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Lin P, Tian X, Wang X. Seizures after transplantation. Seizure 2018; 61:177-185. [PMID: 30179843 DOI: 10.1016/j.seizure.2018.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 08/09/2018] [Accepted: 08/11/2018] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To summarize information on the history, incidence, clinical manifestation, best treatment, as well as prognosis of seizures in transplant recipients. METHODS In October 2017, we searched the literature on PubMed in English with the search terms: "transplantation" AND "seizure", "transplantation" AND "epilepsy", "transplantation"AND "status epilepticus", "immunosuppressant" AND "seizure", "immunosuppressant" AND "epilepsy". Publications not based on new data and original research were not included in this article. RESULTS Seizures including generalized seizures, focal seizures and status epilepticus are a common central nervous system complication after transplantation. The incidence of seizures varied between different kinds of transplantations. The reported incidence of seizures was 7%-27% in association with solid organ transplantations and 1.6%-15.4% with hematopoietic stem cell transplantation. Most of seizures appeared in the early post-transplantation period. Patients often had a favorable prognosis, however, in some conditions, recurrent or intractable seizures may occur. CONCLUSIONS The underlying pathogenesis of new-onset seizures or epilepsy in recipients of transplantation needs to be further elucidated. In addition, more information is required from prospective studies and research focusing on therapeutic strategies.
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Affiliation(s)
- Peijia Lin
- Department of Neurology, Chongqing Key Laboratory of Neurology, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Chongqing 400016, China.
| | - Xin Tian
- Department of Neurology, Chongqing Key Laboratory of Neurology, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Chongqing 400016, China.
| | - Xuefeng Wang
- Department of Neurology, Chongqing Key Laboratory of Neurology, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Chongqing 400016, China; Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing 100871, China.
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2
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Affiliation(s)
- D.C. Bergen
- Department of Neurological Sciences, Sections of Epilepsy, Chicago, IL-USA
| | - R. Ristanovic
- Department of Neurological Sciences, Sections of Epilepsy, Chicago, IL-USA
| | | | - S. Kathpalia
- Rush Medical College, and Department of Medicine, Michael Reese Hospital, Chicago, IL-USA
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3
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Brown CA, Munday JS, Mathur S, Brown SA. Hypertensive Encephalopathy in Cats with Reduced Renal Function. Vet Pathol 2016; 42:642-9. [PMID: 16145210 DOI: 10.1354/vp.42-5-642] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The clinical, hemodynamic, and pathologic features of hypertensive encephalopathy in two cats with reduced renal mass are described. The cats developed a progressive syndrome of lethargy, ataxia, blindness, stupor, and seizures following an abrupt increase in blood pressure associated with a surgical reduction in renal mass. The cats had severe gross brain edema, evidenced by cerebellar changes of caudal coning and cranial displacement over the corpora quadrigemina and cerebral changes of widening and flattening of the gyri. Histologically, interstitial edema was most pronounced in the cerebral white matter. Hypertensive vascular lesions were present as hyaline arteriolosclerosis in one cat and hyperplastic arteriolosclerosis in the other. Rare foci of parenchymal microhemorrhages and necrosis were also observed. Systemic hypertension (especially severe or rapidly developing) accompanied by neurologic signs and the pathologic findings of diffuse brain edema with cerebral arteriolosclerosis are consistent with an etiologic diagnosis of hypertensive encephalopathy.
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Affiliation(s)
- C A Brown
- Athens Diagnostic Laboratory, College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA.
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Drake K, Nehus E, Goebel J. Hyponatremia, hypo-osmolality, and seizures in children early post-kidney transplant. Pediatr Transplant 2015; 19:698-703. [PMID: 26299753 DOI: 10.1111/petr.12575] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2015] [Indexed: 11/29/2022]
Abstract
Post-transplant seizures are uncommon in young kidney transplant recipients but can be harbingers of devastating outcomes such as cerebral edema and death. We reviewed all transplants performed at our institution from January 2013 to January 2014 and compared three patients who seized within 24 h post-transplant (cases) with the remaining 33 transplant recipients (controls). Records were reviewed for hyponatremia, hypocalcemia, hypomagnesemia, BUN clearance, osmolality shifts, and blood pressure control in the first 24 h post-transplant. All cases had more pronounced (p < 0.001) shifts in serum sodium and calculated serum osmolality, with their sodium decreasing by >15 mmol/L to nadir values of 124, 131, and 131 mmol/L, respectively. There were no differences in serum calcium corrected for hypoalbuminemia, serum magnesium, urine output, or blood pressure control between the groups. Our study suggests that mild hyponatremia and an acute decrease in serum osmolality are risk factors for potentially severe postoperative neurologic complications following kidney transplantation. Thus, peri-transplant management should be optimized to anticipate and prevent these abnormalities.
