Renal transplant recipient seizure practical management

Table 1 Causes of seizures in renal transplant

Encephalopathy

Uraemic encephalopathy

Dialysis disequilibrium syndrome

Aluminium encephalopathy

Reversible posterior encephalopathy syndrome

Metabolic derangement

Hyponatremia

Hypocalcemia

Hypomagnesemia

Immunosuppression neurotoxicity

Tacrolimus (FK-506)

Cyclosporin

High dose corticosteroids

CNS infections

Meningitis

Encephalitis

Abscess

Drug toxicity

Quinolone antibiotics (e.g., Ciprofloxacin)

Beta Lactams (e.g., Penicillin, Mezlocillin, Cephalosporins)

Antidepressants

Bupropion HCL

Cerebrovascular disease

Subdural haematoma

Cerebral infarct

Intracerebral haemorrhage

Co-existing epilepsy

Primary CNS lymphoma

Action myoclonus – renal failure syndrome

Table 2 A practical approach to generalised tonic clonic seizure in renal transplant patients (modified from Chabolla et al[14], 2006)

Acute onset generalised tonic clonic seizure
Monitor ABC
IV Lorazepam 2 mg
Post seizure	Persistent seizure or recurrent seizures without regaining consciousness follow status epilepticus protocol
Eliminate or correct identified provocative factors
Neurologic examination, EEG, MRI brain
If all negative, monitor without AED
If any positive (Neurologic examination abnormal or EEG – Epileptic activity or MR structural lesion) OR spontaneous recurrence when monitoring without AED -> then Initiate AED

EEG: Electroencephalography; MRI: Magnetic resonance imaging; AED: Antiepileptic drug.

Table 3 Dose adjustment for antiepileptic drugs in patients with renal impairment

GFR (mL/min)	60-90	30-60	15-30	< 15	Haemodialysis
Levetiracetam	500-1000 mg BD	250-750 mg BD	250-500 mg BD	500-1000 mg OD	Plus 250-500 mg/d
Toparimate	50% decrease	50% decrease	50% decrease		50-100 mg after HD
Zonisamide	100-400 mg	100-400 mg
Oxcarbazepine	300-600 mg BD	300-600 mg BD	300 mg/d starting dose	NA	NA
Esclicarbazepine	None	400-600 mg OD	400-600 mg OD
Clobazam	None	None	None	NA	None
Pregabalin	None	50% decrease	25-125 mg/d	25-75 mg /d	25-150 mg after HD
Lacosamide	None	None	300 mg/d		Plus < 50% after HD
Rufinamide	None	None	None	NA	Plus 30% after HD
Vigabatrin	25% decrease	50% decrease	75% decrease	NA	NA
Tiagabine	None	None	None	None	None
Lamotrigine	None	None	None	None	NA
Phenytoin	None	None	None	None	May need in high flux HD
Carbamazepine	None	NA	NA	75% dose	Plus 75% after HD
Valproate	None	None	None	None	May need in high flux HD
Perampanel	None	None	NA	NA	NA
Brivaracetam	None	None	NA	NA	None

This table is modified from Glynn et al[9], Diaz et al[15] Lexicomp online drug information[16]. NA: Not available.