1
|
Page MM, Hardikar W, Alex G, Bates S, Srinivasan S, Stormon M, Hall K, Evans HM, Johnston P, Chen J, Wigg A, John L, Ekinci EI, O'Brien RC, Jones R, Watts GF. Long-term outcomes of liver transplantation for homozygous familial hypercholesterolaemia in Australia and New Zealand. Atherosclerosis 2023; 387:117305. [PMID: 37863699 DOI: 10.1016/j.atherosclerosis.2023.117305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/14/2023] [Accepted: 09/20/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND AND AIMS Homozygous familial hypercholesterolaemia (FH) causes severe cardiovascular disease from childhood. Conventional drug therapy is usually ineffective; lipoprotein apheresis (LA) is often required. Liver transplantation (LT) can correct the metabolic defect but is considered a treatment of last resort. Newer drugs including lomitapide and evinacumab might reduce the need for apheresis and LT. We sought to determine the long-term outcomes following LT in Australia and New Zealand. METHODS We analysed demographic, biochemical and clinical data from all patients in Australia and New Zealand who have received LT for homozygous FH, identified from the Australia and New Zealand Liver and Intestinal Transplant Registry. RESULTS Nine patients (five female; one deceased; seven aged between 3 and 6 years at the time of LT and two aged 22 and 26 years) were identified. Mean follow-up was 14.1 years (range 4-27). Baseline LDL-cholesterol off all treatment was 23 ± 4.1 mmol/L. Mean LDL-cholesterol on medical therapy (including maximal statin therapy in all patients, ezetimibe in three and LA in five) was 11 ± 5.7 mmol/L (p < 0.001). After LT, mean LDL-cholesterol was 2.6 ± 0.9 mmol/L (p = 0.004) with three patients remaining on statin therapy and none on LA. One patient died from acute myocardial infarction (AMI) three years after LT. Two patients required aortic valve replacement, more than 10 years after LT. The remaining six patients were asymptomatic after eight to 21 years of follow-up. No significant adverse events associated with immunosuppression were reported. CONCLUSIONS LT for homozygous FH was highly effective in achieving substantial long-term reduction in LDL-cholesterol concentrations in all nine patients. LT remains an option for severe cases of homozygous FH where drug therapy combined with apheresis is ineffective or unfeasible.
Collapse
Affiliation(s)
- Michael M Page
- Medical School, The University of Western Australia, Perth, Australia; Western Diagnostic Pathology, Perth, Australia
| | - Winita Hardikar
- Gastroenterology and Clinical Nutrition, The Royal Children's Hospital Melbourne, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - George Alex
- Gastroenterology and Clinical Nutrition, The Royal Children's Hospital Melbourne, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Sue Bates
- Gastroenterology and Clinical Nutrition, The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Shubha Srinivasan
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Michael Stormon
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Gastroenterology and Hepatology, The Children's Hospital at Westmead, Sydney, Australia
| | - Kat Hall
- Hepatobiliary and Liver Transplant Surgery Unit, Austin Health, Melbourne, Australia
| | - Helen M Evans
- Paediatric Gastroenterology and Hepatology, Starship Child Health, Auckland, New Zealand; Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Peter Johnston
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - John Chen
- South Australia Liver Transplant Unit, Flinders Medical Centre, Adelaide, Australia; College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Alan Wigg
- South Australia Liver Transplant Unit, Flinders Medical Centre, Adelaide, Australia; College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Libby John
- South Australia Liver Transplant Unit, Flinders Medical Centre, Adelaide, Australia
| | - Elif I Ekinci
- Department of Endocrinology, Austin Health, Melbourne, Australia; The Australian Centre for Accelerating Diabetes Innovation, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia; Department of Medicine, Austin Health, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Richard C O'Brien
- Department of Endocrinology, Austin Health, Melbourne, Australia; Department of Medicine, Austin Health, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Robert Jones
- Hepatobiliary and Liver Transplant Surgery Unit, Austin Health, Melbourne, Australia; Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Gerald F Watts
- Medical School, The University of Western Australia, Perth, Australia; Department of Cardiovascular Medicine, Royal Perth Hospital, Perth, Australia.
