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• W2981306389 abstract "SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Tacrolimus and other calcineurin inhibitors have been known to cause neurotoxicity, although there have been no reports of tacrolimus leading to a central apnea or causing hypercapnia via another mechanism. CASE PRESENTATION: 61 year old female with alcoholic cirrhosis status post orthotopic liver transplant two months prior, presented to our intensive care unit (ICU) with acute hypercapnic respiratory failure. Approximately one week prior she developed a right-sided pleural effusion. She was also noted to have intermittent fatigue, confusion and “absent spells”. She was admitted to the hospital due to tachypnea and altered mentation, but subsequently developed severe encephalopathy with slurred speech. Arterial blood gas demonstrated severe hypercapnia with acidosis and the patient was emergently intubated. Computerized tomography and magnetic resonance imaging of the head were largely normal. Two weeks prior to admission, her serum tacrolimus level was noted to be significantly elevated; dosing was modified such that her level was therapeutic at the time of admission. Her serum bicarbonate levels had been steadily rising in the two months after transplant, but had been normal previously. The patient had no prior history of sleep disordered breathing and was not on opioids, benzodiazepines, or other respiratory depressants. While on volume control ventilation, the hypercapnia readily corrected. However, on pressure support ventilation she had episodic apnea and bradypnea with associated CO2 rise. Due to concern for a central respiratory drive disorder which may not be easily reversible, she underwent elective tracheostomy placement and tacrolimus was stopped. Her apneic episodes did eventually decrease and she was liberated from mechanical ventilation. She was subsequently started on sirolimus. Due to concerns of subacute organ rejection, tacrolimus was restarted at a low dose, with sirolimus and mycophenolate mofetil. She was still noted to have apneic episodes during sleep, but maintained adequate ventilation and cognitive status. Her tracheostomy was decannulated about 3 weeks after placement. DISCUSSION: Liver transplant patients are particularly susceptible to neurologic complications due to a history of hepatic encephalopathy, which she did have pre-transplant. After careful elimination of other potential respiratory depressants, tacrolimus was the most likely culprit. It has been observed that most neurotoxic events associated with tacrolimus occur within the first two months of starting the medication, and with greater frequency compared to other calcineurin inhibitors. She may have been at increased susceptibility due to the briefly elevated level. Neurotoxicity often manifests as a tremor and less commonly with symptoms similar to posterior leukoencephalopathy. CONCLUSIONS: To our knowledge this appears to be the first reported case of tacrolimus induced central apnea. Reference #1: Shrestha BM. Two Levels of Tacrolimus in Renal Transplant: Basic Science and Clinical Evidences. Exp Clin Transplant. 2017; 1:1-9 Reference #2: Wu SY, Chen TW, Feng AC, Fan HL, Hsieh CB, Chung KP. Comprehensive risk assessment for early neurologic complications after liver transplantation. World J Gastroenterol. 2016;22(24):5548-57. Reference #3: Bilbao, C. Dopazo, L. Castells, J. Lazaro, M. Caralt, G. Sapisochin, R. Charco, Immunosuppression Based on Everolimus in Liver Transplant Recipients With Severe Early Post-transplantation Neurotoxicity. Transplantation Proceedings. 2014;46(9):3104-3107 DISCLOSURES: No relevant relationships by Jamie Felzer, source=Web Response No relevant relationships by Krishnan Rangarajan, source=Web Response" @default.
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• W2981306389 date "2019-10-01" @default.
• W2981306389 modified "2023-09-24" @default.
• W2981306389 title "WHEN TACRO TAKES YOUR BREATH AWAY" @default.
• W2981306389 doi "https://doi.org/10.1016/j.chest.2019.08.1185" @default.
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