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Affiliation(s)
- Keri Drake
- Division of Pediatric Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Edward Nehus
- Division of Pediatric Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jens Goebel
- Division of Pediatric Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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5
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Ghosh PS, Kwon C, Klein M, Corder J, Ghosh D. Neurologic complications following pediatric renal transplantation. J Child Neurol 2014; 29:793-8. [PMID: 23752071 DOI: 10.1177/0883073813490074] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 04/21/2013] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Partha S Ghosh
- Pediatric Neurology Center, Children's Hospital, Cleveland Clinic, Cleveland, OH, USA Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Charles Kwon
- Department of Nephrology, Children's Hospital, Cleveland Clinic, Cleveland, OH, USA
| | - Melanie Klein
- Department of Nephrology, Children's Hospital, Cleveland Clinic, Cleveland, OH, USA
| | - Julie Corder
- Department of Nephrology, Children's Hospital, Cleveland Clinic, Cleveland, OH, USA
| | - Debabrata Ghosh
- Pediatric Neurology Center, Children's Hospital, Cleveland Clinic, Cleveland, OH, USA
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6
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Friedman D, Claassen J, Hirsch LJ. Continuous electroencephalogram monitoring in the intensive care unit. Anesth Analg 2009; 109:506-23. [PMID: 19608827 DOI: 10.1213/ane.0b013e3181a9d8b5] [Citation(s) in RCA: 186] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Because of recent technical advances, it is now possible to record and monitor the continuous digital electroencephalogram (EEG) of many critically ill patients simultaneously. Continuous EEG monitoring (cEEG) provides dynamic information about brain function that permits early detection of changes in neurologic status, which is especially useful when the clinical examination is limited. Nonconvulsive seizures are common in comatose critically ill patients and can have multiple negative effects on the injured brain. The majority of seizures in these patients cannot be detected without cEEG. cEEG monitoring is most commonly used to detect and guide treatment of nonconvulsive seizures, including after convulsive status epilepticus. In addition, cEEG is used to guide management of pharmacological coma for treatment of increased intracranial pressure. An emerging application for cEEG is to detect new or worsening brain ischemia in patients at high risk, especially those with subarachnoid hemorrhage. Improving quantitative EEG software is helping to make it feasible for cEEG (using full scalp coverage) to provide continuous information about changes in brain function in real time at the bedside and to alert clinicians to any acute brain event, including seizures, ischemia, increasing intracranial pressure, hemorrhage, and even systemic abnormalities affecting the brain, such as hypoxia, hypotension, acidosis, and others. Monitoring using only a few electrodes or using full scalp coverage, but without expert review of the raw EEG, must be done with extreme caution as false positives and false negatives are common. Intracranial EEG recording is being performed in a few centers to better detect seizures, ischemia, and peri-injury depolarizations, all of which may contribute to secondary injury. When cEEG is combined with individualized, physiologically driven decision making via multimodality brain monitoring, intensivists can identify when the brain is at risk for injury or when neuronal injury is already occurring and intervene before there is permanent damage. The exact role and cost-effectiveness of cEEG at the current time remains unclear, but we believe it has significant potential to improve neurologic outcomes in a variety of settings.
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Affiliation(s)
- Daniel Friedman
- Department of Neurology, Comprehensive Epilepsy Center, Columbia University, NewYork City, New York, USA
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Cansick J, Rees L, Koffman G, Van't Hoff W, Bockenhauer D. A fatal case of cerebral oedema with hyponatraemia and massive polyuria after renal transplantation. Pediatr Nephrol 2009; 24:1231-4. [PMID: 19153773 DOI: 10.1007/s00467-008-1100-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Revised: 11/25/2008] [Accepted: 11/25/2008] [Indexed: 10/21/2022]
Abstract
We report the case of a child who died from severe cerebral oedema in the context of hyponatraemia and extreme polyuria immediately after renal transplantation. The patient was treated according to a standard post-transplantation protocol, receiving 0.45% saline solution for urine output replacement. The case highlights the dangers of massive fluid therapy in the context of polyuria and, therefore, the need for intensive monitoring.
