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Etta PK, Bavikar P, Phani R. Tacrolimus-Associated Cerebral Vasculopathy Presenting with Recurrent Intracerebral Hemorrhage. Indian J Nephrol 2023; 33:398-399. [PMID: 37881729 PMCID: PMC10593301 DOI: 10.4103/ijn.ijn_281_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 01/31/2023] [Indexed: 10/27/2023] Open
Affiliation(s)
- Praveen Kumar Etta
- Department of Nephrology and Kidney Transplantation, TX Hospitals, Hyderabad, Telangana, India
| | - Purva Bavikar
- Department of Nephrology and Kidney Transplantation, TX Hospitals, Hyderabad, Telangana, India
| | - Ram Phani
- Department of Nephrology and Kidney Transplantation, TX Hospitals, Hyderabad, Telangana, India
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Wang YH, Chen YJ, Yang Y, Zhang KY, Chen XZ, Yang CY, Wang J, Lei XJ, Quan YL, Chen WX, Zhao HL, Yang LK, Feng H. Cyclophilin D-induced mitochondrial impairment confers axonal injury after intracerebral hemorrhage in mice. Neural Regen Res 2023; 18:849-855. [PMID: 36204853 PMCID: PMC9700082 DOI: 10.4103/1673-5374.353495] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The mitochondrial permeability transition pore is a nonspecific transmembrane channel. Inhibition of mitochondrial permeability transition pore opening has been shown to alleviate mitochondrial swelling, calcium overload, and axonal degeneration. Cyclophilin D is an important component of the mitochondrial permeability transition pore. Whether cyclophilin D participates in mitochondrial impairment and axonal injury after intracerebral hemorrhage is not clear. In this study, we established mouse models of intracerebral hemorrhage in vivo by injection of autologous blood and oxyhemoglobin into the striatum in Thy1-YFP mice, in which pyramidal neurons and axons express yellow fluorescent protein. We also simulated intracerebral hemorrhage in vitro in PC12 cells using oxyhemoglobin. We found that axonal degeneration in the early stage of intracerebral hemorrhage depended on mitochondrial swelling induced by cyclophilin D activation and mitochondrial permeability transition pore opening. We further investigated the mechanism underlying the role of cyclophilin D in mouse models and PC12 cell models of intracerebral hemorrhage. We found that both cyclosporin A inhibition and short hairpin RNA interference of cyclophilin D reduced mitochondrial permeability transition pore opening and mitochondrial injury. In addition, inhibition of cyclophilin D and mitochondrial permeability transition pore opening protected corticospinal tract integrity and alleviated motor dysfunction caused by intracerebral hemorrhage. Our findings suggest that cyclophilin D is used as a key mediator of axonal degeneration after intracerebral hemorrhage; inhibition of cyclophilin D expression can protect mitochondrial structure and function and further alleviate corticospinal tract injury and motor dysfunction after intracerebral hemorrhage. Our findings provide a therapeutic target for preventing axonal degeneration of white matter injury and subsequent functional impairment in central nervous diseases.
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Model-informed Estimation of Acutely Decreased Tacrolimus Clearance and Subsequent Dose Individualization in a Pediatric Renal Transplant Patient with Posterior Reversible Encephalopathy Syndrome. Ther Drug Monit 2022; 45:376-382. [PMID: 36728342 DOI: 10.1097/ftd.0000000000001045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/22/2022] [Indexed: 02/03/2023]
Abstract
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.
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Kemna MS, Shaw DW, Kronmal RA, Ameduri RK, Azeka E, Bradford TT, Kindel SJ, Lin KY, Möller T, Reardon LC, Schumacher KR, Shih R, Stendahl GL, West SC, Wisotzkey B, Zangwill S, Menteer J. Posterior reversible encephalopathy syndrome (PRES) after pediatric heart transplantation: A multi-institutional cohort. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Shah S, Ojha R, Chamlagain R, Chhetri S, Prasad P, Baral B, Gyawali B, Shrestha A, Yadav JK. Therapeutic drug level of tacrolimus causing intracranial hemorrhage in a patient with renal transplant. Clin Case Rep 2022; 10:e05788. [PMID: 35498342 PMCID: PMC9043708 DOI: 10.1002/ccr3.5788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 03/17/2022] [Accepted: 04/04/2022] [Indexed: 11/22/2022] Open
Abstract
Tacrolimus is used in solid organ transplant patients to prevent rejection, and no case of intracerebral hemorrhage (ICH) has been reported till date. We report a case of 31‐year‐old man with diabetes and hypertension for ten years who had a renal transplant four years back; diagnosed with tacrolimus‐induced ICH.
