Post-Renal Transplant Neurological Complications Salem Najjar
1 BA ,
Claudia F. Kirsch 1Donald
Background
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and Souhel Najjar
1 MD
Results/Imaging
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Figure 3: 19 year old male status post renal transplant 2 years prior in hypertensive crisis, MRI with (A) FLAIR, (B) ADC, (C) Diffusion weighted imaging, demonstrating findings of posterior reversible encephalopathy (PRES), with patchy FLAIR and DWI hyper-intensity in the bilateral frontal and parietal lobes near vertex with ADC T2-shine through and without restricted diffusion. F
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Figure 1: 58 year old male status post renal transplant on mycophenolic acid, one year after transplant with mental status and behavioral changes. MRI (A) Axial T1, (B) Post-gadolinium contrast Axial T1, (C) Axial FLAIR, (D) Axial ADC, (E) Axial diffusion weighted imaging, (F) Spectroscopy with voxel over affected left frontal white matter and control normal voxel over lying the left parietal white matter. Images demonstrate patchy irregular decreased T1 signal with minimal enhancement, T2 and FLAIR white matter hyperintensity with DWI and ADC T2-shine through. The spectroscopy of the abnormal frontal white matter demonstrates a markedly decreased NAA/Creatine ratio indicative of neuronal loss, and elevated Choline/Creatine ratio with inverted significant lactate peaks at 144 ppm are highly suggestive of progressive multifocal leukoencephalopathy, which was eventually confirmed with biopsy. (NAA= N-Acetyl Aspartate- measures neuronal number and health).
Comorbidities Medications Immunosuppression Infection Metabolic abnormalities Surgical complications
Encephalopathy Cognitive Impairment Neurotoxicities of Calcineurin Inhibitors Neurological and neuropsychiatric disturbances associated with corticosteroids Central nervous system infections Lymphoma Cerebrovascular events Osmotic Demyelination Syndrome Neuropathies Myopathies
1 MD ,
and Barbara Zucker School of Medicine at Hofstra/Northwell
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Etiologies
Complications
Ernesto P. Molmenti
Results/Imaging
Renal transplants are among the most common solid organ transplants with a steady rise in their numbers, particularly over the recent years (Shoskes, 2019). Some reports suggest that about 9 out 10 transplant recipients experience some forms of neurological symptoms (Piotrowski, 2017). Other reports indicate that 30-60 % of post-renal transplant individuals may develop some neurological complications (Dhar, 2011), with an estimated prevalence rate of 8% (Mohammadi, 2019). The central neurological complications may have similar clinical presentations despite their diverse etiologies. Further, these complications are frequently associated with a higher rate of morbidity and mortality. Thus, early recognition and treatment can prevent or limit life-threatening sequelae associated with these complications and optimize the clinical outcome (Mohammadi, 2019) (Shepherd, 2017). In this chapter we review the central and peripheral neurological complications following renal transplant, including those related to immunosuppressants.
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Conclusions Despite the fact that renal transplantation has become safer, neurological complications remain significant contributors to the morbidity and mortality among transplant recipients. Thus, early recognition and treatment of these serious and potentially lifethreatening conditions can substantially improve the clinical outcome in this specific population. This work will be published as a chapter of a kidney and pancreas transplant textbook.
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Figure 2: 87 year old female status post renal transplant 15 years prior, with remote right occipital infarct and new left middle cerebral artery infarct. (A) Axial FLAIR MRI with remote right posterior cerebral artery (PCA) infarct with encephalomalacia and gliosis in the right occipital lobe, (B) Axial FLAIR MRI with new infarct in the left middle cerebral artery (MCA) distribution in the left frontal lobe. (C) MRI ADC with restricted diffusion in the left MCA territory with (D) corresponding hyperintense DW signal intensity, note there is no restricted diffusion in the remote area of prior right PCA infarction. (D) Perfusion CT demonstrating decreased cerebral blood flow with new infarct in left frontal lobe. (F) 3D CT angiography demonstrating tortuous proximal internal carotid artery (yellow arrow), likely reflecting underlying hypertension. (G) 3D CT angiography of the brain demonstrating decreased blood supply in the right PCA and left MCA regions (purple arrow).
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