021), and Pesaro class 3 (HR, 3.367; 95% CI, 1.210 to 9.368; P  =  0.020) were associated with PRES.

CONCLUSIONS

The severe hypertension is an independent risk factor for PRES post-HCT in children with thalassemia major. Patients of Pesaro class 3 may benefit from optimum control of blood pressure post-HCT for prophylaxis of PRES.

Posterior reversible leukoencephalopathy syndrome (PRES) after kidney transplantation: a case report

INTRODUCTION

Posterior reversible leukoencephalopathy syndrome (PRES) was first described by Hinchey in 1996. The syndrome is characterized by altered level of consciousness, headache, visual changes, and seizures associated with a vasogenic edema of the white matter that occurs predominantly in the occipital and parietal lobes. Imaging tests such as computed tomography (CT) and especially magnetic resonance imaging (MRI) support the diagnosis.

CASE REPORT

We report a case of a 48-year-old female patient who underwent a deceased donor kidney transplant and received tacrolimus as a part of the immunosuppressive regimen. Five weeks after transplantation she was admitted to the emergency due to sudden onset of confusion, disorientation, visual disturbances, and major headache. PRES was suspected and the diagnosis confirmed by brain MRI. Tacrolimus was withdrawn and rapid improvement of the neurological signs occurred leading to the conclusion that this drug triggered the syndrome.

CONCLUSION

PRES is an unusual complication after organ transplantation and should be considered in the appropriate clinical setting. Physicians must be aware of this condition in order to provide early detection and appropriate treatment since delay in removing the cause may lead to permanent sequelae.

Neurologic complications after allogeneic hematopoietic stem cell transplantation: risk factors and impact

Neurologic complications (NCs) may be a significant source of morbidity and mortality after hematopoietic cell transplantation (HCT). We performed a retrospective study of 263 consecutive patients undergoing allogeneic HCT for hematological malignancies to determine the incidence, risk factors and clinical impact of NCs in the first 5 years after HCT. We determined the incidence of central nervous system (CNS) infection, intracranial hemorrhage, ischemic stroke, metabolic encephalopathy, posterior reversal encephalopathy syndrome, seizure and peripheral neuropathy. In all, 50 patients experienced 63 NCs-37 early (⩽day +100), 21 late (day +101 to 2 years) and 5 very late (2 to 5 years). The 1- and 5-year cumulative incidences of all NCs were 15.6% and 19.2%, respectively, and of CNS complication (CNSC; all of the above complications except peripheral neuropathy) were 12.2 and 14.5%. Risk factors for CNSC were age (hazard ratio (HR)=1.06 per year, P=0.0034), development of acute GvHD grade III-IV (HR=2.78, P=0.041), transfusion-dependent thrombocytopenia (HR=3.07, P=0.025) and delayed platelet engraftment (>90th centile; HR=2.77, P=0.043). CNSCs negatively impacted progression-free survival (HR=2.29, P=0.0001), overall survival (HR=2.63, P<0.0001) and non-relapse mortality (HR=8.51, P<0.0001). NCs after HCT are associated with poor outcomes, and usually occur early after HCT.

Sirolimus-Induced Combined Posterior Reversible Encephalopathy Syndrome and Lymphocytic Pneumonitis in a Renal Transplant Recipient: Case Report and Review of the Literature

The mammalian target of rapamycin inhibitor sirolimus was introduced into clinical transplant practice in 1999. Dose-related myelosuppression and hyper lipidemia are the most common adverse effects. Pulmonary toxicity has been reported since 2004 and can cause interstitial pneumonitis, organizing pneumonia, and alveolar hemorrhage. Moreover, it can occasionally induce posterior reversible encephalopathy syndrome, as documented in scarce reports. To our knowledge; this is the 1st report of combined posterior reversible encephalopathy syndrome and lymphocytic pneumonitis to be induced by sirolimus. Here, we present a renal transplant recipient with reversible sirolimus-induced brain lesions who was diagnosed after exclusion of infections (viral, bacterial, and fungal), tumors, sarcoidosis, and autoimmune disorders. Both brain lesions and pneumonitis resolved completely after sirolimus discontinuation with excellent patient and graft outcome. Early and gradual sirolimus withdrawal can reverse posterior reversible encephalopathy syndrome and lymphocytic pneumonitis with preservation of stable graft function.