| |
Collapse
|
2
|
Mlinaric M, Bratanic N, Dragos V, Skarlovnik A, Cevc M, Battelino T, Groselj U. Case Report: Liver Transplantation in Homozygous Familial Hypercholesterolemia (HoFH)-Long-Term Follow-Up of a Patient and Literature Review. Front Pediatr 2020; 8:567895. [PMID: 33163465 PMCID: PMC7581712 DOI: 10.3389/fped.2020.567895] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 08/28/2020] [Indexed: 01/15/2023] Open
Abstract
Homozygous familial hypercholesterolemia (HoFH) is a rare inherited metabolic disorder, frequently leading to an early cardiovascular death if not adequately treated. Since standard medications usually fail to reduce LDL-cholesterol (LDL-C) levels satisfactorily, LDL-apheresis is a mainstay of managing HoFH patients but, at the same time, very burdensome and suboptimally effective. Liver transplantation (LT) has been previously shown to be a promising alternative. We report on a 14 year-long follow-up after LT in a HoFH patient. At the age of 4, the patient was referred to our institution because of the gradually increasing number of xanthomas on the knees, elbows, buttocks, and later the homozygous mutation c.1754T>C (p.Ile585Thr) on the LDL-receptor gene was confirmed. Despite subsequent intensive treatment with the combination of diet, statins, bile acid sequestrant, probucol, and LDL-apheresis, the patient developed valvular aortic stenosis and aortic regurgitation by 12 years. At 16 years, the patient successfully underwent deceased-donor orthotopic LT. Nine years post-LT, we found total regression of the cutaneous xanthomas and atherosclerotic plaques and with normal endothelial function. Fourteen years post-LT, his clinical condition remained stable, but LDL-C levels have progressively risen. In addition, a systematic review of the literature and guidelines on the LT for HoFH patients was performed. Six of the 17 identified guidelines did not take LT as a treatment option in consideration at all. But still the majority of guidelines suggest LT as an exceptional therapeutic option or as the last resort option when all the other treatment options are inadequate or not tolerated. Most of the observed patients had some kind of cardiovascular disease before the LT. In 76% of LT, the cardiovascular burden did not progress after LT. According to our experience and in several other reported cases, the LDL-C levels are slowly increasing over time post LT. Most of the follow-up data were short termed; only a few case reports have followed patients for 10 or more years after LT. LT is a feasible therapeutic option for HoFH patients, reversing atherosclerotic changes uncontrollable by conservative therapy, thus importantly improving the HoFH patient's prognosis and quality of life.
Collapse
Affiliation(s)
- Matej Mlinaric
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Nevenka Bratanic
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Vlasta Dragos
- Department of Dermatovenereology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Ajda Skarlovnik
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Matija Cevc
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tadej Battelino
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Urh Groselj
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| |
Collapse
|
3
|
Ishigaki Y, Kawagishi N, Hasegawa Y, Sawada S, Katagiri H, Satomi S, Oikawa S. Liver Transplantation for Homozygous Familial Hypercholesterolemia. J Atheroscler Thromb 2018; 26:121-127. [PMID: 30555131 PMCID: PMC6365147 DOI: 10.5551/jat.rv17029] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Pharmacological treatments to decrease low-density lipoprotein (LDL) cholesterol (LDL-C) have limited effects on patients with homozygous familial hypercholesterolemia (HoFH). Since LDL receptors are located mainly in the liver, liver transplantation is considered to be the only way to correct the hepatic cholesterol metabolism abnormalities in HoFH. Liver transplantations, including those combined with heart transplantation, for HoFH have been increasing since 1984, making this a globally established therapeutic option for HoFH. Plasma LDL-C is reported to be dramatically lowered, by 80%, after transplantation, with the rapid regression of cutaneous and tendinous xanthomas. However, long-term cardiovascular benefits remain unclear. The major concerns about liver transplantation include surgical complications, the need for lifelong immunosuppressive therapy, and rejection. In addition, organ transplantations from deceased donors are extremely rare in Japan. We experienced two pediatric siblings with HoFH who received living-donor liver transplantations from their heterozygous parents. Their plasma LDL-C levels decreased immediately and stabilized at approximately 200 mg/dL. Both developed normally with the administration of lipid-lowering medications and have been free of severe problems for more than 10 years, to date, since transplantation. In Japan, where the shortage of deceased donors is critical, the combination of living-donor liver transplant from a heterozygous donor, that is, usually a parent, and medication is regarded as a valid therapeutic option for HoFH. Further studies and clinical experience are required to establish liver transplantation as a safe and effective treatment for HoFH.
