Posterior Reversible Encephalopathy Syndrome in Chronic Kidney Disease: Meta-summary of Case Reports

The aim of this meta-summary was to identify the patient profile, symptomology, risk factors, and outcomes of chronic kidney disease (CKD) patients with posterior reversible encephalopathy syndrome (PRES) by reviewing published case reports and series.

For this meta-summary, we performed a methodical search of PubMed, Google Scholar, and Reference Citation Analysis databases. We used the following search terms: "chronic kidney failure," "chronic renal insufficiency," AND "hypertensive encephalopathy," "PRES," "reversible posterior leukoencephalopathy syndrome," OR "posterior leukoencephalopathy syndrome" in combination. The obtained results were then filtered for case reports published in English and on adult (above 18 years) humans. The relevant literature pertaining to CKD and PRES was manually screened, and duplicate articles from different databases were removed.

A total of 19 case reports and 9 case series with 41 patients meeting the inclusion criteria were included in the final analysis. Commonly reported symptoms were seizures (65.9%) and headache (58.5%). Visual disturbances, varying from blurred vision to cortical blindness, were reported by 36.6% of cases. In two patients, PRES was the first manifestation of CKD. Underlying hypertension was reported in 51.2% of cases, but severe hypertension was reported by 70.7% of patients at the time of presentation. Only 14.6% of patients were posttransplant on immunosuppressive therapy. Along with supportive therapy, modification of antihypertensive therapy was reported in 78.1% of cases. The need for intensive care unit (ICU) admission was reported in 43.9% of cases, with 17.1% of patients requiring invasive mechanical ventilation. The majority of patients completely recovered by the time of discharge, with only 19.5% of cases reporting residual neurological deficit. The median time for reversal was 10.5 days, and only three deaths were reported.

CKD patients may be particularly vulnerable to developing PRES. However, due to nonspecific symptomatology overlapping with several other more common causes of neurological dysfunction in these patients, PRES may be largely missed and underdiagnosed. It may also present without any associated severe hypertension or a background of immunosuppressive therapy, which makes the diagnosis even more difficult. Blood pressure management, along with anti-edema measures and supportive care, may lead to complete recovery.