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Falah N, Pendyal S, Sasannejad C, Gibson A, Lee YL, McDonald M, Koeberl D. The interplay of psychosis and non-compliance with fatal outcome in an adult with MSUD. Am J Med Genet A 2024:e63637. [PMID: 38682838 DOI: 10.1002/ajmg.a.63637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 05/01/2024]
Abstract
Significant progress has been achieved in enhancing early outcomes for individuals with maple syrup urine disease (MSUD), a rare metabolic disorder that leads to the accumulation of branched-chain amino acids leucine, isoleucine, and valine, where leucine is known as the primary neurotoxic metabolite. Newborn screening is helpful in early diagnosis and implementation of dietary treatment, thus reducing neurological deterioration and complications in young children. However, patients face the life-long challenge of maintaining metabolic control through adherence to a strict low-leucine diet to avoid long-term consequences of chronic hyperleucinemia, which include cognitive deficits, mood disorders, and movement disorders. This case report exemplifies the complex involvement of MSUD in adult survivors. Despite presenting early in life, the patient thrived until the onset of psychiatric symptoms. The subject of this case is a 25-year-old woman with MSUD, who remained in her usual state of health until presentation to the emergency department (ED) with psychosis and altered mental status. However, due to a lack of medical records and poor communication, there was a delay in considering MSUD as a primary cause of her psychiatric symptoms. Although a genetics consultation was later arranged and efforts were made to decrease plasma leucine to the therapeutic range, these interventions proved inadequate in halting her deterioration in health. Her condition worsened within 72 h, culminating in her untimely death. This case emphasizes the comorbidity of psychiatric involvement in MSUD, which contributes to metabolic decompensation that can lead to cerebral edema and death. This case also highlights the pressing need for enhanced strategies for the acute management and long-term care of MSUD patients with psychiatric involvement, particularly in scenarios where mental disturbance could lead to noncompliance.
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Affiliation(s)
- Nadia Falah
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- Department of Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Surekha Pendyal
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Cina Sasannejad
- Duke Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Allison Gibson
- Division of Critical Care, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Yu Lin Lee
- Department of Medicine and Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Marie McDonald
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Dwight Koeberl
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, North Carolina, USA
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2
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Seda Neto J, Costa CM, Pugliese R, Vincenzi R, Benavides MR, Travassos NPR, de Oliveira CMV, Roda K, Fernandes DP, Kondo M, Fonseca EA. Living Donor Whole and Partial Liver Grafts, Deceased Donor Whole Liver and SPLIT: Outcome Comparison. J Pediatr Surg 2024:S0022-3468(24)00092-7. [PMID: 38413259 DOI: 10.1016/j.jpedsurg.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/02/2024] [Accepted: 02/14/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Currently, graft options for pediatric liver transplantation (PLT) include whole (WL) and partial (P) grafts, in the form of either deceased donor transplantation (DD) or living donor liver transplantation (LD). WL transplants from LD are commonly referred to as domino LT. The objective of this manuscript is to compare the outcomes of PLT performed with each of the available graft options. METHODS Retrospective cohort study from Jan. 2010 to Dec. 2022. The variables included data on the recipients' preoperative clinical status, intraoperative technical aspects, post-operative complications, and survival studies. There were 4 groups: SPLIT (17), DD-WL (55), LD-WL (824), and LD-P (22). RESULTS The median age and BW of the recipients was smaller in SPLIT, LD-P, and LD-WL compared to DDT-WL groups. HVOO (HR 15.87, 95% CI 1.89-133.06, P = 0.01), retransplantation (HR 7.94, 95% CI 2.63-24.02, P < 0.01), and malignancies (HR 3.08, 95% CI 1.29-7.37, P = 0.01) were independently associated with decreased patient survival. HAT (HR 27.54, 95% CI 10.44-72.68, P < 0.01) and malignancies (HR 2.42, 95% CI 1.10-5.34, P = 0.03) increased the risk of graft loss. The overall survival in this series was 91.4% (mean follow-up of 74.3 months). Patient and graft survival were not different among groups. CONCLUSION HAT and malignancies were associated with reduced graft survival. Whole liver from living donors with MSUD presented 100% patient survival at 120 months. Even without statistical differences in survival among the studied groups, LD-P and LD-WL recipients presented a trend towards better outcomes. LEVEL OF EVIDENCE LEVEL III.