Collapse
Affiliation(s)
- Yasushi Ishigaki
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Iwate Medical University
| | | | - Yutaka Hasegawa
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Iwate Medical University
| | - Shojiro Sawada
- Department of Metabolism and Diabetes, Tohoku University Graduate School of Medicine
| | - Hideki Katagiri
- Department of Metabolism and Diabetes, Tohoku University Graduate School of Medicine
| | - Susumu Satomi
- The Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University
| | - Shinichi Oikawa
- Diabetes and Lifestyle-related Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association
| |
Collapse
|
4
|
Beal EW, Mumtaz K, Hayes D, Whitson BA, Black SM. Combined heart-liver transplantation: Indications, outcomes and current experience. Transplant Rev (Orlando) 2016; 30:261-8. [PMID: 27527917 DOI: 10.1016/j.trre.2016.07.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 04/06/2016] [Accepted: 07/12/2016] [Indexed: 11/15/2022]
Abstract
Combined heart-liver transplantation is a rare, life-saving procedure that treats complex and often fatal diseases including familial amyloidosis polyneuropathy and late stage congenital heart disease status-post previous repair. There were 159 combined heart-liver transplantations performed between January 1, 1988 and October 3, 2014 in the United States. A multitude of potential techniques to be used for combined heart and liver transplant including: orthotopic heart transplant (OHT) and orthotopic liver transplant (OLT) on full cardiopulmonary bypass (CPB), OHT with CPB and OLT with venovenous bypass (VVB), OHT with CPB and OLT without VVB, en-bloc technique and sequential transplantation. Outcomes of combined heart-liver transplant have been demonstrated to be comparable to outcomes of isolated heart and isolated liver transplant. The liver graft may provide some tolerance of other allografts.
Collapse
Affiliation(s)
- Eliza W Beal
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Khalid Mumtaz
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Don Hayes
- Departments of Pediatrics and Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Bryan A Whitson
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Division of Cardiothoracic Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sylvester M Black
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Division of Transplantation Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| |
Collapse
|
5
|
Græsdal A, Bogsrud MP, Holven KB, Nenseter MS, Narverud I, Langslet G, Brekke M, Retterstøl K, Arnesen KE, Ose L. Apheresis in homozygous familial hypercholesterolemia: The results of a follow-up of all Norwegian patients with homozygous familial hypercholesterolemia. J Clin Lipidol 2012; 6:331-9. [DOI: 10.1016/j.jacl.2012.03.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 03/12/2012] [Accepted: 03/16/2012] [Indexed: 10/28/2022]
|
6
|
Rauchfuss F, Breuer M, Dittmar Y, Heise M, Bossert T, Hekmat K, Settmacher U. Implantation of the liver during reperfusion of the heart in combined heart-liver transplantation: own experience and review of the literature. Transplant Proc 2012; 43:2707-13. [PMID: 21911150 DOI: 10.1016/j.transproceed.2011.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 04/19/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND There are only a few reports about combined heart-liver transplantations. The surgical techniques differ widely, ranging from sequential implantation of the organs to simultaneous transplantations. We report our experience with simultaneous, combined heart-liver transplantations without using a veno-venous bypass demonstrating that this is a feasible surgical technique. METHODS Since 2005, we performed 4 combined heart-liver transplantations by implanting the liver during the reperfusion period of the newly implanted heart. We retrospectively reviewed patient clinical data and outcomes. RESULTS The mean operative time was 534 ± 247 minutes and the ischemia times for heart and liver were 190 ± 72 minutes (cold ischemia time for the heart), 98 ± 96 minutes (warm ischemia time for the heart), 349 ± 101 minutes (cold ischemia time for the liver), and 36.25 ± 3.5 minutes (warm ischemia time for the liver). Three patients were discharged from the hospital after an uneventful clinical course. One patient died due to multi-organ failure during the intensive care unit stay on the 23rd postoperative day. CONCLUSION We suggest that combined, simultaneous heart-liver transplantation without veno-venous bypass is a feasible surgical technique.
Collapse
Affiliation(s)
- F Rauchfuss
- Department of General, Visceral and Vascular Surgery, Friedrich-Schiller-University Jena, Jena, Germany.
| | | | | | | | | | | | | |
Collapse
|
7
|
El-Rassi I, Chehab G, Saliba Z, Alawe A, Jebara V. Fatal cardiac atherosclerosis in a child 10 years after liver transplantation: a case report and a review. J Clin Lipidol 2011; 5:329-32. [PMID: 21784380 DOI: 10.1016/j.jacl.2011.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Revised: 04/28/2011] [Accepted: 05/09/2011] [Indexed: 01/03/2023]
Abstract
We hereby review liver transplantation for homozygous familial hypercholesterolemia and report the case of a 14-year-old girl presenting with severe bilateral coronary ostial stenosis and tight supra-valvular aortic narrowing 10 years after liver transplantation. Despite normalization of the lipids after liver transplantation, the patient showed evidence of severe cardiac atherosclerosis 10 years later and died of apparent sepsis.