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Affiliation(s)
- Sangam Shah
- Maharajgunj Medical Campus Institute of Medicine Tribhuvan University Maharajgunj Nepal
| | - Rajeev Ojha
- Department of Internal Medicine Institute of Medicine Tribhuvan University Maharajgunj Nepal
| | - Rajan Chamlagain
- Department of Neurology Institute of Medicine Tribhuvan University Maharajgunj Nepal
| | - Santosh Chhetri
- Department of Nephrology Institute of Medicine Tribhuvan University Maharajgunj Nepal
| | - Pravin Prasad
- Department of Clinical Pharmacology Institute of Medicine Tribhuvan University Maharajgunj Nepal
| | - Bikash Baral
- Maharajgunj Medical Campus Institute of Medicine Tribhuvan University Maharajgunj Nepal
| | - Bindu Gyawali
- Maharajgunj Medical Campus Institute of Medicine Tribhuvan University Maharajgunj Nepal
| | - Ashish Shrestha
- Department of Internal Medicine Institute of Medicine Tribhuvan University Maharajgunj Nepal
| | - Jayant Kumar Yadav
- Department of Neurology Institute of Medicine Tribhuvan University Maharajgunj Nepal
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Huenges K, Kolat P, Panholzer B, Haneya A. CSA-Induced PRES after Heart Transplantation-Report of Two Cases and Review. Thorac Cardiovasc Surg Rep 2021; 10:e59-e60. [PMID: 34777943 PMCID: PMC8580731 DOI: 10.1055/s-0041-1732344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background
Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disease possibly associated with the use of calcineurin inhibitors (CNI) like cyclosporine A.
Case Description
The case of a patient who developed severe PRES under CNI therapy shortly after heart transplantation is presented here. Cerebral computed tomography led to the diagnose of PRES in our patient. New therapy strategy with a quadruple immunosuppressive protocol (cortisone, mycophenolate mofetil, low-dose CNI, and a mechanistic target of rapamycin inhibitor) was started.
Conclusion
Under the quadruple therapy, a neurologic recovery occurred. In PRES, the presented alternative therapy strategy may lead to improving neurological conditions and preserved transplant organ functions.
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Affiliation(s)
- Katharina Huenges
- Department of Cardiovascular Surgery, University of Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Philipp Kolat
- Department of Cardiovascular Surgery, University of Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Bernd Panholzer
- Department of Cardiovascular Surgery, University of Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Assad Haneya
- Department of Cardiovascular Surgery, University of Schleswig-Holstein Campus Kiel, Kiel, Germany
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Nassar N, Chater C, Chelala A. Posterior reversible encephalopathy syndrome associated with focal segmental glomerulosclerosis in a child. BMJ Case Rep 2021; 14:14/4/e240085. [PMID: 33853815 PMCID: PMC8054056 DOI: 10.1136/bcr-2020-240085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a rare neurological entity, typically manifested by reversible oedema in the parieto-occipital lobes. It is usually associated with primary hypertension, autoimmune diseases and immunosuppressants. Renal disease is an uncommon cause of PRES. We report a case of an 11-year-old boy with STimulator of INterferon Genes-associated vasculopathy with onset in infancy complicated by focal segmental glomerulosclerosis leading to hypertension and PRES. The patient presented with headache, acute bilateral visual loss and hypertension. Brain MRI showed atypical features revealed by parieto-occipital haemorrhage. The child improved few days after antihypertensive therapy. Follow-up MRI showed complete resolution of haemorrhage. It is important to keep high index of suspicion for the uncommon association of PRES with underlying kidney disease with or without immunosuppressive agents. This combination is the first to our knowledge to be described in paediatric population. Atypical MRI features such as haemorrhage should be kept in mind. Symptoms are reversible within days to weeks with early diagnosis and treatment.
