Introdução: A literatura existente apresenta perspectivas variadas sobre o impacto da COVID-19 em receptores de transplante de fígado. No entanto, nenhuma pesquisa investigou especificamente o papel das diferenças de gênero na manifestação da COVID-19 entre os receptores de transplante de fígado. Este estudo pretende examinar os efeitos da COVID-19 em receptores de transplante de fígado, com foco nas diferenças de gênero na apresentação e progressão da doença. Métodos: Conduzida como um estudo de coorte histórico multicêntrico, esta pesquisa coletou registros de pacientes por meio de um questionário on-line. O principal objetivo foi avaliar a mortalidade relacionada à COVID. Além disso, foram coletados dados demográficos, clínicos e laboratoriais relativos à apresentação e progressão da doença. Resultados: O estudo incluiu um total de 283 pacientes, sendo 76 do sexo feminino e 206 do sexo masculino. O período médio de acompanhamento para os homens foi de 99 dias (IQR 38-283), enquanto para as mulheres foi de 126 dias (IQR 44-291). Foi observada uma maior prevalência de doença cardiovascular nos homens (p=0,002). As mulheres frequentemente apresentavam perda de olfato (p=0,021), enquanto os homens geralmente apresentavam febre (p=0,031). Os níveis de ALT e gama-glutamil transferase foram significativamente elevados nos homens (p=0,008 e 0,004, respectivamente). Embora tenha havido uma tendência de aumento da mortalidade nos homens, ela não alcançou significância estatística. Conclusão: Este estudo é a primeira tentativa de investigar as diferenças de gênero na COVID-19 entre os receptores de transplante de fígado. Nossos achados destacam a necessidade de uma abordagem abrangente e personalizada para tratar essa população de pacientes e ressaltam a importância de elucidar melhor a apresentação da doença nesses indivíduos.

Introduction: Existing literature presents varying perspectives on the impact of COVID-19 on liver transplant recipients. However, no research has specifically investigated the role of gender differences in the manifestation of COVID-19 among liver transplant recipients. This study aims to examine the effects of COVID-19 on liver transplant recipients, with a focus on gender differences in disease presentation and progression. Methods: Conducted as a multicenter historical cohort study, this research collected patient records through an online questionnaire. Assessing COVID-related mortality was the main objective. Additionally, demographic, clinical, and laboratory data pertaining to disease presentation and progression were collected. Results:The study included a total of 283 patients, of whom 76 were female and 206 were male. The median follow-up period for males was 99 days (IQR 38-283), while for females, it was 126 days (IQR 44-291). A higher prevalence of cardiovascular disease was observed in males (p=0.002). Females frequently experienced a loss of smell (p=0.021), whereas males commonly exhibited fever (p=0.031). Levels of ALT and gamma-glutamyl transferase were significantly elevated in males (p=0.008 and 0.004, respectively). Although there was a trend towards increased mortality in males, it did not reach statistical significance.Conclusion: This study is the first attempt to investigate gender differences in COVID-19 among liver transplant recipients. Our findings highlight the need for a comprehensive and personalised approach to treating this patient population and underscore the importance of further elucidating the disease presentation in these individuals

Background. Infections by SARS-CoV-2 in liver transplant recipients (LT) patients are of particular concern, notably due to perceived added risks related to immunosuppression and comorbidity burden. Current literature on this topic often relies on small, non-standardized, and geographically limited studies. This manuscript describes COVID-19 presentations and causes for elevated mortality in a large cohort of LT recipients. Methods. This study was designed as a multicentric historical cohort, including LT recipient patients with COVID-19 in 25 study centers, with the primary endpoint being COVID-related death. We also collected demographic, clinical, and laboratory data regarding presentation and disease progression. Results. Two hundred and thirty-four cases were included. The study population was predominantly male and White and had a median age of 60 years. The median time from transplantation was 2.6 years (IQR 1-6). Most patients had at least one comorbidity (189, 80.8%). Patient age (P = .04), dyspnea (P < .001), intensive care unit admission (P < .001), and mechanical ventilation (P < .001) were associated with increased mortality. Modifications of immunosuppressive therapy (P < .001), specifically the suspension of tacrolimus, maintained significance in multi-variable analysis. Conclusions. Attention to risk factors and the individualization of patient care, especially regarding immunosuppression management, is crucial for delivering more precise interventions to these individuals.