Collapse
Affiliation(s)
- Issam El-Rassi
- Hotel-Dieu de France Hospital, Boulevard Naccach, PO Box 166830, Beirut, Lebanon.
| | | | | | | | | |
Collapse
|
8
|
Küçükkartallar T, Yankol Y, Kanmaz T, Topaloğlu S, Acarli K, Kalayoglu M. Liver transplantation as a treatment option for three siblings with homozygous familial hypercholesterolemia. Pediatr Transplant 2011; 15:281-4. [PMID: 21235710 DOI: 10.1111/j.1399-3046.2010.01469.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
FH is a hereditary inherited disorder of cholesterol metabolism. Homozygous form of the disease associates severe form of atherosclerotic disease. Clinicians have been tried to inhibit the progression of the homozygous FH with medical and surgical treatment. We here present three siblings with homozygous FH who were successfully treated with liver transplantation.
Collapse
Affiliation(s)
- Tevfik Küçükkartallar
- Department of Organ Transplantation, Istanbul Memorial Hospital, Okmeydani, Istanbul.
| | | | | | | | | | | |
Collapse
|
9
|
Combined heart and liver transplantation on cardiopulmonary bypass: report of four cases. Can J Anaesth 2010; 57:355-60. [DOI: 10.1007/s12630-010-9263-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Accepted: 01/05/2010] [Indexed: 10/19/2022] Open
|
10
|
Kakaei F, Nikeghbalian S, Kazemi K, Salahi H, Bahador A, Dehghani SM, Dehghani M, Nejatollahi SM, Shamsaeefar A, Khosravi MB, Malek-Hosseini SA. Liver transplantation for homozygous familial hypercholesterolemia: two case reports. Transplant Proc 2010; 41:2939-41. [PMID: 19765481 DOI: 10.1016/j.transproceed.2009.07.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Homozygous familial hypercholesterolemia (HFHC) is a rare inherited condition with an incidence of one in one million. It is associated with severe premature atherosclerosis and early death from cardiovascular complications. Mutation in the gene that encodes the synthesis of the cellular receptor for low-density lipoprotein (LDL) is responsible for this metabolic disorder. Currently, the only effective treatment for this disease is liver transplantation, which alone or in association with medications, normalizes plasma cholesterol level. The authors report the results of liver transplantation for two cases of HFHC. The first case, a 15-year-old boy received a whole liver from a deceased donor, and the second, an 11-year-old boy, received a left liver lobe transplant from his mother's sister. Their preoperative fasting lipid concentrations were grossly raised. The older boy had severe atherosclerotic heart disease and had undergone coronary artery bypass grafting 5 months before transplantation. Both had preoperative plasma cholesterol levels higher than 750 mg/dL with normal thyroid and liver function tests. After the operation, the patients received methylprednisolone as pulse therapy followed by oral prednisolone, mycophenolate mofetil, and tacrolimus for immunosuppression. Their hospital stays were 24 and 13 days, respectively. The first case needed reexploration because of bleeding on the second day after the operation. The lipid concentrations rapidly returned to the normal range in the first week after the operation, remaining in this range over the first 6 months of follow-up. Liver transplantation offers an highly effective treatment for HFHC. It is better to operate on patients before severe atherosclerotic changes in the coronary arteries. All patients must undergo a complete cardiac evaluation before surgery.
Collapse
Affiliation(s)
- F Kakaei
- Shiraz Transplant Center, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Te HS, Anderson AS, Millis JM, Jeevanandam V, Jensen DM. Current state of combined heart-liver transplantation in the United States. J Heart Lung Transplant 2008; 27:753-9. [PMID: 18582805 DOI: 10.1016/j.healun.2008.04.004] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2008] [Revised: 02/18/2008] [Accepted: 04/21/2008] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Combined heart-liver transplantation (CHLT) has been increasingly performed in the USA, but published data on overall patient and graft outcomes have been limited. METHODS This study aimed to review the indications, immunosuppression, complications and outcomes of CHLT in the USA. From October 1987 to December 2005, a total of 47 cases of combined heart-liver (n = 41) and heart-liver-kidney transplantation (n = 6) were reported to the United Network for Sharing (UNOS) database. One pediatric case was excluded from the analysis. The mean age of recipients was 46 years (range, 22 to 65 years) and included 31 (67%) men and 16 (33%) women. RESULTS The most common indication for both heart and liver transplantation was amyloidosis (30%). Patients were followed for a mean duration of 1,362 days or 3.7 years (range, 1 to 4,598 days or 0 to 12.6 years). Patient, heart and liver graft survival rates were 84.8%, 84.8% and 82.4% at 1 year, and 75.6%, 75.6% and 73.5% at 5 years, respectively. At the latest follow-up of patients who survived at least 6 months after transplantation (n = 39), 28.2% of patients were on a single immunosuppressive agent. CONCLUSIONS Combined heart-liver transplantation is a viable option for candidates who require the combined transplantation, with outcomes comparable to those of single-organ recipients.