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Affiliation(s)
- Janette Cansick
- Department of Nephrology, Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London, WC1N 3JH, UK
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Hamiwka LD, Midgley JP, Hamiwka LA. Seizures in children after kidney transplantation: has the risk changed and can we predict who is at greatest risk? Pediatr Transplant 2008; 12:527-30. [PMID: 18672484 DOI: 10.1111/j.1399-3046.2007.00813.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Children undergoing kidney transplantation are at increased risk for symptomatic seizures with a previously reported incidence of approximately 20%. Little data exist to help predict which children may be at risk. We retrospectively reviewed all children who underwent kidney transplantation evaluation at our center between October 1993 and August 2007 and identified 41 children who had an EEG prior to transplant. Demographic data as well as the following were collected: immunosuppressive medications, developmental status, history of seizures, family history of seizures, post-transplant seizures and EEG results. EEGs were classified as normal or abnormal. Prior to transplantation, one child had a history of febrile seizures and six experienced afebrile seizures. Nine (22%) children identified had an abnormal EEG prior to transplant. In eight cases the EEG was non-epileptiform and in one case was epileptiform. Abnormal EEGs did not correlate with a family history of seizures. Delayed development was noted in seven children and was not associated with an epileptiform EEG. Following kidney transplantation, no child experienced a seizure. Our single center study suggests that current rates of seizures following kidney transplantation are lower than previously reported and that routine EEG as part of the pretransplant evaluation in these children is of limited use to predict those at risk.
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Affiliation(s)
- Lorie D Hamiwka
- Division of Pediatric Neurology, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
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Updates in the Management of Seizures and Status Epilepticus in Critically Ill Patients. Neurol Clin 2008; 26:385-408, viii. [DOI: 10.1016/j.ncl.2008.03.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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10
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Abou Khaled KJ, Hirsch LJ. Advances in the management of seizures and status epilepticus in critically ill patients. Crit Care Clin 2007; 22:637-59; abstract viii. [PMID: 17239748 DOI: 10.1016/j.ccc.2006.06.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Seizures and status epilepticus are common in critically ill patients. They can be difficult to recognize because most are non-convulsive and require electroencephalogram monitoring to detect; hence, they are currently underdiagnosed. Early recognition and treatment are essential to obtain maximal response to first-line treatment and to prevent neurologic and systemic sequelae. Anti-seizure medication should be combined with management of the underlying cause and reversal of factors that can lower the seizure threshold, including many medications, fever, hypoxia, and metabolic imbalances. This article discusses specific treatments and specific situations, such as hepatic and renal failure patients and organ transplant patients.
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Affiliation(s)
- Karine J Abou Khaled
- Comprehensive Epilepsy Center, Department of Neurology, Columbia University Neurological Institute, New York, NY 10032, USA
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Qvist E, Pihko H, Fagerudd P, Valanne L, Lamminranta S, Karikoski J, Sainio K, Rönnholm K, Jalanko H, Holmberg C. Neurodevelopmental outcome in high-risk patients after renal transplantation in early childhood. Pediatr Transplant 2002; 6:53-62. [PMID: 11906644 DOI: 10.1034/j.1399-3046.2002.1o040.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Patient and graft survival rates of pediatric renal transplant recipients are currently excellent, but there are few reports regarding the long-term neurodevelopmental outcome after renal transplantation (Tx) in early childhood. Children with renal failure from infancy would be expected to have a less favorable developmental prognosis. We report the neurodevelopmental outcome in 33 school-age children transplanted between 1987 and 1995 when < 5 yr of age. We prospectively performed a neurological examination, magnetic resonance imaging (MRI) of the brain, electroencephalograms (EEGs), audiometry, and neuropsychological tests (NEPSY), and measured cognitive performance (WISC-R); we related these results to school performance and to retrospective risk factors prior to Tx. Twenty-six (79%) children attended normal school and 76% had normal motor performance. Six of the seven children attending a special school had brain infarcts on MRI. The EEG was abnormal in 11 (35%), and five (15%) received anti-convulsive treatment after Tx. Sensorineural hearing loss was documented in six patients. The mean intelligence quotient (IQ) was 87, and 6-24% showed impairment in neuropsychological tests. The children attending a special school had been more premature, but had not had a greater number of pre- or neonatal complications. They had experienced a greater number of hypertensive crises (p = 0.002) and seizures (p = 0.03), mainly during dialysis, but the number of septic infections and the mean serum aluminum levels were not significantly greater than in the children with normal school performance. In these previously lethal diseases, the overall neurodevelopmental outcome is reassuring. However, it is of crucial importance to further minimize the risk factors prior to Tx.
