Tacrolimus-induced posterior reversible encephalopathy syndrome following liver transplantation

Abstract

In this editorial, we talk about a compelling case focusing on posterior reversible encephalopathy syndrome (PRES) as a complication in patients undergoing liver transplantation and treated with Tacrolimus. Tacrolimus (FK 506), derived from Streptomyces tsukubaensis, is a potent immunosuppressive macrolide. It inhibits T-cell transcription by binding to FK-binding protein, and is able to amplify glucocorticoid and progesterone effects. Tacrolimus effectively prevents allograft rejection in transplant patients but has adverse effects such as Tacrolimus-related PRES. PRES presents with various neurological symptoms alongside elevated blood pressure, and is primarily characterized by vasogenic edema on neuroimaging. While computed tomography detects initial lesions, magnetic resonance imaging, especially the Fluid-Attenuated Inversion Recovery sequence, is superior for diagnosing cortical and subcortical edema. Our discussion centers on the incidence of PRES in solid organ transplant recipients, which ranges between 0.5 to 5 +ACU-, with varying presentations, from seizures to visual disturbances. The case of a 66-year-old male status post liver transplantation highlights the diagnostic and management challenges associated with Tacrolimus-related PRES. Radiographically evident in the parietal and occipital lobes, PRES underlines the need for heightened vigilance among healthcare providers. This editorial emphasizes the importance of early recognition, accurate diagnosis, and effective management of PRES to optimize outcomes in liver transplant patients. The case further explores the balance between the efficacy of immunosuppression with Tacrolimus and its potential neurological risks, underlining the necessity for careful monitoring and intervention strategies in this patient population.

Keywords: Posterior reversible encephalopathy syndrome, Liver transplantation, Tacrolimus, Immunocompromised patients, Neurological complications, Solid organ transplant

Core Tip: Tacrolimus, a crucial immunosuppressant in liver transplantation, is associated with the rare but serious complication of posterior reversible encephalopathy syndrome (PRES). Although the incidence is relatively low (0.5%-5%) in solid organ transplant recipients, the presentation of PRES can vary significantly, including seizures and visual disturbances. This condition, primarily affecting the parietal and occipital lobes, underscores the need for diligent monitoring and early intervention in liver transplant patients undergoing Tacrolimus therapy. The case presented highlights the complexities in diagnosing and managing Tacrolimus-related PRES, emphasizing the critical balance between adequate immunosuppression and the risk of severe neurological adverse effects.