Posterior Reversible Encephalopathy Syndrome Following Liver Transplantation: A Report of Two Cases and the Crucial Role of Nursing Surveillance

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a neurologically toxic condition evidence by clinical and radiological features. The major symptoms are headache, tremors, altered gait, seizures, altered mentation, and disturbed vision. It is commonly associated with severe hypertension or exposure to calcineurin inhibitors (CNIs) such as tacrolimus, especially among solid organ transplant recipients. We describe two liver transplant recipients – one adult and one pediatric – who developed PRES within 24–72 h of tacrolimus initiation. Both presented with generalized seizures and required mechanical ventilation. Magnetic resonance imaging brain revealed bilateral posterior cortical and subcortical hyperintensities on T2/FLAIR sequences, consistent with PRES. Tacrolimus was discontinued and substituted with cyclosporine. Both patients recovered fully following prompt recognition and supportive management. Intensive care and transplant nurses play an important role in early identification of PRES through vigilant neurological assessments, electrolyte monitoring, and timely reporting of even subtle neurological changes. Such vigilance plays a crucial role in early diagnosis and reducing the risk of irreversible complications. Tacrolimus-induced PRES may develop very early after transplantation, even in normotensive patients. Nurses play a pivotal role in identifying the subtle changes in the patients before the clinical deterioration occurs. A collaborative approach involving nurses and clinicians is essential for early detection and intervention to ensure complete neurological recovery.