Hemophagocytic lymphohistiocytosis (HL) is a rare syndrome characterized by a hyperinflam-matory state, resulting from an excessive but ineffective immune response. There is a continuous stimulation of TCD8 + lymphocytes, associated with an uncontrolled release of cytokines, caus-ing the infiltration of multiple organs by histiocytes and activated lymphocytes. HL can be a pri-mary condition as a consequence of genetic disorder that most often affects children, or it can be secondary to neoplasms, autoimmune conditions or various infectious diseases in patients of all ages. HL caused by infection by Mycobacterium tuberculosis is highly unusual, with few cases reported in the literature. There is no clinical manifestation or laboratorial finding that is specific to HL, and a high index of clinical suspicion is necessary for the correct diagnosis, which is usu-ally confirmed by biopsy. Treatment consists of controlling the causative event and the use of immunosuppressant drugs such as corticosteroids, etoposide, and cyclosporine to suppress the exacerbated immune response. We report the case of a patient who developed HL 2 months after liver transplantation. The initial presentation was persistent fever, prompting a search for a site of infection and the use of broad-spectrum antibiotics. As the clinical condition of the patient continued to deteriorate, HL was diagnosed through a bone marrow biopsy, and a cerebrospinal fluid culture positive for M. tuberculosis established the diagnosis of disseminated tuberculosis. Despite optimal treatment with immunosuppressors and antituberculosis drugs, there was no sig-nificant response and the patient died. This article is compliant with the Helsinki Congress and the Istanbul Declaration.

BACKGROUND:The association between ulcerative colitis (UC) and primary sclerosing cholangitis has been described for several years and can be classified as having a distinct disease phenotype from inflammatory bowel diseases (IBD). The simultaneous occurrence of decompensated liver disease requiring liver transplant and active IBD is a management challenge, considering that these patients may be at increased risk of infections, thromboembolic events, bleeding, and drug hepatotoxicity.CASE PRESENTATION:We describe a case of a 37-year-old patient with UC and sclerosing cholangitis presenting with severe decompensated rectocolitis complicated with thromboembolic phenomena and severe liver dysfunction who underwent liver transplant while using biological therapy to control bowel disease.CONCLUSIONS:This case highlights the evolution of sclerosing cholangitis to liver transplant in patients with decompensated UC. Despite the risk of recurrence, primary sclerosing cholangitis has excellent results after liver transplant. Despite the use of immunosuppression after liver transplant, biological therapy may be necessary to control IBD.

Sickle cell anemia is the most common of the hemoglobinopathies, in which the abnormal hemoglobin formed in deoxygenation states undergoes a polymerization process with consequent erythrocyte deformation and vaso-occlusive events. The need for multiple blood transfusions, prolonged ineffective erythropoiesis, hemolysis, and increased iron absorption can cause iron overload in the liver, leading to liver fibrosis. Hematopoietic stem cell transplantation (HSCT) is currently the only treatment with a curative potential for this disease and can establish normal complete or partial donor-derived erythropoiesis and stabilize or restore function in affected organs, preventing further deterioration of function. However, it does not reverse preexisting liver fibrosis and siderosis. One of the possible complications of patients who undergo HSCT is chronic liver disease, which has a multifactorial cause, with iron overload being an important factor. In the long term, the prevalence of chronic liver disease in HSCT patients, including cirrhosis and its complications, can be significant. Solid organ transplantation after allogeneic hematopoietic cell transplantation for end-organ failure remains a very rare event. It may offer a valuable treatment strategy in selected recipients, although it is associated with significant morbidity and mortality. We report the case of a patient with sickle cell anemia who underwent HSCT and developed severe liver dysfunction requiring liver transplantation 13 years after the procedure. We found no previous report in the literature of orthotopic liver transplant after HCT for the treatment of sickle cell disease.

BACKGROUND:Portal vein thrombosis is a relatively frequent complication in patients with liver cirrhosis. Its detection and management are essential to avoid worsening portal hypertension or liver function complications. This complication can also negatively impact or even preclude liver transplant.CASE PRESENTATION:We report the case of a patient who presented with acute portal vein thrombosis, which allowed the diagnosis of liver cirrhosis and hepatocarcinoma within the Milan criteria. Chemical thrombolysis was performed with a mechanical aspiration of the thrombus, and in a second moment, the patient was submitted to a liver transplant.CONCLUSIONS:Advances in the therapeutic approach to portal vein thrombosis and surgical techniques have allowed the condition to no longer be an absolute contraindication to liver transplantation. Diagnosis in the acute phase is associated with greater therapeutic success, aiming to avoid the extension of thrombosis and achieve portal vein recanalization.