Collapse
Affiliation(s)
- Helen S Te
- Center for Liver Diseases, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois 60637, USA.
| | | | | | | | | |
Collapse
|
12
|
Abstract
The aim of this article is to provide essential information for hepatologists, who primarily care for adults, regarding liver-based inborn errors of metabolism with particular reference to those that may be treatable with liver transplantation and to provide adequate references for more in-depth study should one of these disease states be encountered.
Collapse
Affiliation(s)
- Keli Hansen
- Division of Transplant Surgery and Division of Gastroenterology, Children's Hospital and Regional Medical Center, Seattle, WA 98105, USA
| | | |
Collapse
|
13
|
Schmidt HHJ, Tietge UJF, Buettner J, Barg-Hock H, Offner G, Schweitzer S, Dedoussis GV, Rodeck B, Kallfelz HC, Schlitt HJ, Oldhafer K, Klempnauer J. Liver transplantation in a subject with familial hypercholesterolemia carrying the homozygous p.W577R LDL-receptor gene mutation. Clin Transplant 2008; 22:180-4. [PMID: 18339137 DOI: 10.1111/j.1399-0012.2007.00764.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Mutations within the low density lipoprotein (LDL)-receptor gene result in familial hypercholesterolemia, an autosomal dominant inherited disease. Clinical homozygous affected subjects die of premature coronary artery disease as early as in early childhood. We identified a girl at the age of five yr with clinical homozygous familial hypercholesterolemia presenting with achilles tendon xanthomas and arcus lipoides. Her total cholesterol reached up to 1050 mg/dL. Molecular characterization of the LDL-receptor gene revealed a homozygous p.W577R mutation. Despite intensive treatment interventions with the combination of diet, statins, colestipol, and LDL-apheresis, the patient developed symptomatic coronary artery disease at the age of 16 yr. Subsequently, orthotopic liver transplantation was performed to cure the defective LDL-receptor gene. Clinical follow-up for almost nine yr post-transplantation revealed excellent liver function, normal liver enzymes, normal LDL-cholesterol, and regression of both tendon xanthomas and symptomatic coronary artery disease. In conclusion, liver transplantation can effectively reduce LDL-cholesterol in a familial hypercholesterolemia recipient with subsequent regression of xanthomas and atherosclerosis. Timing is extremely important in these exceptional cases to exclude the demand for heart transplantation due to severe coronary artery disease. In addition, the identification of the LDL-receptor as etiology of clinical homozygous hypercholesterolemia is a prerequisite once liver transplantation is considered as therapeutic option.
Collapse
Affiliation(s)
- Hartmut H-J Schmidt
- Transplantationshepatologie, Universitätsklinikum Münster, Münster, Germany.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Abstract
The aim of this article is to provide essential information for hepatologists, who primarily care for adults, regarding liver-based inborn errors of metabolism with particular reference to those that may be treatable with liver transplantation and to provide adequate references for more in-depth study should one of these disease states be encountered.
Collapse
Affiliation(s)
- Keli Hansen
- Children's Hospital and Regional Medical Center, Seattle, WA 98105, USA.
| | | |
Collapse
|
15
|
Ahualli L, Stewart-Harris A, Bastianelli G, Radlovachki D, Bartolomé A, Trigo PL, Cejas N, Aballay Soteras G, Duek F, Lendoire J, Imventarza O, Parisi C, Belforte S, Maiolo E, Castro C, Merino D, Picone V. Combined cardiohepatic transplantation due to severe heterozygous familiar hypercholesteremia type II: first case in Argentina--a case report. Transplant Proc 2007; 39:2449-53. [PMID: 17889215 DOI: 10.1016/j.transproceed.2007.07.068] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Heterozygous familial hypercholesteremia type II is a recessive autonomic disease with a population incidence <or=1:500. It develops as a consequence of a mutation in the LDLR gene. Patients suffer extremely high LDL and VLDL cholesterol values, dying from coronary compromise at early ages. As cholesterol synthesis is an hepatic process, and as there is a lack of gene therapy, hepatic transplantation is the only therapeutic option in cases refractory to medical treatment. In this report, we have described the first case of combined cardiohepatic transplantation in Argentina, which was performed in a male patient with severe aortic stenosis and terminal ischemic cardiopathy secondary to severe familial hypercholesteremia type II.
