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Moghe A, Dickey A, Erwin A, Leaf RK, O'Brien A, Quigley JG, Thapar M, Anderson KE. Acute hepatic porphyrias: Recommendations for diagnosis and management with real-world examples. Mol Genet Metab 2023; 140:107670. [PMID: 37542766 DOI: 10.1016/j.ymgme.2023.107670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/07/2023]
Abstract
Acute hepatic porphyria (AHP) is a group of four rare inherited diseases, each resulting from a deficiency in a distinct enzyme in the heme biosynthetic pathway. Characterized by acute neurovisceral symptoms that may mimic other medical and psychiatric conditions, lack of recognition of the disease often leads to a delay in diagnosis and initiation of effective treatment. Biochemical testing for pathway intermediates that accumulate when the disease is active forms the basis for screening and establishing a diagnosis. Subsequent genetic analysis identifies the pathogenic variant, supporting screening of family members and genetic counseling. Management of AHP involves avoidance of known exogenous and hormonal triggers, symptomatic treatment, and prevention of recurrent attacks. Here we describe six case studies from our own real-world experience to highlight current recommendations and challenges associated with the diagnosis and long-term management of the disease.
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Affiliation(s)
- Akshata Moghe
- Porphyria Laboratory and Center, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States of America.
| | - Amy Dickey
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Angelika Erwin
- Center for Personalized Genetic Healthcare, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, OH, United States of America
| | - Rebecca K Leaf
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Alan O'Brien
- Service de Médecine Génique, Département de Médecine, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - John G Quigley
- Department of Medicine, University of Illinois College of Medicine, Chicago, IL, United States of America
| | - Manish Thapar
- Division of Gastroenterology, Thomas Jefferson University Hospital, Philadelphia, PA, United States of America
| | - Karl E Anderson
- Porphyria Laboratory and Center, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States of America
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2
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Longo M, Paolini E, Meroni M, Dongiovanni P. Cutting-Edge Therapies and Novel Strategies for Acute Intermittent Porphyria: Step-by-Step towards the Solution. Biomedicines 2022; 10:biomedicines10030648. [PMID: 35327450 PMCID: PMC8945550 DOI: 10.3390/biomedicines10030648] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/07/2022] [Accepted: 03/09/2022] [Indexed: 12/24/2022] Open
Abstract
Acute intermittent porphyria (AIP) is an autosomal dominant disease caused by the hepatic deficiency of porphobilinogen deaminase (PBGD) and the slowdown of heme biosynthesis. AIP symptomatology includes life-threatening, acute neurovisceral or neuropsychiatric attacks manifesting in response to precipitating factors. The latter promote the upregulation of 5-aminolevulinic acid synthase-1 (ALAS1), the first enzyme of heme biosynthesis, which promotes the overload of neurotoxic porphyrin precursors. Hemin or glucose infusions are the first-line therapies for the reduction of ALAS1 levels in patients with mild to severe AIP, while liver transplantation is the only curative treatment for refractory patients. Recently, the RNA-interference against ALAS1 was approved as a treatment for adult and adolescent patients with AIP. These emerging therapies aim to substitute dysfunctional PBGD with adeno-associated vectors for genome editing, human PBGD mRNA encapsulated in lipid nanoparticles, or PBGD protein linked to apolipoprotein A1. Finally, the impairment of glucose metabolism linked to insulin resistance, and mitochondrial aberrations during AIP pathophysiology provided new therapeutic targets. Therefore, the use of liver-targeted insulin and insulin-mimetics such as α-lipoic acid may be useful for overcoming metabolic dysfunction in these subjects. Herein, the present review aims to provide an overview of AIP pathophysiology and management, focusing on conventional and recent therapeutical approaches.
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Affiliation(s)
- Miriam Longo
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Pad. Granelli, Via F Sforza 35, 20122 Milan, Italy; (M.L.); (E.P.); (M.M.)
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Erika Paolini
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Pad. Granelli, Via F Sforza 35, 20122 Milan, Italy; (M.L.); (E.P.); (M.M.)