Liver transplantation is the only potentially curative treatment for patients with end-stage liver disease. After the procedure, histopathologic analysis of the liver explant may reveal neoplasms that were not previously diagnosed in preoperative imaging examinations. This incidental finding of primary liver neoplasms in the explant is not an uncommon situation in liver transplant, and hepatocarcinomas and cholangiocarcinomas are the types of tumors most frequently encountered in this scenario. These are the most common primary neoplasms of the liver, and liver transplantation is often a curative treatment for these types of tumors when they are in their earlier stages. In contrast, liver plasmacytoma is a rare type of plasma cell neoplasm, consisting of a single mass of monoclonal plasma cells, which is treated primarily by radiotherapy and is seldom encountered in the setting of liver transplant. We report the case of a patient who underwent liver transplantation for the treatment of cryptogenic cirrhosis, with no preoperative diagnosis of liver tumors. Analysis of the liver explant revealed the presence of three synchronous neoplasms with different histologic origins: a 27-mm hepatocellular carcinoma, a 17-mm intrahepatic cholangiocarcinoma, and a 25-mm solitary hepatic plasmacytoma. The patient received no further adjuvant treatment and remained well and with no signs of disease recurrence over an observation period of 44 months. We found no previous report in the literature of the synchronous presence of these three types of liver neoplasms.

Progressive familial intrahepatic cholestasis type 2 (PFIC2) is a rare autosomal recessive disorder caused by mutations in the ABCB11 gene. Clinical manifestations include cholestasis with low γ-glutamyltransferase (GGT), hepatosplenomegaly, and severe pruritus. Liver transplantation is required for individuals with progressive liver disease or failure of the bypass procedure and has been considered curative. However, in the case of PFIC2, although bile salt excretory pump (BSEP) deficiency is a liver-specific condition rather than a systemic disease, evidence of recurrent BSEP disease has been shown in a small proportion of allografts. We describe an unusual case of a 21-year-old individual with PFIC2 and evidence of recurrent BSEP disease after liver transplantation, with clinical and laboratory improvement after pulse therapy with methylprednisolone for 3 days and adjustment of oral immunosuppression. This case report highlights the recurrence of PFIC2 in patients post liver transplant. It also emphasizes the importance of clinical suspicion, which should be considered in cases of posttransplant cholestasis in PFIC2 patients, especially those with low γ-glutamyltransferase (GGT) and without signs of acute graft rejection. Having knowledge of the condition favors a targeted diagnostic approach and contributes to early therapeutic management and a higher success rate.

BACKGROUND:Liver transplantation is a unique treatment opportunity for patients with chronic liver disease and hepatocellular carcinoma (HCC). Selection of HCC patients for transplantation was revolutionized by Milan-based criteria, but tumor recurrence and shortage of organs are still a major concern. Nowadays, additional preoperative tumor parameters can help to refine the graft allocation process. The objective of this study was to evaluate the prognostic value and cut-off points of pretransplant serum alpha-fetoprotein (AFP) levels and radiological tumor parameters on liver transplantation outcomes.METHODS:This is a single-team retrospective cohort of 162 consecutive deceased donor liver transplants (DDLT) with pathologically confirmed HCC. Pretransplant serum AFP levels and radiological tumor parameters were retrieved from a preoperative follow-up. Receiver-operating characteristics (ROC) curves were used to evaluate cut-off points for each outcome. Multivariate Cox regression model was used to assess the predictors of HCC relapse and recipient mortality.RESULTS:Twelve recipients (7.4%) had HCC recurrence after transplantation, with median survival time of 5.8 months. Pretransplant AFP ≥30 ng/mL (hazard ratio [HR]: 13.84, P = .003) and radiological total tumor diameter (TTD) ≥5 cm (HR: 12.89, P = .005) were independent predictors for HCC relapse. Moreover, pretransplant AFP ≥150 ng/mL was independently associated with recipient mortality (HR: 4.45, P = .003).CONCLUSIONS:Pretransplant AFP levels and radiological TTD were independently associated with HCC relapse and recipient mortality after DDLT, with different cut-off points predicting different outcomes. These findings may contribute to improving decision-making in the context of liver transplantation for HCC patients.