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Affiliation(s)
- Nadine Nassar
- Department of Radiology, Notre Dame des Secours University Hospital Center, Jbeil, Mont-Liban, Lebanon.,Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Jounieh, Lebanon
| | - Charbel Chater
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Jounieh, Lebanon .,Department of General Surgery, Notre Dame des Secours University Hospital Center, Jbeil, Mont-Liban, Lebanon
| | - Amal Chelala
- Department of Radiology, Notre Dame des Secours University Hospital Center, Jbeil, Mont-Liban, Lebanon.,Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Jounieh, Lebanon
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Ghali MGZ, Styler MJ. Etiologies, Cerebral Vasomotion, and Endothelial Dysfunction in the Pathophysiology of Posterior Reversible Encephalopathy Syndrome in Pediatric Patients. JOURNAL OF PEDIATRIC NEUROLOGY 2020. [DOI: 10.1055/s-0040-1702934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AbstractThe posterior reversible encephalopathy syndrome was characterized by Hinchey and colleagues in the 1990s. The condition frequently afflicts patients suffering from hematologic and solid organ malignancy and individuals undergoing transplantation. Cases are more frequently described in the adult population compared with children. In the pediatric population, malignancy, transplantation, renal disease, and hypertension represent the most common etiologies. Theories on pathogenesis have centered upon cerebrovascular dysautoregulation with increases in blood–brain barrier permeability. This generates vasogenic edema of the cerebral parenchyma and consequent neurologic deficits. The parietal and occipital lobes are affected with greatest prevalence, though frontal and temporal lobe involvement is frequent, and that of the contents of the infratentorial posterior cranial fossa are occasionally described. The clinical presentation involves a characteristic constellation of neurologic signs and symptoms, most typically inclusive of headache, visual-field disturbances, abnormalities of visual acuity, and seizures. Supportive care, withdrawal of the offending agent, antihypertensive therapy, and prophylactic anticonvulsants affect convalescence in majority of cases. The principal challenge lies in identifying the responsible agent precipitating the condition in patients with malignancy and those having undergone transplantation and thus deciding which medication among a multidrug treatment regimen to withhold, the duration of drug cessation required to effect clinical resolution, and the safety of resuming treatment with the compound. We accordingly reviewed and evaluated the literature discussing the posterior reversible encephalopathy syndrome in children.
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Affiliation(s)
- Michael G. Z. Ghali
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, United States
| | - Michael J. Styler
- Department of Hematology and Oncology, Hahnemann University Hospital, Philadelphia, Pennsylvania, United States
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Yamagami K, Maeda Y, Iihara K. Variant Type of Posterior Reversible Encephalopathy Syndrome Associated with Deep Brain Hemorrhage: Case Report and Review of the Literature. World Neurosurg 2019; 134:176-181. [PMID: 31712110 DOI: 10.1016/j.wneu.2019.10.196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 10/30/2019] [Accepted: 10/31/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Various radiologic patterns of posterior reversible encephalopathy syndrome (PRES) have been reported. Among them, PRES involving brainstem, thalamus, or deep white matter and lacking parieto-occipital edema is rare. Although PRES in general has a benign course, PRES-related intracranial hemorrhage has been associated with a poor prognosis. We report a case of variant type of PRES associated with deep brain hemorrhage and discuss the characteristics of PRES-related intracranial hemorrhage via a literature review. CASE DESCRIPTION A woman aged 41 years with a history of untreated hypertension presented to our hospital complaining of severe headache and with an elevated blood pressure of 237/142 mmHg. Computed tomography revealed a hemorrhage in the left thalamus and basal ganglia. Magnetic resonance imaging revealed remarkable hyperintensity in the left cerebellum, pons, bilateral temporal lobes, bilateral basal ganglia, and bilateral cerebral white matter on fluid-attenuated inversion recovery imaging, which represented vasogenic edema. The parieto-occipital regions were unremarkable. Given this clinical presentation, PRES associated with deep brain hemorrhage was suspected. The patient received strict blood pressure control treatment, which resulted in gradual symptom improvement. Magnetic resonance images obtained 1 month after admission demonstrated an almost complete resolution of the edema. CONCLUSIONS Although hemorrhage in the thalamus, basal ganglia, or brainstem is uncommon in patients with PRES, it may occur in patients with variant type of PRES involving these lesions. It is important to recognize the presence of variant patterns of clinical features and radiologic findings of PRES to allow for early identification and appropriate treatment.