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Affiliation(s)
- João Seda Neto
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil.
| | - Carolina M Costa
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Renata Pugliese
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Rodrigo Vincenzi
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Marcel R Benavides
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Nathália P R Travassos
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Caio M V de Oliveira
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Karina Roda
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Debora P Fernandes
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Mário Kondo
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Eduardo A Fonseca
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
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3
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Eldredge JA, Hardikar W. Current status and future directions of liver transplantation for metabolic liver disease in children. Pediatr Transplant 2024; 28:e14625. [PMID: 37859572 DOI: 10.1111/petr.14625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/03/2023] [Accepted: 10/08/2023] [Indexed: 10/21/2023]
Abstract
Orthotopic liver transplantation (OLT) in the care of children with inborn errors of metabolism (IEM) is well established and represent the second most common indication for pediatric liver transplantation in most centers worldwide, behind biliary atresia. OLT offers cure of disease when a metabolic defect is confined to the liver, but may still be transformative on a patient's quality of life reducing the chance of metabolic crises causing neurological damage in children be with extrahepatic involvement and no "functional cure." Outcomes post-OLT for inborn errors of metabolism are generally excellent. However, this benefit must be balanced with consideration of a composite risk of morbidity, and commitment to a lifetime of post-transplant chronic disease management. An increasing number of transplant referrals for children with IEM has contributed to strain on graft access in many parts of the world. Pragmatic evaluation of IEM referrals is essential, particularly pertinent in cases where progression of extra-hepatic disease is anticipated, with long-term outcome expected to be poor. Decision to proceed with liver transplantation is highly individualized based on the child's dynamic risk-benefit profile, their family unit, and their treating multidisciplinary team. Also to be considered is the chance of future treatments, such as gene therapies, emerging in the medium term.
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Affiliation(s)
- Jessica A Eldredge
- Department of Gastroenterology, Hepatology and Clinical Nutrition, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Winita Hardikar
- Department of Gastroenterology, Hepatology and Clinical Nutrition, Royal Children's Hospital University of Melbourne, Parkville, Victoria, Australia
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4
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Pontoizeau C, Gaborit C, Tual N, Simon-Sola M, Rotaru I, Benoist M, Colella P, Lamazière A, Brassier A, Arnoux JB, Rötig A, Ottolenghi C, de Lonlay P, Mingozzi F, Cavazzana M, Schiff M. Successful treatment of severe MSUD in Bckdhb -/- mice with neonatal AAV gene therapy. J Inherit Metab Dis 2024; 47:41-49. [PMID: 36880392 DOI: 10.1002/jimd.12604] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/11/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023]
Abstract
Maple syrup urine disease (MSUD) is rare autosomal recessive metabolic disorder caused by the dysfunction of the mitochondrial branched-chain 2-ketoacid dehydrogenase (BCKD) enzyme complex leading to massive accumulation of branched-chain amino acids and 2-keto acids. MSUD management, based on a life-long strict protein restriction with nontoxic amino acids oral supplementation represents an unmet need as it is associated with a poor quality of life, and does not fully protect from acute life-threatening decompensations or long-term neuropsychiatric complications. Orthotopic liver transplantation is a beneficial therapeutic option, which shows that restoration of only a fraction of whole-body BCKD enzyme activity is therapeutic. MSUD is thus an ideal target for gene therapy. We and others have tested AAV gene therapy in mice for two of the three genes involved in MSUD, BCKDHA and DBT. In this study, we developed a similar approach for the third MSUD gene, BCKDHB. We performed the first characterization of a Bckdhb-/- mouse model, which recapitulates the severe human phenotype of MSUD with early-neonatal symptoms leading to death during the first week of life with massive accumulation of MSUD biomarkers. Based on our previous experience in Bckdha-/- mice, we designed a transgene carrying the human BCKDHB gene under the control of a ubiquitous EF1α promoter, encapsidated in an AAV8 capsid. Injection in neonatal Bckdhb-/- mice at 1014 vg/kg achieved long-term rescue of the severe MSUD phenotype of Bckdhb-/- mice. These data further validate the efficacy of gene therapy for MSUD opening perspectives towards clinical translation.
