Delusions And Hallucinations In Post-Liver Transplant Patients

An in-depth exploration with patient stories, mechanisms, and management

Introduction

Liver transplantation saves lives, yet recovery extends well beyond the operating room. A frequently under-recognized challenge is the emergence of delusions and hallucinations after transplant—often multifactorial, involving medications (notably calcineurin inhibitors and opioids), metabolic disturbances (e.g., hyperammonemia, hyponatremia), sleep disruption, infection, and pre-existing vulnerabilities. Early identification and a coordinated response improve safety, adherence, and outcomes.

Delusions vs. Hallucinations: Working Definitions

Delusions

Fixed, false beliefs maintained despite clear contradictory evidence (e.g., persecutory, grandiose, somatic themes).

Hallucinations

Perceptions without corresponding external stimuli (auditory most common; also visual or multimodal).

Subtypes & Illustrative Patient Stories

Persecutory Delusions

Vignette: A 56-year-old becomes convinced the team is withholding or “poisoning” medications, leading to refusal and clinical decline.

Grandiose Delusions

Vignette: A patient believes they possess special healing powers and stops essential immunosuppression.

Somatic Delusions

Vignette: A patient insists the graft is “turning malignant,” pursuing risky alternatives despite reassuring evidence.

Auditory Hallucinations

Vignette: Command voices urge disobedience, causing distress and missed therapies.

Visual Hallucinations

Vignette: Shadowy figures misidentified as staff trigger agitation and safety events.

Multimodal Hallucinations

Vignette: Combined visual–auditory phenomena amplify fear and impede care.

Common Contributors After Transplant

Immunosuppressants

  • Tacrolimus & cyclosporine: delirium, psychosis, seizures, PRES; risk can occur even at therapeutic levels.

Analgesics

  • Opioids (e.g., morphine class): rare but documented hallucinations and delirium, especially in older adults or polypharmacy.

Antibiotics

  • Fluoroquinolones (e.g., levofloxacin): FDA-warned CNS effects (confusion, hallucinations) and dysglycemia.

Metabolic Factors

  • Hyperammonemia & hepatic encephalopathy: cognitive/psychiatric changes.
  • Hyponatremia: acute drops can provoke confusion, seizures; over-rapid correction risks ODS.
  • Insulin dysregulation (post-transplant diabetes): delirium/cognitive fluctuation.

Corticosteroids

  • Can precipitate mood changes, mania, and psychosis—risk increases with higher doses.

Treatment & Team-Based Approach

  • Rapid safety assessment: protect airway, evaluate agitation, rule out infection, rejection, stroke, hypoxia, hypoglycemia.
  • Medication review: check tacrolimus/cyclosporine levels; consider dose adjustments/substitutions when appropriate.
  • Correct metabolic drivers: manage ammonia (per HE guidelines), sodium, glucose.
  • Targeted pharmacotherapy: short-term antipsychotics (e.g., haloperidol or atypicals) when risk/benefit favors use; monitor QT and interactions.
  • Psychological interventions: psychoeducation for patient/family; Cognitive Behavioral Therapy for Psychosis (CBTp) adjunct when feasible.
  • Environment & sleep: orienting cues, lighting, non-pharmacologic sleep hygiene.
  • Multidisciplinary follow-up: transplant, psychiatry, pharmacy, hepatology, nursing, and family caregivers.

Conclusions & Future Directions

Neuropsychiatric symptoms after liver transplant are common, complex, and treatable. Systems that standardize screening, metabolic checks, medication level monitoring, and family-inclusive education can reduce harm and improve adherence and recovery.

References (Selected, Linked)

  1. Nogueira JM, et al. Psychosis Associated with Tacrolimus Use. 2021.
  2. Diduch M, et al. Calcineurin Inhibitor–Induced Psychosis. 2021.
  3. Gunther M, et al. Delayed-Onset Psychosis Secondary to Tacrolimus. 2023.
  4. Sivanesan E, et al. Opioid-Induced Hallucinations: Review. 2016.
  5. Pask S, et al. Opioids & Cognition in Older Adults. 2020.
  6. FDA. Fluoroquinolone Safety Communication (CNS effects incl. hallucinations). 2016; see also web update.
  7. Jayakumar AR, Norenberg MD. Hyperammonemia in Hepatic Encephalopathy. 2018.
  8. AASLD Guidance. Hepatic Encephalopathy in Chronic Liver Disease. 2014.
  9. Kengne FG, et al. Hyponatremia and the Brain. 2017.
  10. Seethapathy H, et al. Severe Hyponatremia: Correction & Outcomes. 2023.
  11. MacMillan TE, et al. Osmotic Demyelination in Hyponatremia. 2023.
  12. NICE CG178. Psychosis & Schizophrenia in Adults: CBTp Recommended. 2014 (surveillance 2017).
  13. Health Quality Ontario. Cognitive Behavioural Therapy for Psychosis. 2018.
  14. Nasereddin L, et al. Corticosteroid-Induced Psychiatric Disorders. 2024.
  15. Wierzbinski P, et al. Fluoroquinolones & CNS Adverse Effects. 2023.
  16. Bugallo-Carrera C, et al. Neuropsychiatric Symptoms after Liver Transplant. 2022.

Note: Evidence evolves; consult current transplant center protocols and medication labels for the latest recommendations.

Medical Disclaimer: This content is for educational purposes only and is not a substitute for professional medical advice. If you or a loved one experience concerning symptoms after transplant, contact your transplant team or emergency services immediately.