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Affiliation(s)
- Keitaro Yamagami
- Department of Neurosurgery, Hachisuga Hospital, Munakata, Japan; Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Yoshihisa Maeda
- Department of Neurosurgery, Hachisuga Hospital, Munakata, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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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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11
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Ko SB. Perioperative stroke: pathophysiology and management. Korean J Anesthesiol 2018; 71:3-11. [PMID: 29441169 PMCID: PMC5809704 DOI: 10.4097/kjae.2018.71.1.3] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 11/19/2017] [Indexed: 01/01/2023] Open
Abstract
Although perioperative stroke is uncommon during low-risk non-vascular surgery, if it occurs, it can negatively impact recovery from the surgery and functional outcome. Based on the Society for Neuroscience in Anesthesiology and Critical Care Consensus Statement, perioperative stroke includes intraoperative stroke, as well as postoperative stroke developing within 30 days after surgery. Factors related to perioperative stroke include age, sex, a history of stroke or transient ischemic attack, cardiac surgery (aortic surgery, mitral valve surgery, or coronary artery bypass graft surgery), and neurosurgery (external carotid-internal carotid bypass surgery, carotid endarterectomy, or aneurysm clipping). Concomitant carotid and cardiac surgery may further increase the risk of perioperative stroke. Preventive strategies should be individualized based on patient factors, including cerebrovascular reserve capacity and the time interval since the previous stroke.
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Affiliation(s)
- Sang-Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
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12
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Safety and Tolerance of Donor-Derived Mesenchymal Stem Cells in Pediatric Living-Donor Liver Transplantation: The MYSTEP1 Study. Stem Cells Int 2017; 2017:2352954. [PMID: 28740511 PMCID: PMC5504958 DOI: 10.1155/2017/2352954] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 05/08/2017] [Indexed: 12/14/2022] Open
Abstract
Background Calcineurin inhibitors (CNI) have significantly improved patient and graft survival in pediatric liver transplantation (pLT). However, CNI toxicity leads to significant morbidity. Moreover, CNIs cannot prevent long-term allograft injury. Mesenchymal stem (stromal) cells (MSC) have potent immunomodulatory properties, which may promote allograft tolerance and ameliorate toxicity of high-dose CNI. The MYSTEP1 trial aims to investigate safety and feasibility of donor-derived MSCs in pLT. Methods/Design 7 to 10 children undergoing living-donor pLT will be included in this open-label, prospective pilot trial. A dose of 1 × 106 MSCs/kg body weight will be given at two time points: first by intraportal infusion intraoperatively and second by intravenous infusion on postoperative day 2. In addition, participants will receive standard immunosuppressive treatment. Our primary objective is to assess the safety of intraportal and intravenous MSC infusion in pLT recipients. Our secondary objective is to evaluate efficacy of MSC treatment as measured by the individual need for immunosuppression and the incidence of biopsy-proven acute rejection. We will perform detailed immune monitoring to investigate immunomodulatory effects. Discussion Our study will provide information on the safety of donor-derived MSCs in pediatric living-donor liver transplantation and their effect on immunomodulation and graft survival.
