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Posterior reversible encephalopathy syndrome in patients with TTP linked to worse renal function

Burrus TM. Arch Neurol. 2010;67:831-834.

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Encephalopathy in patients with thrombotic thrombocytopenic purpura and decreased glomerular filtration rate may be cause for suspicion of posterior reversible encephalopathy syndrome, according to the findings of a retrospective study.

Between January 1997 and June 2007, researchers examined brain imaging from 47 patients aged older than 18 years with thrombotic thrombocytopenic purpura (TTP). Two independent investigators evaluated either head CT or brain MRI from these patients. Seventy percent of patients had brain MRI.

They hypothesized that the presence or degree of hypertension or other laboratory abnormalities may predict posterior reversible encephalopathy syndrome (PRES).

However, systolic hypertension, defined as blood pressure greater than 140 mm Hg, was not linked to radiological evidence of posterior reversible encephalopathy syndrome on MRI only (P=.55). Systolic blood pressure greater than 160 mm Hg was also not linked to the presence of PRES (P=.41).

Researchers, however, identified an association between renal function and PRES.

Decreased glomerular filtration rate, with normal defined as greater than 60 mL/per min/1.73 m², was associated with the presence of PRES on brain MRI (P=.02).

No significant association was found between posterior reversible encephalopathy syndrome and degree of leukocytosis, anemia, azotemia, thrombocytopenia, bilirubinemia, prothrombotic state and inflammatory markers, according to the researchers.

These findings raise the question of whether there could be a common target in the brain and kidneys affected as part of the pathophysiology of the disease, according to the researchers.

“This association may provide further insight into the pathophysiology of posterior reversible encephalopathy syndrome,” they said.

Neurological impairment in TTP is common, and in fact was described as part of the TTP pentad, but the causes and consequences have not been well understood. For many years it has been appreciated that TTP patients can make a complete recovery from what may appear to be severe central nervous system injury manifest by impaired consciousness, or focal neurological lesions. The past several years are starting to provide insight into the etiology of the neurological impairment of TTP patients. The application of MRI investigations has shown that posterior reversible encephalopathy syndrome (PRES) is a relatively common occurrence in TTP patients. The retrospective study by Burrus and colleagues continues to extend our knowledge of PRES in TTP. A significant proportion of investigated TTP patients had MRI evidence of PRES in this study. Multiple associations were investigated and most did not demonstrate correlation, with the exception of renal impairment. Whether this is a collateral or a coincidental association remains to be elucidated. However, this and similar studies help provide insight into the neurological impairment that frequently complicates TTP.

– John G. Kelton, MD
HemOnc Today Editorial Board member

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