Posterior Reversible Encephalopathy Syndrome after Heart Transplantation: Diagnosis and Immunosuppressive Therapy

Posterior reversible encephalopathy syndrome, an infrequent neurotoxicity associated with the use of tacrolimus, was first described in 1996, as a reversible syndrome manifested by headache, altered mental function, seizures, and visual disturbances. We describe the case of a 37-year-old woman who developed neurologic symptoms consistent with encephalopathy after treatment with tacrolimus, which was prescribed to maintain immunosuppression after orthotopic heart transplantation. This report also discusses the imaging methods used in the diagnosis of posterior reversible encephalopathy and highlights the difficulty of maintaining immunosuppression and managing medication-related adverse effects, while taking into account the risk of acute rejection after transplantation.

Posterior Reversible Encephalopathy Syndrome After Orthotopic Heart Transplantation: A Case Report

BACKGROUND Calcineurin inhibitor-induced posterior reversible encephalopathy syndrome (PRES) is well described in liver and kidney transplant patients, but there is a paucity of data in heart transplant patients. PRES syndrome in the setting of heart transplantation can occur as early as 5 days following transplantation. CASE REPORT A 32-year-old woman who had recently undergone orthotopic heart transplantation developed headaches, visual disturbances, and generalized tonic clonic seizures 5 days after initiating anti-rejection therapy (tacrolimus, mycophenolate, and prednisone). No focal neurological deficits were noted on physical exam. Multifocal subcortical fluid attenuation inversion recovery (FLAIR) hyperintensity signals and areas of diffusion restriction with postcontrast enhancement, diagnostic of PRES, were found on MRI brain. Her symptoms resolved 2 days after tacrolimus was switched to cyclosporine. A follow-up MRI after 6 weeks demonstrated complete resolution of areas of flair hyperintensity signal. She was sent home on a short course of seizure prophylaxis, which was discontinued after the resolution of radiological findings. She had no further episodes of seizures for 6 months following discontinuation of her anti-epileptic regimen. CONCLUSIONS Tacrolimus-induced PRES can occur as early as 5 days after orthotopic heart transplantation. Early recognition of symptoms and management can prevent permanent neurological sequelae.

Neurologic Complications of Commonly Used Drugs in the Hospital Setting

This chapter reviews the neurologic complications of medications administered in the hospital setting, by class, introducing both common and less common side effects. Detail is devoted to the interaction between pain, analgesia, sedation, and their residual consequences. Antimicrobials are given in nearly every hospital setting, and we review their capacity to produce neurologic sequelae with special devotion to cefepime and the antiviral treatment of human immunodeficiency virus. The management of hemorrhagic stroke has become more complex with the introduction of novel oral anticoagulants, and we provide an update on what is known about reversal of the new oral anticoagulants. Both central and peripheral nervous system complications of immunosuppressants and chemotherapies are reviewed. Because diagnosis is generally based on clinical acumen, alone, neurotoxic syndromes resulting from psychotropic medications may be easily overlooked until severe dysautonomia develops. We include a practical approach to the diagnosis of serotonin syndrome and neuroleptic malignant syndrome.

Calcineurin Inhibitors Associated Posterior Reversible Encephalopathy Syndrome in Solid Organ Transplantation: Report of 2 Cases and Literature Review

Posterior reversible encephalopathy syndrome (PRES) is a rare neurologic side effect of calcineurin inhibitors (CNIs) with poorly understood clinical features.We report cases of 2 patients with PRES developing after kidney transplantation and summarize PRES clinical features through a literature review.The 1st case was a 28-year-old man who received a kidney transplant from a deceased donor. Initial immunosuppressive therapy consisted of tacrolimus/mycophenolate mofetil/prednisolone. He developed headache and blurred vision with visual field loss15 days after transplantation and generalized seizures 4 days later. The 2nd case was a 34-year-old man who received a living kidney transplant. His initial immunosuppressive therapy comprised tacrolimus/mycophenolate mofetil/prednisolone. Two months after transplantation, he developed seizures. Both patients were diagnosed with PRES based on neurological symptoms and magnetic resonance imaging (MRI) findings; they recovered after switching from tacrolimus to either a cyclosporine or a lower tacrolimus dose. CNI-associated PRES is an acute neurological syndrome with seizures, encephalopathy, visual abnormalities, headache, focal neurological deficits, and nausea/vomiting. It is always accompanied by hypertension. A fluid-attenuated inversion recovery signal MRI scan typically shows reversible subcortical white matter changes in the posterior cerebral hemisphere that usually occur within the 1st month after transplantation. CNI-associated PRES has a generally favorable prognosis with early diagnosis and prompt treatment including alternating or discontinuing CNIs and blood pressure control.CNI-associated PRES should be considered in patients exhibiting acute neurological symptoms after transplantation. Early diagnosis and immediate treatment are critical for a favorable prognosis.