Introduction: Amid the COVID-19 pandemic, the consequences of infection by the SARS-CoV 2 virus in Liver Transplant recipients (LT) patients is of particular concern, notably due to the perceived added risk of these patients related to immunosuppression and comorbidity burden. Current literature on this topic often uses small, non-standardized, and ethnically limited samples. This study describes COVID-19 presentation and complications in a large, multicentric, and ethnically diverse population of LT recipients. Methods: We designed this study as a multi-centric historical cohort, analyzing patient records submitted by an online questionnaire. The study included LT recipient patients with suspected or confirmed COVID-19 already in follow-up at the study centers. The primary endpoint was COVID-related death. We also collected demographic, clinical, and laboratory data regarding presentation and disease progression. Results: We included 314 patients from 25 participant centers in Brazil. It is, to our knowledge, the largest current cohort of LT recipients with COVID-19. The median age was 60 years old (IQR: 53-66), and the hospitalization rate was 56%, with an overall mortality rate of 17,9%. Patients were mostly male (66%), white (59%), and overweight, with a median BMI of 27 (IQR 24-32). The median follow-up time was 117 days (IQR 41,291). The two most prevalent comorbidities were hypertension (N= 138 - 48%) and diabetes (N= 129 - 45%). Increased mortality was associated with fewer years from transplantation (p=0.03), increased BMI (p=0.02), the presence of dyspnea (p<0.001), and lost sense of smell (p=0.01) at presentation, and alterations to immunosuppression after admission (p<0.001). The use of mycophenolate at admission was also associated with increased mortality (p=0.02). Liver function test results were not associated with mortality. Median time from admission to death was 22 days (IQR: 12-35). Conclusion: This large, multicentric study suggests novel risk factors for mortality not previously reported in other studies - notably the use of Mycophenolate and fewer years from transplantation. As such, the results of this study are paramount to the comprehensive and individualized treatment of this multifaceted patient population and stand as a stepping stone for further understanding of the disease presentation in these patients. Regina G Santos, Laura CM Pinto, Simone R Peralles, Leticia Zanaga, Rita CMF Silva, Luiz AC Dalbuquerque, Renata Ferreira Bezerra, Marcelo Nogara, Huda M Noujam, Agnaldo S Lima, Ana F Passos, Ivelise RC Brasil, Renato Hidalgo, Christian E Garcia, Ajith K Sankarankutty, Adriano M Gonzales, Andre I David, Mauricio Barros, Ben-Hur E Ferraz-Neto, Claudemiro Quireze-Júnior, Eduardo Fonseca.

The Covid-19 epidemiological profile of disease presented two main waves in the world as well as in Brazil between 2020 and 2021.There are no robust works describing the profile of liver transplant patients who are victims of COVID-19, especially when it comes to comparing this profile against the waves. We carried out a national multicenter study that can cover a significant number of liver transplant patients and verify the prognostic factors of survival of these patients according to the period of illness by COVID-19. The main objective of this study was to evaluate factors associated with wave survival in COVID-19 disease, in the postoperative period of liver transplantation.This is a cross-sectional, retrospective study, with analysis of data from the medical records of patients with suspicion or positivity for COVID-19 provided by the coordinators of the Liver Transplantation Groups of Brazil (GTxF-COVID-19/Brazil), through a survey applied online. In this study, 25 centers were evaluated, totaling 311 patients in the postoperative period of liver transplantation, of which 128 (41.1%) were treated at home and 183 (58.9%) were hospitalized. Of the 183 hospitalized, 54 (hospital mortality of 29.5%) died. The need for mechanical ventilation was 65/183 (35.5%).The prevalence in this study was 311/16345 (1.9% or 1,900) and mortality was about 291.2 per 100,000 inhab. (17.36%). There were no records of deaths at home. Evaluating the number of cases according to the waves of COVID-19, we observed that in wave 1 there were 131 cases (47.3%) and in wave 2 there were 146 cases (52.7%).In the two waves, the most frequent symptoms (over 10 cases) were: fever, cough, dyspnea, fatigue, coryza, headache, diarrhea, myalgia and dyspnea. The most frequent comorbidities in both waves were diabetes, hypertension, obesity, smoking, kidney disease and heart disease. The length of stay in ICU days was longer in the first wave (5.72 ± 11.79; p=0.04) than in the second wave. There was a greater number of hospital admissions in the first wave, 70.2% against 53.4% in the second wave (p=0.004). There was a greater number of “pre” COVID-19 treatment (use of hydroxychloroquine, chloroquine and azithromycin) in the first wave (65.6%) compared to the second wave (51.9%) and this difference was significant (p= 0.03).There was less management, reduction or withdrawal of immunosuppression in these patients in the second wave (p=0.02). The actuarial survival curve estimated by the Kaplan-Meier method comparing survival from the onset of symptoms to resolution of the patients’ clinical condition did not show a statistically significant difference between the two waves.As already mentioned, there are no reports of cases similar to ours in relation to COVID-19 after liver transplantation, however, studies such as the one presented here are imperative in order to create solid foundations for definitions of the management of this population that requires attention and safe criteria.