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Ban SP, Hwang G, Kim CH, Kwon OK. Reversible cerebral vasoconstriction syndrome combined with posterior reversible encephalopathy syndrome after heart transplantation. J Clin Neurosci 2017; 42:118-121. [PMID: 28416081 DOI: 10.1016/j.jocn.2017.03.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/13/2017] [Indexed: 11/26/2022]
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) combined with posterior reversible encephalopathy syndrome (PRES) is a rare complication in patients treated with immunosuppressants. A 52-year-old male patient presented with seizures after heart transplantation. The patient was suspected of having PRES on brain images. Despite the strict blood pressure control, the patient presented with altered mentality and the brain images showed a newly developed large acute infarction. Digital subtraction angiography (DSA) revealed the classic "sausage on a string" appearance of the cerebral arteries - potential feature of RCVS. To our knowledge, this is the first case report to describe RCVS combined with PRES after heart transplantation.
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Affiliation(s)
- Seung Pil Ban
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Gyojun Hwang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Chang Hyeun Kim
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - O-Ki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
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Ollivier M, Bertrand A, Clarençon F, Gerber S, Deltour S, Domont F, Trunet S, Dormont D, Leclercq D. Neuroimaging features in posterior reversible encephalopathy syndrome: A pictorial review. J Neurol Sci 2017; 373:188-200. [DOI: 10.1016/j.jns.2016.12.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 12/06/2016] [Accepted: 12/07/2016] [Indexed: 10/20/2022]
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Öcal R, Kibaroğlu S, Derle E, Tanoğlu C, Camkıran A, Pirat A, Can U, Sezgin A. Neurologic Complications After Cardiac Transplant. EXP CLIN TRANSPLANT 2016. [PMID: 27309851 DOI: 10.6002/ect.2016.0127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Cardiac transplant is the best available therapy for patients with end-stage heart failure. Neurologic complications occur at a rate of 30% to 70% in patients undergoing cardiac transplant, and they affect mortality and morbidity of these patients. Risk factors for neurologic complications include immunosuppressive medication toxicity, infections, brain lesions, and metabolic disorders. The aim of our study was to determine the incidence of neurologic complications in adult patients undergoing cardiac transplant. MATERIALS AND METHODS We retrospectively evaluated the medical records of 70 patients who underwent cardiac transplant between 2004 and April 2016. We recorded the demographic data, neurologic symptoms, neurologic examination findings, laboratory test results, brain imaging study results, and treatments received of the patients. RESULTS Of the 70 patients enrolled, 55 were male and 15 were female patients. The age range was 18 to 63 years, and the mean age was 42.4 years. Twelve patients had encephalopathy, 4 had neuropathic pain, 3 had tremor, 2 had ischemic cerebrovascular accident, 7 had posterior reversible encephalopathy syndrome, and 1 had drop foot. Encephalopathy usually developed secondary to other neurologic disorders. The incidence of neurologic complications in adult patients undergoing cardiac transplant was 30%. CONCLUSIONS Neurologic complications are common after cardiac transplant. We observed an incidence of 30% for neurologic complications in our clinic, with encephalopathy being the most common complication. Encephalopathy most commonly developed secondary to posterior reversible encephalopathy syndrome.
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Affiliation(s)
- Ruhsen Öcal
- From the Department of Neurology, Baskent University Faculty of Medicine, Ankara, Turkey
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Eilers B, Albers E, Law Y, McMullan DM, Shaw D, Kemna M. Posterior reversible encephalopathy syndrome after pediatric heart transplantation: Increased risk for children with preexisting Glenn/Fontan physiology. Pediatr Transplant 2016; 20:552-8. [PMID: 27139146 DOI: 10.1111/petr.12702] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2016] [Indexed: 11/29/2022]
Abstract
Identification of risk factors for PRES after organ transplant can improve early detection and avoid permanent neurological injury. High calcineurin-inhibitor levels and hypertension are recognized risk factors for PRES in adult transplant recipients. Limited data exist regarding PRES after pediatric HTx, with studies limited to case reports. We performed a retrospective review of 128 pediatric HTx recipients to identify risk factors for PRES. Seven of 128 (5.5%) recipients developed PRES at a median of 10 days (5-57) after HTx. The median age of recipients with PRES was 10.0 yr (5.7-19.0), compared to 1.4 yr (0.0-19.8) for recipients without PRES (p = 0.010). Fewer than half of recipients with PRES had elevated post-transplant calcineurin-inhibitor levels (n = 3) and/or preceding severe hypertension (n = 3). Four of seven who developed PRES (57%) had pretransplant Glenn or Fontan physiology (G/F). G/F was a significant risk factor for PRES (RR 4.99, 95% CI: 1.19-21.0, p = 0.036). Two recipients (29%), both with severe PRES, had residual neurological symptoms. In summary, PRES occurred in 5.5% of pediatric HTx recipients and presented early after HTx. All recipients with PRES were > 5 yr. Patients with pretransplant G/F were at increased risk, a risks factor not previously described.