Collapse
Affiliation(s)
- L Ahualli
- Heart Transplantation Unit, Argerich Hospital, Buenos Aires, Argentina.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Barshes NR, Udell IW, Joyce DL, Southard RE, O'Mahony CA, Goss JA. A Pooled Analysis of Posttransplant Survival Following Combined Heart-Liver Transplantation. Transplantation 2007; 83:95-8. [PMID: 17220801 DOI: 10.1097/01.tp.0000243731.29657.87] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Because no single center has accumulated a large experience with this complex operation, the effectiveness of combined orthotopic heart transplantation (OHT) and orthotopic liver transplantation (OLT) in achieving long-term survival has been unknown. Cases of OHT-OLT were pooled from a U.S. transplant recipient registry and from previously published literature. Aggregate data from these sources was used for survival analysis. Thirty-six patients having undergone OHT-OLT were listed in the national registry; the one- and five-year patient survival rates of these patients were 88% and 78%, respectively. Many patients remain alive at 8+ years after transplantation. An analysis of the pooled results of previously-published cases estimated a one-year patient survival rate of 84%. In selected disease processes, OHT-OLT can correct underlying metabolic deficiencies. While rarely indicated, OHT-OLT is a successful treatment for patients with end-stage heart and liver disease, with survival comparable to that seen after isolated orthotopic heart or orthotopic liver transplantation.
Collapse
Affiliation(s)
- Neal R Barshes
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
| | | | | | | | | | | |
Collapse
|
17
|
Gandelman G, Aronow WS, Weiss MB. Resolving hyperlipidemia after liver transplantation in a patient with primary sclerosing cholangitis. Am J Ther 2006; 13:171-4. [PMID: 16645435 DOI: 10.1097/00045391-200603000-00014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A 64-year-old man with primary sclerosing cholangitis (PSC) and resultant liver failure presented to our hospital with severe dyslipidemia (total cholesterol, 525 mg/dL; low-density lipoprotein (LDL) cholesterol, 489 mg/dL; high-density lipoprotein (HDL) cholesterol, 13 mg/dL; triglycerides, 114 mg/d) and coronary artery disease. The abnormal lipid profile of patients with cholestatic liver disease, such as PSC, includes an abnormal atherogenic LDL called lipoproteinX. The patient's dyslipidemia persisted despite treatment with a statin. Lipids normalized only after liver transplantation (total cholesterol, 135 mg/dL; LDL cholesterol, 60 mg/dL; high-density lipoprotein cholesterol, 48 mg/dL; triglycerides, 130 mg/dL). To the best of our knowledge, the dramatic improvement in the lipid profile after liver transplantation represents the first such published report for PSC. The recognition of dyslipidemia and atherosclerosis in those with cholestatic liver disease and the normalization of lipid profile after liver transplantation warrant further study. We present a review of dyslipidemia in cholestatic liver disease, its relationship to atherosclerosis, and its treatment.
Collapse
Affiliation(s)
- Glenn Gandelman
- Cardiology Division, Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, New York 10595, USA
| | | | | |
Collapse
|
18
|
Diaz GC, Renz JF, Nishanian E, Kinkhabwala M, Emond JC, Wagener G. Anesthetic management of combined heart-liver transplantation. J Cardiothorac Vasc Anesth 2006; 21:253-6. [PMID: 17418742 DOI: 10.1053/j.jvca.2006.01.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2005] [Indexed: 12/31/2022]
Affiliation(s)
- Geraldine C Diaz
- Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, New York, NY, USA.
| | | | | | | | | | | |
Collapse
|
19
|
Abstract
Coronary heart disease (CHD) is the leading cause of death in the United States. Dyslipidemias, like decreased high-density lipoprotein (HDL) and increased low-density lipoprotein (LDL), have been linked through epidemiologic and experimental studies with the development of atherosclerosis and an increased risk of CHD. The introduction of various classes of lipid-lowering drugs, especially the hydroxymethylglutaryl-coenzyme-A-reductase inhibitors (statins), has allowed for effective treatment of hyperlipidemia. This article reviews the following nonpharmacologic approaches to hyperlipidemia: LDL apheresis, surgery, the emergence of HDL as a therapeutic target, gene therapy, and finally, the possibility of developing a vaccine against atherosclerosis.
Collapse
Affiliation(s)
- Tanaz Kermani
- Department of Medicine, Mayo Clinic/Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | | |
Collapse
|
20
|
Alkofer BJ, Chiche L, Khayat A, Deshayes JP, Lepage A, Saloux E, Reznik Y. Liver Transplant Combined With Heart Transplant in Severe Heterozygous Hypercholesterolemia: Report of the First Case and Review of the Literature. Transplant Proc 2005; 37:2250-2. [PMID: 15964390 DOI: 10.1016/j.transproceed.2005.03.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2004] [Indexed: 10/25/2022]
Abstract
Familial hypercholesterolemia (FH) is a dominant inherited disease of low-density lipoprotein (LDL) metabolism caused by mutations of LDL receptors mainly located in the liver. This metabolic disorder is responsible for severe cardiovascular disease, from coronary lesions to chronic heart failure (CHF). Liver transplantation in homozygous FH provides the missing functional LDL receptors and thus partially restores LDL receptor activity to more than 50% of normal. Combined heart and liver transplantation was successfully performed in a homozygous FH patient with end-stage heart failure. Herein we report our experience with a heterozygous male patient with terminal CHF, and review data from the literature on short- and long-term results of such procedures.