Osmotic demyelination syndrome is an uncommon neurologic condition, characterized by noninflammatory demyelination involving the pons and other areas of the central nervous system. As chronic hyponatremia is frequently associated with cirrhosis, patients undergoing liver transplantation are at an increased risk for developing this condition. We report the case of a patient who developed refractory hypernatremia and osmotic demyelination syndrome after liver transplantation. The patient was a 40-year-old man, who underwent liver transplantation for the treatment of cryptogenic cirrhosis, and had a preoperative sodium level of 128 mmol/L. Although there were no intraoperative complications, the patient showed signs of mental confusion and drowsiness in the second postoperative day, and we noticed an increase to 136 mmol/L in his serum sodium. Treatment with 5% dextrose and desmopressin was initiated, but his serum sodium continued to increase steadily, while his neurologic condition gradually worsened. Serum sodium rose to 157 mmol/L, and a magnetic resonance imaging of the brain showed extensive lesions consistent with osmotic demyelination syndrome. The clinical condition of the patient continued to deteriorate until his death 17 days after the transplant. Although the occurrence of this syndrome after liver transplantation is well described, the steady increase in serum sodium despite early treatment, as described in this case, is highly unusual, and highlights the great attention that must be taken with monitoring and control of serum sodium in patients who undergo liver transplant in the context of chronic hyponatremia. This manuscript is compliant with the Helsinki Congress and the Istanbul Declaration.

BACKGROUND Acute intermittent porphyria is an inherited disease caused by a defect in heme biosynthesis, with accumulation of neurotoxic metabolites leading to acute neurovisceral symptoms. Some patients develop long-term neurological and renal damage after the acute episodes, many of them requiring hemodialysis. Since heme production in the human body occurs predominantly in the bone marrow and liver, liver transplantation has been shown to significantly reduce the production of neurotoxic metabolites, effectively controlling the disease. Patients with severe acute intermittent porphyria who have chronic kidney failure may benefit from combined kidney and liver transplant. Only 2 uses of this approach have been previously reported in the literature. CASE REPORT We report here the case of a 19-year-old male patient who received a combined liver and kidney transplant for the treatment of acute intermittent porphyria. He presented the first symptoms of the disease 4 years before the procedure, with abdominal pain and significant neurological impairment, with weakness requiring prolonged mechanical ventilation. He also had chronic kidney failure secondary to the porphyria. A combined liver and kidney transplant was performed, with no intraoperative complications. The explanted liver showed light siderosis, as well as portal and perisinusoidal fibrosis at microscopy. At 3.5 years of follow-up, he remains clinically well, with normal hepatic and renal function, had had no further acute porphyria episodes, and shows progressive neurological recovery. CONCLUSIONS This case demonstrates that combined liver and kidney transplant can be a curative treatment for patients with severe acute intermittent porphyria associated with end-stage renal failure. The patient shows satisfactory long-term function of both grafts, with no clinical or biochemical signs of porphyria recurrence.

Leishmaniasis is an infection caused by protozoa of the genus Leishmania, transmitted by sandflies and endemic to more than 88 countries. Visceral leishmaniasis in immunosuppressed patients is a growing concern. We report the case of a 61-year-old male patient with a previous history of alcoholic cirrhosis and portal vein thrombosis who underwent liver transplantation for the treatment of hepatocellular carcinoma. Thirty-six days after the procedure, the patient showed an increase in liver enzymes and was diagnosed with moderate acute rejection of the graft. He was treated with high-dose intravenous corticosteroids, and while showing improvement in biochemical markers, he became febrile 12 days after corticosteroid treatment. He presented daily episodes of fever, even after the use of several antimicrobial, antiviral, and antifungal agents, and a number of negative cultures from different sites were obtained. A bone marrow biopsy was then performed, showing a large number of amastigote forms of Leishmania spp. Treatment with liposomal amphotericin B was initiated; however, the patient progressed to refractory septic shock and death. This case highlights several aspects of visceral leishmaniasis in liver transplant recipients, such as the association of malnutrition to Leishmania infection and the challenges of diagnosing leishmaniasis in cirrhotic patients in which splenomegaly and pancytopenia, the hallmarks of leishmaniasis, may also be attributed to portal hypertension and end-stage liver disease. A high index of suspicion is necessary for the correct diagnosis and treatment of leishmaniasis in this group of patients. This study is compliant with the Helsinki Congress and the Istanbul Declaration.