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, 20133 Milan, Italy
| | - Marica Meroni
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Pad. Granelli, Via F Sforza 35, 20122 Milan, Italy; (M.L.); (E.P.); (M.M.)
| | - Paola Dongiovanni
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Pad. Granelli, Via F Sforza 35, 20122 Milan, Italy; (M.L.); (E.P.); (M.M.)
- Correspondence: ; Tel.: +39-02-5503-3467; Fax: +39-02-5503-4229
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3
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Liver transplantation for intermittent acute porphyria resistant to medical treatment. Cir Esp 2021; 99:695-697. [PMID: 34674987 DOI: 10.1016/j.cireng.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/11/2020] [Indexed: 11/22/2022]
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da Fonseca Neto OCL, Moutinho LER, Filgueira NA, Jucá NT, Rabêlo PJM, de Melo PSV, Amorim AG, Lacerda CM. Recurrence of mild neuropathic pain, following deceased donor liver transplantation, in patient with acute intermittent porphyria: Could timing explain it? A case report. JOURNAL OF LIVER TRANSPLANTATION 2021. [DOI: 10.1016/j.liver.2021.100039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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5
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Patel NC, Wroe N, McNally D, Stein P, Bradberry SM, Elamin MEMO. Safety of haem arginate in overdose: report of an uneventful fourfold accidental overdose. Clin Toxicol (Phila) 2021; 60:410-411. [PMID: 34538189 DOI: 10.1080/15563650.2021.1961146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - Nicholas Wroe
- Acute Medical Unit, Pinderfields Hospital, Wakefield, UK
| | - Daniel McNally
- Acute Medical Unit, Pinderfields Hospital, Wakefield, UK
| | - Penny Stein
- Haematological Medicine Unit, Kings College Hospital, London, UK
| | - Sally M Bradberry
- National Poisons Information Service (Birmingham unit), Birmingham, UK.,West Midlands Poisons Unit, City Hospital, Birmingham, UK
| | - Muhammad E M O Elamin
- National Poisons Information Service (Birmingham unit), Birmingham, UK.,West Midlands Poisons Unit, City Hospital, Birmingham, UK
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6
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Abstract
The acute hepatic porphyrias (AHP) are a group of four inherited diseases of heme biosynthesis. They present with similar severe, episodic, acute neurovisceral symptoms due to abnormally elevated levels of porphyrin precursors delta-aminolevulinic acid (ALA). Recently genetic screening indicates that the prevalence of mutation carrier state is more common than previously thought, occurring in 1 in 1,500, though the clinical penetrance of symptomatic AHP is low at ~1%. Symptomatic attacks occur primarily in females during their reproductive years. In an acute porphyria attack, the primary symptom is abdominal pain, due to intestinal dysmotility from autonomic nerve injury. Other manifestations include seizures, weakness and mood changes, point to injury involving peripheral and central nervous system. Due to the non-specific nature of the symptoms and signs in AHP, the diagnosis is often delayed by many years. The diagnosis of AHP depends on biochemical evidence of elevated ALA and PBG levels in urine during symptomatic attacks. Genetic testing is used for confirmation of the gene involved and the exact mutation. Treatment involves administration of heme, which downregulates production of ALA. Long-term management centers on educating genetic carriers on avoiding triggers that increase the risk of acute attacks and screening family members.