Posterior Reversible Encephalopathy Syndrome After Transplantation: a Review

Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disease. Recently, an increase in the number of transplantations has led to more cases being associated with PRES than what was previously reported. Calcineurin inhibitors (CNIs) are major risk factors for PRES in posttransplantation patients. The mechanisms of the development of PRES remain to be unclear. The typical clinical symptoms of PRES include seizures, acute encephalopathy syndrome, and visual symptoms. The hyperintense signal on fluid-attenuated inversion recovery image is the characteristic of the imaging appearance in these patients. In addition, other abnormal signals distributed in multiple locations are also reported in some atypical cases. Unfortunately, PRES is often not recognized or diagnosed too late due to complicated differential diagnoses, such as ischemic stroke, progressive multifocal leukoencephalopathy, and neurodegenerative diseases. Thus, this review emphasizes the importance of considering the possibility of PRES when neurological disturbances appear after solid organ transplantation or hematopoietic cell transplantation. Moreover, this review demonstrates the molecular mechanisms of PRES associated with CNIs after transplantation, which aims to help clinicians further understand PRES in the transplantation era.

PRES in Children Undergoing Hematopoietic Stem Cell or Solid Organ Transplantation

Posterior reversible encephalopathy syndrome (PRES) is a clinical neuroradiologic entity that is becoming increasingly well known and documented in pediatrics. It is characterized by a variable association of seizures, headache, vomiting, altered mental status, visual disturbances, and seizures, as well as imaging suggesting white-gray matter edema involving the posterior regions of the central nervous system in most cases. The pathophysiology of PRES remains unclear. Although PRES has been associated with a widespread range of clinical conditions, namely infections, adverse drug events, autoimmune diseases, and many others, its onset after hematopoietic stem cell and solid organ transplantation remains the most commonly reported. Historically, PRES has proved to be generally reversible and associated with good clinical outcomes; however, severe complications, sometimes life-threatening, can also occur. Most reported cases of childhood PRES after hematopoietic stem cell or solid organ transplantation have been case reports or series across a broad spectrum of different transplant settings, and no clear consensus exists regarding how best to manage the syndrome. Thus, in this article, we provide a comprehensive review of the pathophysiological, clinical, and diagnostic aspects of PRES in children, with a specific focus on the transplant scenario. Differential diagnoses with other neurologic complications after pediatric transplantation are reviewed, and crucial issues in the management of PRES and the development of future research are ultimately addressed.

Neurological complications after liver transplantation as a consequence of immunosuppression: univariate and multivariate analysis of risk factors

Neurological complications (NCs) can frequently and significantly affect morbidity and mortality of liver transplant (LT) recipients. We analysed incidence, risk factors, outcome and impact of the immunosuppressive therapy on NC development after LT. We analysed 478 LT in 440 patients, and 93 (19.5%) were followed by NCs. The average LOS was longer in patients experiencing NCs. The 1-, 3- and 5-year graft survival and patient survival were similar in patients with or without a NC. Multivariate analysis showed the following as independent risk factors for NC: a MELD score ≥20 (OR = 1.934, CI = 1.186-3.153) and an immunosuppressive regimen based on calcineurin inhibitors (CNIs) (OR = 1.669, CI = 1.009-2.760). Among patients receiving an everolimus-based immunosuppression, the 7.1% developed NCs, vs. the 16.9% in those receiving a CNI (P = 0.039). There was a 1-, 3- and 5-year NC-free survival of 81.7%, 81.1% and 77.7% in patients receiving a CNI-based regimen and 95.1%, 93.6% and 92.7% in those not receiving a CNI-based regimen (P < 0.001). In patients undergoing a LT and presenting with nonmodifiable risk factors for developing NCs, an immunosuppressive regimen based on CNIs is likely to result in a higher rate of NCs compared to mTOR inhibitors.

Tacrolimus associated posterior reversible encephalopathy syndrome - a case series and review

Tacrolimus is an immunosuppressive drug mainly used to lower the risk of transplant rejection in individuals who are post solid organ or hematopoietic transplantation. It is a macrolide which reduces peptidyl-propyl isomerase activity and inhibits calcineurin, thus inhibiting T-lymphocyte signal transduction and interleukin-2 (IL-2) transcription. It has been associated with Posterior Reversible Encephalopathy Syndrome (PRES), a disease of sudden onset that can present as a host of different symptoms, depending on the affected area of the brain. While infectious causes of encephalopathy must always be entertained, the differential diagnosis should also include PRES in the appropriate context. We report three cases of PRES in patients with acute myeloid leukemia (AML) placed on tacrolimus after receiving a bone marrow transplant (BMT). The focus of this review is to enhance clinical recognition of PRES as it is related to an adverse effect of Tacrolimus in the setting of hematopoietic transplantation.