INTRODUCTION: Primary hepatolithiasis is a rare disease in western countries and it is associated with repeated attacks of acute cholangitis. Without proper treatment, hepatolithiasis can lead to progressive biliary strictures and secondary biliary cirrhosis. PRESENTATION OF CASE: A 40 years old male was admitted due to recurrent cholangitis during the last 18 years. Bilateral primary hepatolithiasis was diagnosed and treated by left hepatectomy with an intrahepatic hepaticocutaneous jejunostomy. There were no postoperative complications and the patient was discharged after 7 days. DISCUSSION: The management of patients with primary hepatolithiasis remains a challenging task due to the high incidence of residual and recurrent stones after treatment. CONCLUSION: Primary bilateral hepatolithiasis is a complex disease that can be managed with partial hepatectomy with an intrahepatic hepaticocutaneous jejunostomy. (C) 2020 The Author(s). Published by Elsevier Ltd on behalf of US Publishing Group Ltd.

BACKGROUND Cryptococcosis is a fungal infection caused by the yeast-like encapsulated basidiomycetous fungus of the Cryptococcus neoformans (C. neoformans) species complex. These fungi are ubiquitous in soil and bird droppings, and infection by them is an important global health concern, particularly in immunosuppressed patients, such as organ transplant recipients and those infected by the human immunodeficiency virus. The fungus usually enters the body through the respiratory tract, but extremely rare cases of infection acquired by transplantation of solid organs have been reported. CASE SUMMARY We report a case of disseminated cryptococcosis in a liver transplant recipient, diagnosed 2 wk after the procedure. The patient initially presented with fever, hyponatremia and elevated transaminase levels, manifesting intense headache after a few days. Blood cultures were positive for C. neoformans. Liver biopsy showed numerous fungal elements surrounded by gelatinous matrix and sparse granulomatous formations. Magnetic resonance imaging of the brain showed multiple small lesions with low signal in T2, peripheric enhancement and edematous halo, diffuse through the parenchyma but more concentrated in the subcortical regions. Treatment with amphotericin B for 3 wk, followed by maintenance therapy with fluconazole, led to complete resolution of the symptoms. The recipients of both kidneys from the same donor also developed disseminated cryptococcosis, confirming the transplant as the source of infection. The organ donor lived in a rural area, surrounded by tropical rainforest, and had negative blood cultures prior to organ procurement. CONCLUSION This case highlights the risk of transmission of fungal diseases, specifically of C. neoformans, through liver graft during liver transplantation.

Psychotic disorders are a group of psychiatric disorders characterized by the presence of delusions, hallucinations, bizarre behavior, and disorganized speech. There are several possible causes for the occurrence of psychotic disorders in patients who underwent solid organ transplant, including pre-existing mental illness, electrolyte disturbances, infections of the central nervous system, and adverse reaction to drugs. Calcineurin inhibitors are a class of immunosuppressive drugs, such as tacrolimus and cyclosporine, that are currently considered the mainstay in the immunosuppressive drug regimen of patients who underwent solid organ transplant. Neurotoxicity is one of the adverse reactions associated with the use of calcineurin inhibitors, ranging from upper limb tremors to psychotic disorders and seizures. We report the cases of 2 liver transplant recipients who developed severe psychotic disorder 1 month after the procedure. After an extensive investigation for other possible triggers of psychiatric disease, the use of tacrolimus was considered to be the most likely cause for the acute psychotic disorder. In less than 24 hours after suspension of that drug, all symptoms disappeared in both patients, making a causal relationship with tacrolimus even more likely. The patients were then given cyclosporine, another drug from the same class, allowing for adequate immunosuppression and preserved graft function, with no further psychiatric symptoms. This report confirms that a 24-hour trial of tacrolimus suspension can be safe and effective in the diagnosis of drug-related psychotic disorders in patients who underwent liver transplant. This article is compliant with the Helsinki Congress and the Istanbul Declaration.