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Affiliation(s)
- Bruce Wang
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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7
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Lissing M, Nowak G, Adam R, Karam V, Boyd A, Gouya L, Meersseman W, Melum E, Ołdakowska‐Jedynak U, Reiter FP, Colmenero J, Sanchez R, Herden U, Langendonk J, Ventura P, Isoniemi H, Boillot O, Braun F, Perrodin S, Mowlem E, Wahlin S. Liver Transplantation for Acute Intermittent Porphyria. Liver Transpl 2021; 27:491-501. [PMID: 37160035 PMCID: PMC8248103 DOI: 10.1002/lt.25959] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 10/19/2020] [Accepted: 11/03/2020] [Indexed: 12/14/2022]
Abstract
Recurrent attacks of acute intermittent porphyria (AIP) result in poor quality of life and significant risks of morbidity and mortality. Liver transplantation (LT) offers a cure, but published data on outcomes after LT are limited. We assessed the pretransplant characteristics, complications, and outcomes for patients with AIP who received a transplant. Data were collected retrospectively from the European Liver Transplant Registry and from questionnaires sent to identified transplant and porphyria centers. We studied 38 patients who received transplants in 12 countries from 2002 to 2019. Median age at LT was 37 years (range, 18-58), and 34 (89%) of the patients were women. A total of 9 patients died during follow-up, and 2 patients were retransplanted. The 1-year and 5-year overall survival rates were 92% and 82%, which are comparable with other metabolic diseases transplanted during the same period. Advanced pretransplant neurological impairment was associated with increased mortality. The 5-year survival rate was 94% among 19 patients with moderate or no neuropathy at LT and 83% among 10 patients with severe neuropathy (P = 0.04). Pretransplant renal impairment was common. A total of 19 (51%) patients had a GFR < 60 mL/minute. Although few patients improved their renal function after LT, neurological impairments improved, and no worsening of neurological symptoms was recorded. No patient had AIP attacks after LT, except for a patient who received an auxiliary graft. LT is a curative treatment option for patients with recurrent attacks of AIP. Severe neuropathy and impaired renal function are common and increase the risk for poor outcomes. If other treatment options fail, an evaluation for LT should be performed early.
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Affiliation(s)
- Mattias Lissing
- Hepatology DivisionDepartment of Upper GI DiseasesPorphyria Centre SwedenKarolinska Institutet and Karolinska University HospitalStockholmSweden
| | - Greg Nowak
- Department of Clinical Science, Intervention and Technology (CLINTEC)Karolinska Institutet and Karolinska University HospitalStockholmSweden
| | - René Adam
- Paul Brousse HospitalUniversity Paris‐SudInserm U935VillejuifFrance
| | - Vincent Karam
- Paul Brousse HospitalUniversity Paris‐SudInserm U935VillejuifFrance
| | | | - Laurent Gouya
- Centre Francais des PorphyriesHôpital Louis MourierAssistance Publique‐Hôpitaux de ParisParisFrance
| | - Wouter Meersseman
- Department of General Internal MedicineUniversitair Ziekenhuis (UZ) LeuvenLeuvenBelgium
| | - Espen Melum
- Section for GastroenterologyNorwegian Primary Sclerosing Cholangitis (PSC) Research CenterDepartment of Transplantation MedicineResearch Institute of Internal MedicineDivision of SurgeryInflammatory Diseases and TransplantationOslo University Hospital RikshospitaletHybrid Technology Hub‐Centre of ExcellenceInstitute of Basic Medical SciencesInstitute of Clinical MedicineFaculty of MedicineUniversity of OsloOsloNorway
| | | | - Florian P. Reiter
- Liver Center MunichDepartment of Medicine IIUniversity HospitalLudwig Maximilian University (LMU) MunichMunichGermany
| | - Jordi Colmenero
- Liver Transplant UnitHospital Clínic de BarcelonaInstitut d'Investigacions Biomèdiques August Pi i SunyerCentro de Investigación Biomédica en Red en Enfermedades Hepáticas y DigestivasUniversitat de BarcelonaBarcelonaSpain
| | - Rosario Sanchez
- Institute of Sanitary and Biomedical Investigation of AlicanteAlicanteSpain
| | - Uta Herden
- Department of Visceral Transplant SurgeryUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Janneke Langendonk
