Progressive hemochromatotic cardiomyopathy despite reversal of iron deposition after liver transplantation

Liver transplantation()

Orthotopic liver transplantation (OLT) involves the substitution of a diseased native liver with a normal liver (or part of one) taken from a deceased or living donor. Considered an experimental procedure through the 1980s, OLT is now regarded as the treatment of choice for a number of otherwise irreversible forms of acute and chronic liver disease.The first human liver transplantation was performed in the United States in 1963 by Prof. T.E. Starzl of the University of Colorado. The first OLT to be performed in Italy was done in 1982 by Prof. R. Cortesini. The procedure was successfully performed at the Policlinico Umberto I of the University of Rome (La Sapienza).The paper reports the indications for liver transplantation, donor selection and organ allocation in our experience, surgical technique, immunosuppression, complications and results of liver transplantation in our center.

Endomyocardial biopsy for non-transplant-related disorders

Endomyocardial biopsy (EMB) remains the "gold standard" for diagnosing rejection after cardiac transplantation. In addition, it has value in monitoring patients during treatment with doxorubicin. It also is important in the setting of acute-onset heart failure for the diagnosis of myocarditis, particularly giant cell myocarditis because earlier transplantation usually is undertaken in patients with giant cell morphologic features. EMB has a role in the unexplained cardiomyoapthy for excluding specific disease processes that might lead to similar morphofunctional changes but might be reversible or a contraindication for transplantation. This review focuses on the growing number of diseases that can be diagnosed by EMB in adult and pediatric age groups.

Cardiac transplantation in patients with iron overload cardiomyopathy

A review of the published world experience with heart transplantation for iron overload cardiomyopathy (IOC) between 1967 and 2003 as well as review of unpublished cases from the database of the United Network for Organ Sharing since 1992, identified a total of 16 patients (14 men and 2 women). Mean age was 31 years (range, 14-63 years). IOC etiology was hemochromatosis in 11 patients (69%), thalassemia major in 4 (25%), and Diamond-Blackfan anemia in 1 (6%). The 30-day mortality was 12%. Three patients (19%) died within 1 year of the transplant, all of infectious complications. An additional patient died at 7.14 years (unknown cause). The actuarial Kaplan-Meier 1-, 3-, and 5-year survival rates were 81% for all 3 time intervals. The actuarial 10-year survival was 41%.

Molecular bases of cellular iron toxicity

Patients with hereditary or secondary hemochromatosis are liable to cardiac and hepatic failure, and type II diabetes. Despite the highly likely conjecture that iron-mediated tissue damage involves the conspiracy of cellular oxidizing and reducing equivalents, the pathophysiologic events have not been fully elucidated. These latter likely involve toxic effects of iron on intracellular organelles, in particular, mitochondria and lysosomes. The tissues at risk-heart, liver, and pancreatic beta cells-all have highly active mitochondria, which incidentally generate activated oxygen species capable of causing synergistic toxicity with intracellular iron. This suggests the general concept that iron may be preferentially toxic to cells with high mitochondrial activity. At least part of the long-term toxicity may involve iron-mediated oxidative damage to the mitochondrial genome with an accumulation of mutational events leading to progressive mitochondrial dysfunction. An alternative-and not mutually exclusive-mechanism for cellular iron toxicity involves iron-catalyzed oxidative destabilization of lysosomes, leading to leak of digestive enzymes into the cell cytoplasm and eventuating in apoptotic or necrotic cell death.

Cardiac dysfunction because of secondary hemochromatosis caused by congenital non-spherocytic hemolytic anemia

Most patients diagnosed with secondary hemochromatosis have had repeated blood transfusions. Cardiac failure accounts for approximately one-third of the deaths associated with hemochromatosis. Liver dysfunction or hormonal disorders such as diabetes generally precede cardiac failure. A 23-year-old woman with hemochromatosis had, despite significant left ventricular dysfunction, liver function within the normal range on biochemical evaluation. She was treated for congestive heart failure and given desferoxamine intravenously. She did not have primary hemochromatosis, and had not received multiple blood transfusions or iron supplement. As a child the patient had been diagnosed with congenital non-spherocytic hemolytic anemia not requiring transfusion; thus, this is a unique case of secondary hemochromatosis.

Liver transplantation. American Association for the Study of Liver Diseases

Liver transplantation has revolutionized the care of patients with end-stage liver disease. Liver transplantation is indicated for acute or chronic liver failure from any cause. Because there are no randomized controlled trials of liver transplantation versus no therapy, the efficacy of this surgery is best assessed by carefully comparing postoperative survival with the known natural history of the disease in question. The best examples of this are in primary biliary cirrhosis and primary sclerosing cholangitis, for which well-validated disease-specific models of natural history are available. There are currently relatively few absolute contraindications to liver transplantation. These include severe cardiopulmonary disease, uncontrolled systemic infection, extrahepatic malignancy, severe psychiatric or neurological disorders, and absence of a viable splanchnic venous inflow system. One of the most frequently encountered contraindications to transplantation is ongoing destructive behavior caused by drug and alcohol addiction. The timing of the surgery can have a profound impact on the mortality and morbidity of patients undergoing liver transplantation. Because of the long waiting lists for donor organs, the need to project far in advance when transplantation might be required has proven to be one of the greatest challenges to those treating patients with end-stage liver disease. Three important questions must be addressed in a patient being considered for liver transplantation: (1) when should the patient be referred for possible transplantation? (2) when should the patient be listed for transplantation? and (3) when is the patient too sick to have a reasonable chance of surviving the perioperative period?

[Cardiac pathology of extracardiac origin (II). The cardiac repercussion of amyloidosis and hemochromatosis]

Although rare, amyloidosis and hemochromatosis are the infiltrative diseases in which the heart is more frequently involved. The most common clinical presentation is heart failure with hemodynamic features of restrictive heart disease in cardiac amyloidosis. The diagnosis is often made because of symptoms of other organ involvement, although sometimes cardiac symptoms may be the initial manifestation. The non-specific clinical presentation and the low prevalence of these cardiomyopathies make the diagnosis difficult if the clinician does not suspect it. Once symptoms develop, the evolution is fast. Usually, the unsatisfactory and ineffective treatment of amyloidosis and hemochromatosis contribute to the poor prognosis. The indication of cardiac transplantation in advanced cases is questionable because of the high recurrence of the illness.

Pediatric gastroenterology. Update on metabolic liver disease

Wilson's disease, genetic and neonatal hemochromatosis, protoporphyria, tyrosinemia, and alpha1-antitrypsin deficiency are updated. Cost effectiveness of screening is discussed. Current therapies are evaluated, including the role of transplantation. The molecular biologic technique PCR is covered. Gene therapy is introduced.

Etiologies, consequences, and treatment of iron overload

From a global perspective, severe systemic iron overload occurs predominantly in individuals affected by geographically specific genetic mutations that permit the daily absorption from the diet of more iron than is physiologically needed. Two main types of hereditary iron overload are well recognized: (1) HLA-linked hemochromatosis in populations derived from Europe and (2) iron overload complicating thalassaemia major and intermedia syndromes in Southeast Asia, the Middle East, and the Mediterranean. Another very common form of iron overload occurs in Africa and is clearly related to high dietary iron content; recent evidence suggests that a genetic predisposition may also contribute to the pathogenesis. Patients with iron overload may develop multiorgan system toxicity; aggressive therapy with phlebotomy or iron chelation to remove excess iron from the body prevents organ damage and prolongs life.