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Affiliation(s)
- Braiden Eilers
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Erin Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Yuk Law
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - D Mike McMullan
- Division of Pediatric Cardiothoracic Surgery, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Dennis Shaw
- Division of Radiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Mariska Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
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Song T, Rao Z, Tan Q, Qiu Y, Liu J, Huang Z, Wang X, Lin T. Calcineurin Inhibitors Associated Posterior Reversible Encephalopathy Syndrome in Solid Organ Transplantation: Report of 2 Cases and Literature Review. Medicine (Baltimore) 2016; 95:e3173. [PMID: 27057842 PMCID: PMC4998758 DOI: 10.1097/md.0000000000003173] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Turun Song
- From the Department of Urology, Institute of Urology, Organ Transplantation Center (TS, ZR, YQ, JL, ZH, XW, TL); and The Third Comprehensive Care Unit, West China Hospital, Sichuan University (QT), Chengdu, Sichuan, China
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Giussani A, Ardissino G, Belingheri M, Dilena R, Raiteri M, Pasciucco A, Colico C, Beretta C. Posterior reversible encephalopathy syndrome after kidney transplantation in pediatric recipients: Two cases. Pediatr Transplant 2016; 20:68-71. [PMID: 26607205 DOI: 10.1111/petr.12640] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2015] [Indexed: 11/26/2022]
Abstract
PRES is a neuro-clinical and radiological syndrome that can result as a consequence of several different conditions including hypertension, fluid overload, and immunosuppressive treatment. Herein, we report two children who received kidney and combined liver-kidney transplantation as treatment for renal hypodysplasia associated with bilateral vesico-ureteral reflux and methylmalonic acidemia, respectively. Early after surgery (seven and 10 days), both patients presented with hypertension and seizures. The patients' immunosuppressive regimen included steroid and calcineurin inhibitors (tacrolimus and cyclosporine, respectively) and basiliximab and one with anti-IL2 receptor. In both cases, the imaging strongly supported the diagnosis of PRES. In details, the CT scan showed hypodensities in the posterior areas of the brain, and brain MRI demonstrated parieto-occipital alterations indicative of vasogenic edema. Treatment with calcineurin inhibitors was temporally discontinued and restarted at lower dosage; arterial hypertension was treated with Ca-channel blockers. Both children fully recovered without any neurological sequels. In conclusion, in children undergoing solid organ transplantation, who develop neurological symptoms PRES, should be carefully considered in the differential diagnosis and once the diagnosis is ruled in, we recommend strict arterial blood pressure control and adjustment or withholding of calcineurin inhibitor therapy should be considered based upon blood levels.
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Affiliation(s)
- Antenore Giussani
- U.O. Trapianti di Rene, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Gianluigi Ardissino
- U.O.C. Nefrologia e Dialisi Pediatrica, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Mirco Belingheri
- U.O. Nefrologia e Dialisi, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Robertino Dilena
- U.O. Neurofisiopatologia Servizio di Epilettologia e Neurofisiopatologia Pediatrica, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Mauro Raiteri
- U.O. Trapianti di Rene, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Antonio Pasciucco
- U.O. Trapianti di Rene, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Caterina Colico
- U.O. Trapianti di Rene, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Claudio Beretta
- U.O. Trapianti di Rene, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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Posterior Reversible Encephalopathy Syndrome After Transplantation: a Review. Mol Neurobiol 2015; 53:6897-6909. [PMID: 26666662 DOI: 10.1007/s12035-015-9560-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 11/29/2015] [Indexed: 12/29/2022]
Abstract
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.
