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Recent Topics on The Mechanisms of Immunosuppressive Therapy-Related Neurotoxicities. Int J Mol Sci 2019; 20:ijms20133210. [PMID: 31261959 PMCID: PMC6651704 DOI: 10.3390/ijms20133210] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 06/26/2019] [Accepted: 06/28/2019] [Indexed: 02/07/2023] Open
Abstract
Although transplantation procedures have been developed for patients with end-stage hepatic insufficiency or other diseases, allograft rejection still threatens patient health and lifespan. Over the last few decades, the emergence of immunosuppressive agents such as calcineurin inhibitors (CNIs) and mammalian target of rapamycin (mTOR) inhibitors have strikingly increased graft survival. Unfortunately, immunosuppressive agent-related neurotoxicity commonly occurs in clinical practice, with the majority of neurotoxicity cases caused by CNIs. The possible mechanisms through which CNIs cause neurotoxicity include increasing the permeability or injury of the blood–brain barrier, alterations of mitochondrial function, and alterations in the electrophysiological state. Other immunosuppressants can also induce neuropsychiatric complications. For example, mTOR inhibitors induce seizures, mycophenolate mofetil induces depression and headaches, methotrexate affects the central nervous system, the mouse monoclonal immunoglobulin G2 antibody (used against the cluster of differentiation 3) also induces headaches, and patients using corticosteroids usually experience cognitive alteration. Therapeutic drug monitoring, individual therapy based on pharmacogenetics, and early recognition of symptoms help reduce neurotoxic events considerably. Once neurotoxicity occurs, a reduction in the drug dosage, switching to other immunosuppressants, combination therapy with drugs used to treat the neuropsychiatric manifestation, or blood purification therapy have proven to be effective against neurotoxicity. In this review, we summarize recent topics on the mechanisms of immunosuppressive drug-related neurotoxicity. In addition, information about the neuroprotective effects of several immunosuppressants is also discussed.
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Shijo T, Nishiyama S, Mukai Y, Tateyama M, Kuroda H, Aoki M. A mismatch between MRI lesions and SPECT hypoperfusion in tacrolimus-related encephalopathy. J Neurol Sci 2016; 367:308-10. [PMID: 27423609 DOI: 10.1016/j.jns.2016.06.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 05/27/2016] [Accepted: 06/16/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Tomomi Shijo
- Department of Neurology, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Shuhei Nishiyama
- Department of Neurology, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Yoshiyuki Mukai
- Department of Neurology, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Maki Tateyama
- Department of Neurology, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Hiroshi Kuroda
- Department of Neurology, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan.
| | - Masashi Aoki
- Department of Neurology, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
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Rodríguez-González MJ, Calvo-Betancourt LS, Echeverría-Correa LE. Síndrome de encefalopatía posterior reversible secundaria a tacrolimus. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2015.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Niemi AK, Kim IK, Krueger CE, Cowan TM, Baugh N, Farrell R, Bonham CA, Concepcion W, Esquivel CO, Enns GM. Treatment of methylmalonic acidemia by liver or combined liver-kidney transplantation. J Pediatr 2015; 166:1455-61.e1. [PMID: 25771389 DOI: 10.1016/j.jpeds.2015.01.051] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 01/13/2015] [Accepted: 01/28/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess biochemical, surgical, and long-term outcomes of liver (LT) or liver-kidney transplantation (LKT) for severe, early-onset methylmalonic acidemia/acid (MMA). STUDY DESIGN A retrospective chart review (December 1997 to May 2012) of patients with MMA who underwent LT or LKT at Lucile Packard Children's Hospital at Stanford. RESULTS Fourteen patients underwent LT (n = 6) or LKT (n = 8) at mean age 8.2 years (range 0.8-20.7). Eleven (79%) were diagnosed during the neonatal period, including 6 by newborn screening. All underwent deceased donor transplantation; 12 (86%) received a whole liver graft. Postoperative survival was 100%. At a mean follow-up of 3.25 ± 4.2 years, patient survival was 100%, liver allograft survival 93%, and kidney allograft survival 100%. One patient underwent liver re-transplantation because of hepatic artery thrombosis. After transplantation, there were no episodes of hyperammonemia, acidosis, or metabolic decompensation. The mean serum MMA at the time of transplantation was 1648 ± 1492 μmol/L (normal <0.3, range 99-4420). By 3 days, post-transplantation levels fell on average by 87% (mean 210 ± 154 μmol/L), and at 4 months, they were 83% below pre-transplantation levels (mean 305 ± 108 μmol/L). Developmental delay was present in 12 patients (86%) before transplantation. All patients maintained neurodevelopmental abilities or exhibited improvements in motor skills, learning abilities, and social functioning. CONCLUSIONS LT or LKT for MMA eradicates episodes of hyperammonemia, results in excellent long-term survival, and suggests stabilization of neurocognitive development. Long-term follow-up is underway to evaluate whether patients who undergo early LT need kidney transplantation later in life.
