Gong Y. Calcineurin inhibitors-related posterior reversible encephalopathy syndrome in liver transplant recipients: Three case reports and review of literature. World J Hepatol 2024; 16(9): 1297-1307 [PMID: 39351518 DOI: 10.4254/wjh.v16.i9.1297]
Corresponding Author of This Article
Yu Gong, MD, Doctor, Department of Intensive Care Unit, Fudan University Affiliated Zhongshan Hospital, No. 1609 Xietu Road, Xuhui District, Shanghai 200032, China. gong.yu@zs-hospital.sh.cn
Research Domain of This Article
Transplantation
Article-Type of This Article
Case Report
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Hepatol. Sep 27, 2024; 16(9): 1297-1307 Published online Sep 27, 2024. doi: 10.4254/wjh.v16.i9.1297
Calcineurin inhibitors-related posterior reversible encephalopathy syndrome in liver transplant recipients: Three case reports and review of literature
Yu Gong
Yu Gong, Department of Intensive Care Unit, Fudan University Affiliated Zhongshan Hospital, Shanghai 200032, China
Author contributions: Gong Y contributed to collection of patient data and composition of articles.
Informed consent statement: The study was approved by the Institutional Review Board at Zhongshan Hospital under Fudan University. Participant gave written consent to participate in the study.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Yu Gong, MD, Doctor, Department of Intensive Care Unit, Fudan University Affiliated Zhongshan Hospital, No. 1609 Xietu Road, Xuhui District, Shanghai 200032, China. gong.yu@zs-hospital.sh.cn
Received: March 25, 2024 Revised: August 22, 2024 Accepted: August 28, 2024 Published online: September 27, 2024 Processing time: 181 Days and 22.8 Hours
Abstract
BACKGROUND
Posterior reversible encephalopathy syndrome (PRES), characterized by acute neurological deterioration and extensive white matter lesions on T2-fluid attenuated inversion recovery magnetic resonance imaging (MRI), is increasingly associated with calcineurin inhibitors (CNI)-related neurotoxicity. Prompt diagnosis is crucial, as early intervention, including the modification or discontinuation of CNI therapy, strict blood pressure management, corticosteroid treatment, and supportive care can significantly improve patient outcomes and prognosis. The growing clinical recognition of CNI-related PRES underscores the importance of identifying and managing this condition in patients presenting with acute neurological symptoms.
CASE SUMMARY
This report describes three cases of liver transplant recipients who developed PRES. The first case involves a 60-year-old woman who experienced seizures, aphasia, and hemiplegia on postoperative day (POD) 9, with MRI revealing ischemic foci followed by extensive white matter lesions. After replacing tacrolimus, her symptoms improved, and no significant MRI abnormalities were observed after three years of follow-up. The second case concerns a 54-year-old woman with autoimmune hepatitis who developed headaches, seizures, and extensive white matter demyelination on MRI on POD24. Following the switch to rapamycin and the initiation of corticosteroids, her symptoms resolved, and she was discharged on POD95. The third case details a 60-year-old woman with hepatocellular carcinoma who developed PRES, evidenced by brain MRI abnormalities on POD11. Transitioning to rapamycin and corticosteroid therapy led to her full recovery, and she was discharged on POD22. These cases highlight the critical importance of early diagnosis, CNI modification, and stringent management in improving outcomes for liver transplant recipients with CNI-related PRES.
CONCLUSION
Clinical manifestations, combined with characteristic MRI findings, are crucial in diagnosing PRES among organ transplant recipients. However, when standard treatments are ineffective or MRI results are atypical, alternative diagnoses should be taken into considered.
Core Tip: Liver transplantation is the only curative option for end-stage liver disease. The rise in liver transplants is accompanied by an increase in the occurrence of neurological complications. The etiology of calcineurin inhibitor (CNI)-related posterior reversible encephalopathy syndrome (PRES) remains unclear, and there are no established preventive measures. Optimal treatment strategies are still a matter of debate. CNIs, although widely used in liver transplants, come with various side effects. Therefore, when new neurological symptoms arise in liver transplant patients on CNIs who meet the diagnostic criteria for PRES, a cerebral magnetic resonance imaging should be promptly conducted to provide diagnostic evidence. Initiating treatment promptly upon confirming the diagnosis is essential for enhancing clinical outcomes.