Collapse
Affiliation(s)
- B J Alkofer
- CHU Caen, Transplantation and Liver Surgery, CHU cote de nacre, Caen 14000, France.
| | | | | | | | | | | | | |
Collapse
|
21
|
Abstract
PURPOSE OF REVIEW This review focuses on recent advances in the management of patients with homozygous familial hypercholesterolaemia, autosomal recessive hypercholesterolaemia and familial defective apolipoprotein B. RECENT FINDINGS Autosomal recessive hypercholesterolaemia has been described as a 'phenocopy' of homozygous familial hypercholesterolaemia. Although the clinical phenotypes are similar, autosomal recessive hypercholesterolaemia seems to be less severe, more variable within a single family, and more responsive to lipid-lowering drug therapy. The cardiovascular complications of premature atherosclerosis are delayed in some individuals and involvement of the aortic root and valve is less common than in homozygous familial hypercholesterolaemia. Apheresis is still the treatment of choice in homozygous familial hypercholesterolaemia and in autosomal recessive hypercholesterolaemia patients in whom maximal drug therapy does not achieve adequate control. In addition to the profound cholesterol-lowering effects of apheresis, other potentially beneficial phenomena have been documented: improved vascular endothelial function and haemorheology, reduction in lipoprotein (a) and procoagulatory status, and a decrease in adhesion molecules and C-reactive protein. SUMMARY Patients with severe homozygous hypercholesterolaemia illustrate the natural history of atherosclerosis within a condensed timeframe. Effective cholesterol-lowering treatment started in early childhood is essential to prevent onset of life-threatening atherosclerotic involvement of the aortic root and valve, and the coronary arteries. Noninvasive methods for regular monitoring of the major sites involved in the atherosclerotic process are necessary in patients with no symptoms or signs of ischaemia. Management of patients with severe homozygous hypercholesterolaemia continues to be a major challenge.
Collapse
Affiliation(s)
- Rossi P Naoumova
- Medical Research Council Clinical Sciences Centre Imperial College, Hammersmith Hospital, London, UK.
| | | | | |
Collapse
|
22
|
Ocel JJ, Edwards WD, Tazelaar HD, Petrovic LM, Edwards BS, Kamath PS. Heart and liver disease in 32 patients undergoing biopsy of both organs, with implications for heart or liver transplantation. Mayo Clin Proc 2004; 79:492-501. [PMID: 15065614 DOI: 10.4065/79.4.492] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine underlying conditions in patients undergoing both heart and liver biopsies. PATIENTS AND METHODS Our study group consisted of 32 patients at the Mayo Clinic in Rochester, Minn, who underwent both endomyocardial and nonsurgical liver biopsies and who underwent at least one of these procedures between January 1,1981, and December 31,2000. Patients were categorized as having (1) heart disease affecting the liver, (2) liver disease affecting the heart, (3) the same disease affecting both organs, or (4) different diseases affecting each organ independently. RESULTS Among 32 patients, cardiac dysfunction was present in 28 (19 systolic, 9 diastolic), and hepatic dysfunction was present in 31. In group 1, 3 of 4 patients had cardiac amyloidosis with secondary hepatic congestion. In group 2, all 3 patients had cirrhosis with cirrhotic cardiomyopathy. Group 3 included 5 patients with hemochromatosis, 3 with alcoholism, and 1 with amyloidosis. In group 4, 8 of 16 patients had idiopathic cardiomyopathy, and 8 had hepatitis. Overall, of 8 patients with hemochromatosis, 3 without cardiac iron had improved cardiac function after phlebotomy, and 1 with cardiac iron had no cardiac dysfunction. Among 7 patients with alcoholism, 3 had alcoholic liver and heart disease. Of 5 patients with cardiac amyloidosis, 1 had hepatic amyloid. Ten patients underwent transplantation (6 liver, 3 heart, and 1 heart and liver). CONCLUSIONS In one half of the patients in the study group, heart and liver diseases had independent causes. In patients with hemochromatosis, there was little correlation between cardiac iron and systolic dysfunction. In patients with chronic alcoholism, liver and heart disorders often had nonalcoholic causes. With cardiac amyloidosis, hepatic dysfunction was generally due to congestion. Specific disease in one organ did not necessarily imply similar involvement in the other. Thus, heart or liver biopsy may be useful in patients being evaluated for liver or heart transplantation, respectively.