- Erasmus MCUniversity Medical Center RotterdamPorphyria Center RotterdamRotterdamThe Netherlands
| | - Paolo Ventura
- Department of Medical and Surgical Sciences for Children and AdultsUniversity of Modena and Reggio EmiliaUnit of Internal MedicinePoliclinico Hospital of ModenaModenaItaly
| | - Helena Isoniemi
- Department of Transplantation and Liver SurgeryHelsinki University HospitalHelsinkiFinland
| | | | - Felix Braun
- Department of General, Visceral, Thoracic, Transplantation and Pediatric SurgeryUniversitätsklinikum Schleswig‐Holstein (UKSH)Campus KielKielGermany
| | - Stéphanie Perrodin
- Department of Visceral Surgery and MedicineInselspital University Hospital of BernBernSwitzerland
| | - Elizabeth Mowlem
- The Liver UnitAddenbrooke's HospitalCambridge University HospitalsCambridgeUK
| | - Staffan Wahlin
- Hepatology DivisionDepartment of Upper GI DiseasesPorphyria Centre SwedenKarolinska Institutet and Karolinska University HospitalStockholmSweden
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8
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Alcázar López C, Rodríguez Laiz GP, Sánchez Martínez R, Pascual Bartolome S, Ramia JM. Liver transplantation for intermittent acute porphyria resistant to medical treatment. Cir Esp 2020; 99:S0009-739X(20)30275-X. [PMID: 33019962 DOI: 10.1016/j.ciresp.2020.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Cándido Alcázar López
- Unidad de Cirugía Hepatobiliopancreática y Trasplante Hepático, Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Alicante, Alicante, España; Instituto de Investigación Sanitaria y Biomédica de Alicante -ISABIAL-, Alicante, España
| | - Gonzalo P Rodríguez Laiz
- Unidad de Cirugía Hepatobiliopancreática y Trasplante Hepático, Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Alicante, Alicante, España; Instituto de Investigación Sanitaria y Biomédica de Alicante -ISABIAL-, Alicante, España.
| | - Rosario Sánchez Martínez
- Instituto de Investigación Sanitaria y Biomédica de Alicante -ISABIAL-, Alicante, España; Unidad de Enfermedades Raras, Servicio de Medicina Interna, Hospital General Universitario de Alicante, Alicante, España
| | - Sonia Pascual Bartolome
- Instituto de Investigación Sanitaria y Biomédica de Alicante -ISABIAL-, Alicante, España; Sección de Hepatología, Servicio de Aparato Digestivo, Hospital General Universitario de Alicante, Alicante, España
| | - José Manuel Ramia
- Unidad de Cirugía Hepatobiliopancreática y Trasplante Hepático, Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Alicante, Alicante, España; Instituto de Investigación Sanitaria y Biomédica de Alicante -ISABIAL-, Alicante, España
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9
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10
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Plasma heme-induced renal toxicity is related to a capillary rarefaction. Sci Rep 2017; 7:40156. [PMID: 28071761 PMCID: PMC5223203 DOI: 10.1038/srep40156] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 12/02/2016] [Indexed: 01/07/2023] Open
Abstract
Severe hypertension can lead to malignant hypertension (MH) with renal thrombotic microangiopathy and hemolysis. The role of plasma heme release in this setting is unknown. We aimed at evaluating the effect of a mild plasma heme increase by hemin administration in angiotensin II (AngII)-mediated hypertensive rats. Prevalence of MH and blood pressure values were similar in AngII and AngII + hemin groups. MH rats displayed a decreased renal blood flow (RBF), increased renal vascular resistances (RVR), and increased aorta and interlobar arteries remodeling with a severe renal microcirculation assessed by peritubular capillaries (PTC) rarefaction. Hemin-treated rats with or without AngII displayed also a decreased RBF and increased RVR explained only by PCT rarefaction. In AngII rats, RBF was similar to controls (with increased RVR). PTC density appeared strongly correlated to tubular damage score (rho = -0.65, p < 0.0001) and also renal Heme Oygenase-1 (HO-1) mRNA (rho = -0.67, p < 0.0001). HO-1 was expressed in PTC and renal tubules in MH rats, but only in PTC in other groups. In conclusion, though increased plasma heme does not play a role in triggering or aggravating MH, heme release appears as a relevant toxic mediator leading to renal impairment, primarily through PTC endothelial dysfunction rather than direct tubular toxicity.
