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  • Updated 01.25.2024
  • Released 10.21.2019
  • Expires For CME 01.25.2027

Transplantation: neurologic complications



Organ transplantation is the last resort in patients having end-stage organ failure. Kidney transplantation is the most frequently performed transplantation. Liver, heart, and lung transplantation are also now routinely performed at many centers. Hematopoietic stem cell transplantation helps in restoring hematopoietic function in patients with severe hematological and immune disorders, and indications for transplantation are expanding to include other disorders such as multiple sclerosis. A variety of neurologic complications is encountered following all kinds of organ transplantation. Immunosuppressive drugs are also associated with various types of neurotoxicity.

A large number (30% to 60%) of transplant recipients experience neurologic complications of variable severity following solid-organ transplantation and hematopoietic stem cell transplantation. Seizures and encephalopathy are seen early in the posttransplant period. Organ transplant recipients are at risk of having opportunistic infections and other neurologic complications for several years after transplant. COVID-19 has a severe course in organ transplant recipients. Immunosuppressive neurotoxicity is responsible for additional complications. Posterior reversible leukoencephalopathy syndrome is seen following use of cyclosporine and tacrolimus (calcineurin inhibitors). Posterior reversible leukoencephalopathy syndrome presents with seizures and altered sensorium. Renal insufficiency and high blood tacrolimus levels significantly predict posterior reversible leukoencephalopathy syndrome among patients with lung transplantation. Prompt diagnosis of neurologic complications along with timely treatment is crucial to reduce the devastating morbidity and improve posttransplant survival. Metagenomic next-generation sequencing of cerebrospinal fluid has been found useful in organ transplant recipients who are likely to have a very wide variety of central nervous system infections.

Key points

• Approximately 30% to 60% of transplant recipients have some kind of neurologic complications.

• The risk of neurologic posttransplant complications can extend up to several years.

• The majority of posttransplant neurologic complications are either toxic, metabolic, or infective or are due to ongoing dysimmune regulation, resulting in either graft rejection or graft-versus-host disease.

• Seizures, stroke, encephalopathy, and opportunistic brain infections are frequent complications.

• Other complications include lymphoproliferative disorder, central pontine myelinosis, and central pontine myelinolysis (now more commonly known as osmotic demyelination syndrome).

• Immunosuppressants can cause neurotoxicity, ranging from mild tremors to posterior leukoencephalopathy syndrome.

• Liver transplants are more frequently associated with encephalopathy.

• Neurologic complications are associated with a high morbidity and mortality; therefore, prompt evaluation and treatment are imperative.

Historical note and terminology

Ancient Indian, Greek, Roman, and Chinese mythological accounts abound with many kinds of transplants, including those involving cadavers or animals (19). The first turning point for modern transplant practices was development of technique to perform vascular anastomoses. This Nobel Prize-winning technique was credited to a French doctor, Alexis Carrel. This surgical technique paved the way for solid-organ transplantation. Credit of first successful renal transplant, performed in 1954, is given to Dr Joseph Murray of the United States. Since then, kidneys have been the most frequently transplanted organ. Credit for the first liver transplant goes to Dr Thomas Starzl, who performed the transplant in 1963. Results were not encouraging initially, but now liver transplant is a successful treatment option for liver failure. Credit for the world's first heart transplant, done in 1967, is given to Dr Christiaan Barnard of South Africa. In the year 1963, a team of surgeons led by Dr. James D Hardy performed the first human lung transplant in the University of Mississippi Medical Center, United States. The discovery of cyclosporine, an immunosuppressant, brought a sea change in patient survival following organ transplantation. The development of organ transplantation roughly coincided with the concept of declaration of death by brain criteria.

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