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Chowdhary M, Kabbani AA, Tobey D, Hope TD. Posterior reversible encephalopathy syndrome in a woman with focal segmental glomerulosclerosis. Neuropsychiatr Dis Treat 2015; 11:1111-4. [PMID: 25960654 PMCID: PMC4411014 DOI: 10.2147/ndt.s84010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a rare syndrome characterized by reversible vasogenic edema in the posterior hemispheres. PRES is most often attributed to primary hypertension, pre-eclampsia, and neurotoxicity secondary to immunosuppressants such as cyclosporine. Renal disease is an infrequent cause of PRES with a majority of cases occurring in adults with complete renal failure or in pediatric cases with underlying renal parenchymal disease and concurrent immunosuppressive therapy. Typical symptoms include seizure, headache, altered mental status, and visual disturbances. PRES is rarely associated with cerebral hemorrhage, and even less so with subarachnoid bleeds. Herein we report on a 25-year-old female with focal segmental glomerulosclerosis who developed PRES. The patient's presentation was more severe as she presented with seizure, nephrotic syndrome, and subarachnoid hemorrhage. Computed tomography and magnetic resonance imaging with concurrent symptoms led us to the final diagnosis. The patient was treated with antihypertensives, diuretics, and corticosteroids and follow-up imaging revealed resolution of PRES. Our case illustrates that underlying kidney disease even without immunosuppressive agents should be added to the list of possible causes for PRES. Symptoms are reversible with treatment of underlying cause or offending agent.
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Affiliation(s)
- Mudit Chowdhary
- Department of Internal Medicine, Mercer University School of Medicine, Macon, GA, USA
| | - Ahmad A Kabbani
- Department of Internal Medicine, Mercer University School of Medicine, Macon, GA, USA
| | - Devon Tobey
- Department of Internal Medicine, Mercer University School of Medicine, Macon, GA, USA
| | - Thomas D Hope
- Department of Neurology, Mercer University School of Medicine, Macon, GA, USA
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Liu F, Zhang H, Zhang K, Wang X, Li S, Yin Y. Rapamycin promotes Schwann cell migration and nerve growth factor secretion. Neural Regen Res 2014; 9:602-9. [PMID: 25206862 PMCID: PMC4146242 DOI: 10.4103/1673-5374.130101] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2014] [Indexed: 11/04/2022] Open
Abstract
Rapamycin, similar to FK506, can promote neural regeneration in vitro. We assumed that the mechanisms of action of rapamycin and FK506 in promoting peripheral nerve regeneration were similar. This study compared the effects of different concentrations of rapamycin and FK506 on Schwann cells and investigated effects and mechanisms of rapamycin on improving peripheral nerve regeneration. Results demonstrated that the lowest rapamycin concentration (1.53 nmol/L) more significantly promoted Schwann cell migration than the highest FK506 concentration (100μmol/L). Rapamycin promoted the secretion of nerve growth factors and upregulated growth-associated protein 43 expression in Schwann cells, but did not significantly affect Schwann cell proliferation. Therefore, rapamycin has potential application in peripheral nerve regeneration therapy.
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Affiliation(s)
- Fang Liu
- Department of Orthopedics, Second Hospital of Yueyang, Yueyang, Hunan Province, China
| | - Haiwei Zhang
- Department of Orthopedics, Second Hospital of Yueyang, Yueyang, Hunan Province, China
| | - Kaiming Zhang
- Department of Orthopedics, Second Hospital of Yueyang, Yueyang, Hunan Province, China
| | - Xinyu Wang
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, and Biomedical Materials and Engineering Center, Wuhan University of Technology, Wuhan, Hunan Province, China
| | - Shipu Li
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, and Biomedical Materials and Engineering Center, Wuhan University of Technology, Wuhan, Hunan Province, China
| | - Yixia Yin
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, and Biomedical Materials and Engineering Center, Wuhan University of Technology, Wuhan, Hunan Province, China
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