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11
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Arora S, Young S, Kodali S, Singal AK. Hepatic porphyria: A narrative review. Indian J Gastroenterol 2016; 35:405-418. [PMID: 27796941 DOI: 10.1007/s12664-016-0698-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 09/15/2016] [Indexed: 02/04/2023]
Abstract
Porphyrias are a group of metabolic disorders, which result from a specific abnormality in one of the eight enzymes of the heme biosynthetic pathway. These have been subdivided based on the predominant site of enzyme defect into hepatic and erythropoietic types and based on clinical presentation into acute neurovisceral and cutaneous blistering porphyrias. This review focuses on hepatic porphyrias, which include acute intermittent porphyria (AIP), variegate porphyria (VP), hereditary coproporphyria (HCP), aminolevulinic acid dehydratase deficiency porphyria (ADP), and porphyria cutanea tarda (PCT). Of these, AIP and ADP are classified as acute porphyria, PCT as cutaneous, while VP and HCP present with both acute and cutaneous clinical manifestations. Porphobilinogen levels in a spot urine sample is the initial screening test for the diagnosis of acute hepatic porphyria, and plasma with spot urine porphyrin levels is the initial screening test to approach patients suspected of cutaneous porphyria. Specific biochemical porphyrin profile for each porphyria helps in determining the specific diagnosis. Pain relief and elimination of triggering agents are the initial steps in managing a patient presenting with an acute attack. Intravenous glucose administration terminates the mild episode of acute porphyria, with intravenous hemin needed for management of moderate to severe episodes. Liver transplantation is curative and may be needed for patients with a life-threatening acute porphyria attack or for patients with recurrent acute attacks refractory to prophylactic treatment. Of the cutaneous porphyrias, PCT is the most common and is frequently associated with a combination of multiple susceptibility factors such as alcohol use, smoking, hepatitis C virus infection, HIV infection, estrogen use, and mutations of the hemochromatosis gene. Regular phlebotomy schedule and low-dose hydroxychloroquine are effective and safe treatment options for management of PCT.
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Affiliation(s)
- Sumant Arora
- Department of Internal Medicine, UAB University of Alabama in Birmingham, Birmingham, AL, USA
| | - Steven Young
- Department of Internal Medicine, UAB University of Alabama in Birmingham, Birmingham, AL, USA
| | - Sudha Kodali
- Department of Internal Medicine, UAB University of Alabama in Birmingham, Birmingham, AL, USA.,Division of Gastroenterology and Hepatology, UAB University of Alabama in Birmingham, Birmingham, AL, USA
| | - Ashwani K Singal
- Department of Internal Medicine, UAB University of Alabama in Birmingham, Birmingham, AL, USA. .,Division of Gastroenterology and Hepatology, UAB University of Alabama in Birmingham, Birmingham, AL, USA.
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12
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Oishi K, Arnon R, Wasserstein MP, Diaz GA. Liver transplantation for pediatric inherited metabolic disorders: Considerations for indications, complications, and perioperative management. Pediatr Transplant 2016; 20:756-69. [PMID: 27329540 PMCID: PMC5142218 DOI: 10.1111/petr.12741] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2016] [Indexed: 12/13/2022]
Abstract
LT is an effective therapeutic option for a variety of IEM. This approach can significantly improve the quality of life of patients who suffer from severe disease manifestations and/or life-threatening metabolic decompensations despite medical/dietary management. Due to the significant risks for systemic complications from surgical stressors, careful perioperative management is vital. Even after LT, some disorders require long-term dietary restriction, medical management, and monitoring of metabolites. Successful liver transplant for these complex disorders can be achieved with disease- and patient-specific strategies using a multidisciplinary approach. In this article, we review indications, complications, perioperative management, and long-term follow-up recommendations for IEM that are treatable with LT.
