Factor XII deficiency acquired by orthotopic liver transplantation: case report and review of the literature

Donor-to-recipient transmission of factor XII deficiency by orthotopic liver transplantation

Transmission of congenital clotting factor deficiencies following orthotopic liver transplantation is rare. There has been one reported case of donor-to-recipient transmission of factor XII deficiency in a transplant, and we report the second case.

Effects of pre-analytical storage time, temperature, and freeze-thaw times on coagulation factors activities in citrate-anticoagulated plasma

Background

Coagulation factor assays are very important for diagnosing, treating, and monitoring inherited and acquired factor deficiencies. Appropriate pre-analytical storage conditions of citrate-anticoagulated plasma are essential for detection of coagulation factor activity. We aimed to investigate the effects of storage temperature and time on coagulation factor (F) II, FV, FVII, FX, FXI, and FXII activity up to 24 h and the effects of freeze-thaw times at -80 °C on factor activity.

Methods

Twenty-two blood samples were analyzed after storage for 0 (baseline), 2, 4, 6, 8, 12, and 24 h at 25 and 4 °C. Mean percent changes, numbers of samples with >10% changes, percent change trend plots, and difference plots were evaluated to determine clinically relevant differences.

Results

The acceptable storage times for FII coagulation activity (FII:C), FV:C, FVII:C, FX:C, FXI:C, and FXII:C were 24, 8, 8, 24, 12, and 12 h at 4 °C and 24, 4, 8, 8, 12, and 12 h at 25 °C, respectively. The acceptable freeze-thaw times for FII:C, FV:C, FVII:C, FX:C, FXI:C, and FXII:C were 2, 2, 3, 3, 2, and 1, respectively.

Conclusions

When factor activity cannot be determined within these acceptable timeframes, we recommend that plasma samples should be frozen and thawed at appropriate times for analysis.

Afibrinogenemia Acquired by Liver Transplant

Liver transplant is a life-saving procedure in patients with end-stage liver disease. However, this procedure may be associated with transmission of various deficiencies of proteins synthesized by the liver. Factor I (fibrinogen) deficiency is one of the rare inherited coagulation disorders with an extremely low risk of transmission by liver transplant. We report a case of a patient with no inherited coagulation disorders but who demonstrated disturbance of fibrinogen after liver transplant. This case highlights the ever-present risk of donor-to-recipient disease transmission during transplant and emphasizes the difficulty in procuring organs from donors in which standard blood tests are insufficient to determine the likelihood of this event.

Liver transplantation using grafts with rare metabolic disorders

Metabolic diseases that involve the liver represent a heterogeneous group of disorders. Apart from the metabolic defect, the subject's liver functions may be normal. With the increasing need for organs, livers from donors with metabolic diseases other than familial amyloid polyneuropathy might be possibly used for transplantation. However, whether such livers qualify as grafts and how they might impact recipient outcome are still unanswered questions. This review of the literature summarizes current experience in the use of such grafts in the context of cadaveric, domino, and living-related liver transplantation.

Acquired pseudoxanthoma elasticum presenting after liver transplantation

BACKGROUND

Pseudoxanthoma elasticum (PXE) is thought to be a metabolic disorder resulting from mutations in the gene encoding the cellular transporter, ABCC6, which is primarily expressed in liver and kidney. We encountered 3 patients who developed clinical and histopathological evidence of PXE after liver transplantation, suggesting that PXE could have been acquired from the transplanted organ.

OBJECTIVE

We sought to delineate the clinical features and screen each patient and samples of donor liver for mutations in the ABCC6 gene.

METHODS

Each patient underwent full clinical examination, skin biopsy, and ophthalmologic examination, and whole genome sequencing using standard techniques. Fixed samples of donor liver tissue were available for mutation analysis in two patients and of donor kidney tissue in one.

RESULTS

All 3 patients had unequivocal clinical and histopathologic evidence of PXE. No patient (or family member available for screening) had evidence of mutations in ABCC6. Neither liver specimen nor the single available kidney specimen showed evidence of mutations in ABCC6.

LIMITATIONS

Liver tissue was not available from one patient and DNA was of poor quality in another, resulting in limited screening. Genetic testing does not detect ABCC6 mutations in 10% of patients with confirmed PXE.

CONCLUSION

Although we were unable to demonstrate ABCC6 mutations in limited screening of fixed donor livers, the absence of any PXE mutations in the affected patients, the timing of onset of PXE, and the known acquisition of other metabolic disorders and coagulopathies from donor livers suggest that PXE was likely acquired via liver transplantation.