From the Guidelines
For a patient with renal transplant on tacrolimus who has increased lumbar puncture (LP) opening pressure, I recommend a comprehensive evaluation for causes of intracranial hypertension while continuing tacrolimus with close monitoring, as suggested by the KDIGO clinical practice guideline for the care of kidney transplant recipients 1. The patient's immunosuppressive regimen, which includes tacrolimus, should be optimized to prevent rejection while minimizing neurological side effects.
- The guideline suggests using a combination of immunosuppressive medications as maintenance therapy, including a CNI and an antiproliferative agent, with or without corticosteroids 1.
- Tacrolimus is recommended as the first-line CNI used 1, and mycophenolate is suggested as the first-line antiproliferative agent 1. Consideration should be given to the potential causes of increased intracranial pressure, including tacrolimus-associated posterior reversible encephalopathy syndrome (PRES), and brain imaging should be performed to rule out this condition.
- Medical therapy, such as acetazolamide or topiramate, may be considered to reduce intracranial pressure, and weight loss should be encouraged if the patient is overweight. Serial lumbar punctures may provide temporary relief while medical therapy takes effect, and tacrolimus levels should be monitored closely to prevent rejection while minimizing neurological side effects. Regular ophthalmologic evaluations are essential to monitor for papilledema and visual changes. It is crucial to coordinate any medication changes with the transplant team to avoid risking transplant rejection.
From the Research
Increase in LP Opening Pressure in Patients with Renal Transplant on Tacrolimus
- The provided studies do not directly address the increase in LP opening pressure in patients with renal transplant on tacrolimus 2, 3, 4, 5, 6.
- However, the studies discuss the pharmacokinetics and clinical implications of tacrolimus in renal transplant patients, including its effects on renal function and blood pressure control 2, 3, 4, 5, 6.
- One study found that conversion from immediate-release to extended-release tacrolimus may improve kidney function in renal transplant patients, which could potentially impact LP opening pressure 4.
- Another study compared the effects of immediate-release and extended-release tacrolimus on blood pressure control in kidney transplant recipients, but did not find a significant difference in systolic or diastolic blood pressure control 6.
- The relationship between tacrolimus and LP opening pressure is not explicitly addressed in the provided studies, and further research would be needed to determine any potential effects 2, 3, 4, 5, 6.
Potential Factors Influencing LP Opening Pressure
- The studies suggest that factors such as tacrolimus formulation, dosage, and patient characteristics (e.g. age, ethnicity) may influence the pharmacokinetics and clinical effects of tacrolimus 2, 3, 4, 5, 6.
- However, the specific relationship between these factors and LP opening pressure is not addressed in the provided studies 2, 3, 4, 5, 6.
- Further research would be needed to investigate the potential effects of tacrolimus on LP opening pressure and to identify any relevant factors that may influence this relationship 2, 3, 4, 5, 6.