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Affiliation(s)
- Kimihiko Oishi
- Departments of Pediatrics, Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Ronen Arnon
- Departments of Pediatrics, Pediatric Gastroenterology and Hepatology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, The Recanati / Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY10029
| | - Melissa P. Wasserstein
- Departments of Pediatrics, Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - George A. Diaz
- Departments of Pediatrics, Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029
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13
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D’Avola D, Gonzalez Aseguinolaza G. Prospect and progress of gene therapy in acute intermittent porphyria. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1191346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Delia D’Avola
- Liver Unit, CIBERehd, and IDISNAt, Clinica Universidad Navarra, Pamplona, Spain
| | - Gloria Gonzalez Aseguinolaza
- Foundation for Applied Medical Research, Gene Therapy and Regulation of Gene Expression, CIMA, and IDISNA, Navarra, Spain
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14
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Willandt B, Langendonk JG, Biermann K, Meersseman W, D'Heygere F, George C, Verslype C, Monbaliu D, Cassiman D. Liver Fibrosis Associated with Iron Accumulation Due to Long-Term Heme-Arginate Treatment in Acute Intermittent Porphyria: A Case Series. JIMD Rep 2015; 25:77-81. [PMID: 26093628 DOI: 10.1007/8904_2015_458] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 05/08/2015] [Accepted: 05/12/2015] [Indexed: 12/25/2022] Open
Abstract
UNLABELLED Acute intermittent porphyria (AIP) is an autosomal dominant disorder of heme biosynthesis due to a mutation in the porphobilinogen deaminase gene. The mutation causes a deficiency in the porphobilinogen deaminase enzyme, thereby causing an accumulation of heme precursors (δ-aminolevulinic acid and porphobilinogen). These neurotoxic heme precursors elicit acute neurovisceral attacks, which can be treated with heme-arginate infusions. Some patients require heme-arginate infusions on a regular basis for many years, which ultimately leads to an iron accumulation (increased serum ferritin and iron accumulation in the liver, spleen, and bone marrow on MRI). We report three AIP patients, who developed iron accumulation (with serum ferritin up to 7,850 microgram/liter) due to multiple heme-arginate infusions. We report for the first time that the iron accumulation in these patients was associated with fibrosis on liver histology. CONCLUSION Regular heme-arginate treatment in AIP does not only lead to increased serum ferritin but may also induce liver fibrosis. This should be taken into account, when weighing the risks and benefits of repeated heme-arginate treatment against the risk and benefits of treating refractory AIP by liver transplantation.
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Affiliation(s)
- Barbara Willandt
- Department of Hepatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Janneke G Langendonk
- Department of Internal Medicine, Center for Lysosomal and Metabolic Diseases, Nederlands Porphyria Center, Erasmus MC, Rotterdam, The Netherlands
| | | | | | | | | | - Chris Verslype
- Department of Hepatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Diethard Monbaliu
- Abdominal Transplantation Unit, University Hospitals Leuven, Leuven, Belgium
| | - David Cassiman
- Department of Hepatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Metabolic Center, University Hospitals Leuven, Leuven, Belgium.
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15
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Audit of the Use of Regular Haem Arginate Infusions in Patients with Acute Porphyria to Prevent Recurrent Symptoms. JIMD Rep 2015; 22:57-65. [PMID: 25762493 DOI: 10.1007/8904_2015_411] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 01/08/2015] [Accepted: 01/22/2015] [Indexed: 12/13/2022] Open
Abstract
The National Acute Porphyria Service (NAPS) provides acute care support and clinical advice for patients in England with active acute porphyria requiring haem arginate treatment and patients with recurrent acute attacks.This audit examined the benefits and complications of regular haem arginate treatment started with prophylactic intent to reduce the frequency of recurrent acute attacks in a group of patients managed through NAPS. We included 22 patients (21 female and 1 male) and returned information on diagnosis, indications for prophylactic infusions, frequency and dose, analgesia, activity and employment and complications including thromboembolic disease and iron overload.The median age at presentation with porphyria was 21 years (range 9-44), with acute abdominal pain as the predominant symptom. Patients had a median of 12 (1-400) attacks before starting prophylaxis and had received a median of 52 (0-1,350) doses of haem arginate. The median age at starting prophylaxis was 28 years (13-58) with a median delay of 4 years (0.5-37) between presentation and prophylaxis. The frequency of prophylactic haem arginate varied from 1 to 8 per month, and 67% patients were documented as having a reduction in pain frequency on prophylaxis. Only one patient developed clinically significant iron overload and required iron chelation, but the number of venous access devices required varied from 1 to 15, with each device lasting a median of 1.2 years before requiring replacement. Six patients stopped haem arginate and in three this was because their symptoms had improved. Prophylactic haem arginate appears to be beneficial in patients with recurrent acute porphyria symptoms, but maintaining central venous access may prove challenging.