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Affiliation(s)
- Anna-Kaisa Niemi
- Division of Medical Genetics, Department of Pediatrics, Stanford University, Stanford, CA.
| | - Irene K Kim
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Stanford, CA
| | - Casey E Krueger
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, CA
| | - Tina M Cowan
- Department of Pathology, Stanford University, Stanford, CA
| | - Nancy Baugh
- Lucile Packard Children's Hospital at Stanford, Stanford, CA
| | - Rachel Farrell
- Division of Medical Genetics, Department of Pediatrics, Stanford University, Stanford, CA; Prenatal Diagnostics, Department of Obstetrics and Gynecology, University of California, San Francisco, San Francisco, CA
| | - Clark A Bonham
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Stanford, CA
| | - Waldo Concepcion
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Stanford, CA
| | - Carlos O Esquivel
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Stanford, CA
| | - Gregory M Enns
- Division of Medical Genetics, Department of Pediatrics, Stanford University, Stanford, CA
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Taskapan H, Kayabas U, Otlu B, Kamisli O, Yaprak CY, Sahin FT. BK virus-induced acute motor-axonal polyneuropathy in a renal transplant patient. CEN Case Rep 2015; 5:1-4. [PMID: 28509156 DOI: 10.1007/s13730-015-0179-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 04/01/2015] [Indexed: 11/30/2022] Open
Abstract
Neurological complications are not uncommon in patients with renal transplantation, mostly affecting the central nervous system, and less frequently the peripheral nerves. BK virus infection is relatively common in transplant recipients and in some cases may lead to neurological complications. In this report, we present an interesting case of a patient who developed acute axonal motor polyneuropathy in the course of BK virus infection 3 months after kidney transplantation. After BK virus clearence in blood, a significant improvement was noted in her polyneuropathy. In patients with acute axonal motor polyneuropathy after transplantation BK virus-induced polyneuropathy should be excluded.
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Affiliation(s)
- Hulya Taskapan
- Department of Nephrology, Turgut Ozal Medical Center, Medical Faculty, Inonu University, Malatya, Turkey.