Collapse
Affiliation(s)
- Joseph J Ocel
- Mayo Medical School, Division of Anatomic Pathology, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA
| | | | | | | | | | | |
Collapse
|
23
|
Popescu I, Simionescu M, Tulbure D, Sima A, Catana C, Niculescu L, Hancu N, Gheorghe L, Mihaila M, Ciurea S, Vidu V. Homozygous familial hypercholesterolemia: specific indication for domino liver transplantation. Transplantation 2004; 76:1345-50. [PMID: 14627914 DOI: 10.1097/01.tp.0000093996.96158.44] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Domino liver transplantation is one possibility to overcome the discrepancy between the small number of liver donors and the long waiting lists. Homozygous familial hypercholesterolemia (FHC) is a genetic disorder of lipoprotein metabolism defined by the absence or small number of functional low-density lipoprotein receptors (LDL-Rs) and the ensuing high levels of serum cholesterol. We report a case of a patient with FHC whose liver was used for domino transplantation in a patient with cirrhosis and hepatocellular carcinoma. METHODS The patient diagnosed with FHC received the large part of a split liver. The liver of the patient with FHC was then transplanted into the patient with cirrhosis and hepatocellular carcinoma. Quantification of extrahepatic LDL-R was performed by flow cytometry on monocytes, and the gene expression of LDL-R was assayed by reverse transcriptase-polymerase chain reaction on monocyte-derived macrophages and cultured fibroblasts isolated from the patients. RESULTS One year after surgery, the donor's serum cholesterol (without treatment) was normal, and the recipient's serum cholesterol (with simvastatin treatment) was slightly increased. Quantification of peripheral LDL-R on monocytes isolated from the patients revealed values of 6.7% in the patient with FHC and 71% in the patient with cirrhosis and hepatocellular carcinoma. The reverse transcriptase-polymerase chain reaction assay revealed the presence of gene expression for LDL-R. CONCLUSIONS Domino transplantation can be efficiently used in a patient with marginal indications for transplantation using a liver from a patient with FHC. The slightly elevated serum cholesterol level in the recipient may be explained by the normal function of extrahepatic LDL-R.
Collapse
Affiliation(s)
- Irinel Popescu
- Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Onaca N, Goldstein RM, Klintmalm GB. Xanthomas disappear rapidly after liver transplantation for familial hypercholesterolemia. Liver Transpl 2003; 9:1334-5. [PMID: 14625835 DOI: 10.1016/jlts.2003.50158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Nicholas Onaca
- Transplant Services, Baylor University Medical Center, Dallas, TX 75246, USA
| | | | | |
Collapse
|
25
|
Marks D, Thorogood M, Neil HAW, Humphries SE. A review on the diagnosis, natural history, and treatment of familial hypercholesterolaemia. Atherosclerosis 2003; 168:1-14. [PMID: 12732381 DOI: 10.1016/s0021-9150(02)00330-1] [Citation(s) in RCA: 380] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Familial hypercholesterolaemia (FH) affects approximately 1 in 500 people (10 million world-wide) and the elevated serum cholesterol concentrations lead to a more than 50% risk of fatal or non-fatal coronary heart disease by age 50 years in men and at least 30% in women aged 60 years. Based on a systematic literature search, we review the natural history of FH, describe the diagnostic criteria, and consider the effectiveness of treatment. METHODS A comprehensive review was conducted of the literature on the diagnosis of FH, the morbidity and mortality related to treated and untreated FH, and the evidence on the effectiveness of treatment of FH in adults and children. Treatment options have changed since statin treatment became available, and we have not considered pre-statin therapy studies of treatment effectiveness. FINDINGS AND DISCUSSION A clinical diagnosis of FH is widely used, but a definitive diagnosis can be made by genetic screening, although mutations are currently only detected in 30-50% of patients with a clinical diagnosis. Under-diagnosis of FH has been reported world-wide ranging from less than 1% to 44%. The relative risk of death of FH patients not treated with statins is between three and fourfold but treatment is effective, and delays or prevents the onset of coronary heart disease. Early detection and treatment is important. Aggressive LDL therapy is more effective in the regression of the carotid intima media thickness than conventional LDL therapy. Diagnosis at birth is problematic, and should be delayed until at least 2 years of age. Statins are not generally recommended for the treatment of children up to adolescence. Resins may be used but poor adherence is a problem. Technical advances in mutation detection, and the identification of other genes that cause FH, are likely to have important implications for the cost effectiveness of genetic diagnosis of FH.
Collapse
Affiliation(s)
- Dalya Marks
- London School of Hygiene and Tropical Medicine, Keppel Street, UK
| | | | | | | |
Collapse
|