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Abstract
The porphyrias comprise a set of diseases, each representing an individual defect in one of the eight enzymes mediating the pathway of heme synthesis. The diseases are genetically distinct but have in common the overproduction of heme precursors. In the case of the acute (neurologic) porphyrias, the cause of symptoms appears to be overproduction of a neurotoxic precursor. For the cutaneous porphyrias, it is photosensitizing porphyrins. Some types have both acute and cutaneous manifestations. The clinical presentation of acute porphyria consists of abdominal pain, nausea, and occasionally seizures. Only a small minority of those who carry a mutation for acute porphyria have pain attacks. The triggers for an acute attack encompass certain medications and severely decreased caloric intake. The propensity of females to acute attacks has been linked to internal changes in ovarian physiology. Symptoms are accompanied by large increases in delta-aminolevulinic acid and porphobilinogen in plasma and urine. Treatment of an acute attack centers initially on pain relief and elimination of inducing factors such as medications; glucose is administered to reverse the fasting state. The only specific treatment is administration of intravenous hemin. An important goal of treatment is preventing progression of the symptoms to a neurological crisis. Patients who progress despite hemin administration have undergone liver transplantation with complete resolution of symptoms. A current issue is the unavailability of a rapid test for urine porphobilinogen in the urgent-care setting.
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Affiliation(s)
- D. Montgomery Bissell
- Correspondence to: D. Montgomery Bissell, University of California, Box 0538, 513, Parnassus Avenue, San Francisco, CA 94143-0538, USA. Tel: +1-415-476-8405, Fax: +1-415-476-0659. E-mail:
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Singal AK, Parker C, Bowden C, Thapar M, Liu L, McGuire BM. Liver transplantation in the management of porphyria. Hepatology 2014; 60:1082-9. [PMID: 24700519 PMCID: PMC4498564 DOI: 10.1002/hep.27086] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Accepted: 02/17/2014] [Indexed: 12/20/2022]
Abstract
UNLABELLED Porphyrias are a group of eight metabolic disorders, each resulting from a mutation that affects an enzyme of the heme biosynthetic pathway. Porphyrias are classified as hepatic or erythropoietic, depending upon the site where the gene defect is predominantly expressed. Clinical phenotypes are classified as follows: (1) acute porphyrias with neurovisceral symptoms: acute intermittent porphyria; delta amino-levulinic acid hydratase deficiency porphyria; hereditary coproporphyria; and variegate porphyria and (2) cutaneous porphyrias with skin blistering and photosensitivity: porphyria cutanea tarda; congenital erythropoietic porphyria; hepatoerythropoietic porphyria and both erythropoietic protoporphyrias: autosomal dominant and X-linked. Liver transplantation (LT) may be needed for recurrent and/or life-threatening acute attack in acute intermittent porphyria or acute liver failure or end-stage chronic liver disease in erythropoietic protoporphyria. LT in acute intermittent porphyria is curative. Erythropoietic protoporphyria patients needing LT should be considered for bone marrow transplantation to achieve cure. CONCLUSION This article provides an overview of porphyria with diagnostic approaches and management strategies for specific porphyrias and recommendations for LT with indications, pretransplant evaluation, and posttransplant management.
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Affiliation(s)
- Ashwani K. Singal
- the Division of Gastroenterology and Hepatology, University of Alabama (UAB), Birmingham, AL
| | - Charles Parker
- Division of Hematology, University of Utah, Salt Lake City, UT
| | | | - Manish Thapar
- Division of Gastroenterology and Hepatology, Drexel University, Philadelphia, PA
| | - Lawrence Liu
- Division of Gastroenterology and Hepatology, Mount Sinai School of Medicine, New York, NY
| | - Brendan M. McGuire
- the Division of Gastroenterology and Hepatology, University of Alabama (UAB), Birmingham, AL
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