| | - Uner Kayabas
- Department of Infectious Diseases and Clinical Microbiology, Turgut Ozal Medical Center, Medical Faculty, Inonu University, Malatya, Turkey
| | - Baris Otlu
- Department of Clinical Microbiology, Turgut Ozal Medical Center, Medical Faculty, Inonu University, Malatya, Turkey
| | - Ozden Kamisli
- Department of Neurology, Turgut Ozal Medical Center, Medical Faculty, Inonu University, Malatya, Turkey
| | - Cisel Yilmaz Yaprak
- Department of Nephrology, Turgut Ozal Medical Center, Medical Faculty, Inonu University, Malatya, Turkey
| | - Fatma Terzioglu Sahin
- Department of Nephrology, Turgut Ozal Medical Center, Medical Faculty, Inonu University, Malatya, Turkey
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Wu G, Weng FL, Balaraman V. Tacrolimus-induced encephalopathy and polyneuropathy in a renal transplant recipient. BMJ Case Rep 2013; 2013:bcr-2013-201099. [PMID: 24311415 DOI: 10.1136/bcr-2013-201099] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Tacrolimus is an immunosuppressant frequently used following solid organ transplantation, including renal transplantation. Peripheral neuropathy is an uncommon neurological side effect of tacrolimus and has rarely been reported in renal transplantation. We report a patient who received a living-related donor kidney transplant and presented with altered mental status and new-onset bilateral foot drop. Laboratory tests including cerebrospinal fluid tests excluded infection, and MRI of the brain showed chronic microvascular ischaemic changes. Electromyography and nerve conduction study confirmed bilateral common peroneal nerve demyelination. He was also found to have inadvertently overdosed on tacrolimus at home. After switching from tacrolimus to cyclosporine, the patient's symptoms improved within 5 months. His renal function was maintained with an immunosuppressant regimen of cyclosporine, prednisone and mycophenolic acid. The prompt recognition of tacrolimus as a potential neurotoxic drug in a patient with renal transplant and substituting tacrolimus with a different immunosuppressant may prevent permanent neurological damage.
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Affiliation(s)
- Geru Wu
- Department of Internal Medicine Residency Program, St. Barnabas Medical Center, Livingston, New Jersey, USA
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Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S, Fedson S, Fisher P, Gonzales-Stawinski G, Martinelli L, McGiffin D, Smith J, Taylor D, Meiser B, Webber S, Baran D, Carboni M, Dengler T, Feldman D, Frigerio M, Kfoury A, Kim D, Kobashigawa J, Shullo M, Stehlik J, Teuteberg J, Uber P, Zuckermann A, Hunt S, Burch M, Bhat G, Canter C, Chinnock R, Crespo-Leiro M, Delgado R, Dobbels F, Grady K, Kao W, Lamour J, Parry G, Patel J, Pini D, Towbin J, Wolfel G, Delgado D, Eisen H, Goldberg L, Hosenpud J, Johnson M, Keogh A, Lewis C, O'Connell J, Rogers J, Ross H, Russell S, Vanhaecke J, Russell S, Vanhaecke J. The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. J Heart Lung Transplant 2010; 29:914-56. [PMID: 20643330 DOI: 10.1016/j.healun.2010.05.034] [Citation(s) in RCA: 1147] [Impact Index Per Article: 81.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2010] [Accepted: 05/31/2010] [Indexed: 12/26/2022] Open
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Oda N, Kato TS, Hanatani A, Niwaya K, Nakatani T, Ishibashi-Ueda H, Kitamura S, Hashimura K, Kitakaze M, Komamura K. Reversible posterior leukoencephalopathy syndrome (RPLS) in a heart transplant recipient treated by substitution of cyclosporine A with tacrolimus. Intern Med 2010; 49:1013-6. [PMID: 20519818 DOI: 10.2169/internalmedicine.49.3012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Reversible posterior leukoencephalopathy syndrome (RPLS) is one of the important adverse events following organ transplantation, associated with calcineurin inhibitors (CNIs). We describe a case of 54-year-old woman, who was diagnosed with RPLS within weeks after transplantation. Considering the risk of causing fatal rejection by discontinuation of CNIs, the immunosuppressive regimen of the patient was switched from a cyclosporine A-based regimen to a tacrolimus-based regimen. The patient recovered rapidly from RPLS following the switch to tacrolimus. This case demonstrated that not only discontinuation but also a substitution of CNIs would be a valid treatment option for RPLS in transplant recipients.
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Affiliation(s)
- Noboru Oda
- Department of Cardiovascular Medicine, National Cardiovascular Center, Suita, Japan
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