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Affiliation(s)
- Erik Qvist
- Pediatric Nephrology and Transplantation, Hospital for Children and Adolescents, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland.
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Rufo Campos M, Vázquez Florido A, Madruga Garrido M, Fijo J, Sánchez Moreno A, Martín Govantes J. Insuficiencia renal como factor desencadenante de crisis epilépticas. An Pediatr (Barc) 2002. [DOI: 10.1016/s1695-4033(02)77785-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Abstract
Seizures are commonly encountered in patients who do not have epilepsy. Factors that may provoke such seizures include organ failure, electrolyte imbalance, medication and medication withdrawal, and hypersensitive encephalopathy. There is usually one underlying cause, which may be reversible in some patients. A full assessment should be done to rule out primary neurological disease. Treatment of seizures in medically ill patients is aimed at correction of the underlying cause with appropriate short-term anticonvulsant medication. Phenytoin is ineffective in the management of seizures secondary to alcohol withdrawal, and in those due to theophylline or isoniazid toxicity. Control of blood pressure is important in patients with renal failure and seizures. Non-convulsive status epilepticus should be considered in any patient with confusion or coma of unclear cause, and electroencephalography should be done at the earliest opportunity. Most ill patients with secondary seizures do not have epilepsy, and this should be explained to patients and their families. Only those patients with recurrent seizures and uncorrectable predisposing factors need long-term treatment with anticonvulsant medication.
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Affiliation(s)
- N Delanty
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia 19104-4283, USA.
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Levin TL, Berdon WE, Seigle RR, Nash MA. Valproic-acid-associated pancreatitis and hepatic toxicity in children with endstage renal disease. Pediatr Radiol 1997; 27:192-3. [PMID: 9028861 DOI: 10.1007/s002470050100] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Farmer ME. Cognitive deficits related to major organ failure: the potential role of neuropsychological testing. Neuropsychol Rev 1994; 4:117-60. [PMID: 8061682 DOI: 10.1007/bf01874831] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Until recently, little attention has been paid to the possibility of cognitive deficits in patients with disease or failure of major organs such as the liver, kidney, or heart. However, there is a growing awareness that major organ failure often has neuropsychological sequelae. These sequelae may at times be quite subtle and not detectable under gross examination. Nevertheless, even subtle deficits may have a major impact on adherence to medical regimens, psychosocial adjustment, and quality of life of patients. Neuropsychological assessment has a potentially valuable role to play both in research and in clinical work. It can be useful in adding to our knowledge of the cognitive effects of various types, severity and duration of major organ disease, as well as sequelae associated with treatment. It also is a potentially valuable clinical tool for identifying cognitive deficits that will affect the quality of life and probability of survival for organ failure patients.
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Affiliation(s)
- M E Farmer
- Department of Psychology, Dalhousie University, Halifax, Nova Scotia, Canada
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Adair JC, Gilmore RL. Meperidine neurotoxicity after organ transplantation. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1994; 32:325-8. [PMID: 8007042 DOI: 10.3109/15563659409017968] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Meperidine neurotoxicity, characterized by recurrent convulsions, myoclonus, and asterixis, was diagnosed in an organ transplant recipient. Aside from cyclosporine toxicity, the literature regarding neurologic complications of transplantation contains limited reference to the neurotoxicity of therapy. The case reported illustrates how pharmacokinetic factors might render transplant patients particularly vulnerable to the neurotoxic side effects of certain medications, such as meperidine.
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Affiliation(s)
- J C Adair
- Shands Hospital, University of Florida School of Medicine, Gainesville
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