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Affiliation(s)
- Clément Pontoizeau
- Necker Hospital, APHP, Biochemistry, Metabolomics Unit, University Paris Cité, Paris, France
- Necker Hospital, APHP, Reference Center for Inborn Error of Metabolism, Pediatrics Department, University Paris Cité, Paris, France
- Inserm UMR_S1163, Institut Imagine, Paris, France
| | | | - Nolan Tual
- Inserm UMR_S1163, Institut Imagine, Paris, France
| | | | - Irina Rotaru
- Inserm UMR_S1163, Institut Imagine, Paris, France
| | | | | | | | - Anaïs Brassier
- Necker Hospital, APHP, Reference Center for Inborn Error of Metabolism, Pediatrics Department, University Paris Cité, Paris, France
| | - Jean-Baptiste Arnoux
- Necker Hospital, APHP, Reference Center for Inborn Error of Metabolism, Pediatrics Department, University Paris Cité, Paris, France
| | - Agnès Rötig
- Inserm UMR_S1163, Institut Imagine, Paris, France
| | - Chris Ottolenghi
- Necker Hospital, APHP, Biochemistry, Metabolomics Unit, University Paris Cité, Paris, France
- Necker Hospital, APHP, Reference Center for Inborn Error of Metabolism, Pediatrics Department, University Paris Cité, Paris, France
- Inserm UMR_S1163, Institut Imagine, Paris, France
| | - Pascale de Lonlay
- Necker Hospital, APHP, Reference Center for Inborn Error of Metabolism, Pediatrics Department, University Paris Cité, Paris, France
- Inserm U1151, Institut Necker Enfants Malades, Paris, France
| | | | - Marina Cavazzana
- Inserm UMR_S1163, Institut Imagine, Paris, France
- Necker Hospital, APHP, Biotherapies Department and Clinical Investigation Center, Inserm, University Paris Cité, Paris, France
| | - Manuel Schiff
- Necker Hospital, APHP, Reference Center for Inborn Error of Metabolism, Pediatrics Department, University Paris Cité, Paris, France
- Inserm UMR_S1163, Institut Imagine, Paris, France
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5
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Kumar V, Gautam V, Agarwal S, Pandey V, Goyal S, Nasa V, Singh SA, Al-Thihli K, Al-Murshedi F, Al Hashmi N, Al Rawahi Y, Al-Bahlani AQ, Al Said K, Gupta S. Domino liver transplantation for maple syrup urine disease in children: A single-center case series. Pediatr Transplant 2023; 27:e14603. [PMID: 37658594 DOI: 10.1111/petr.14603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/20/2023] [Accepted: 08/25/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Domino liver transplant (DLT) represents another type of liver donor to expand the donor pool. Recent reports of successful DLT in children with maple syrup urine disease (MSUD) show promising long-term outcomes. METHODS It was a retrospective study. All children with MSUD were paired with either recipients with end-stage liver disease (ESLD) or non-MSUD metabolic disease. Each pair underwent simultaneous liver transplant (LT), where the MSUD recipient received the graft from a living-related donor and the liver explanted from the MSUD donor was transplanted to the respective paired domino recipient. We report our experience regarding the techniques and outcomes of DLT at our center. RESULTS Eleven children with MSUD and 12 respective DLT recipients were enrolled, one of which was domino split-liver transplantation. DLT recipients included seven ESLD, two propionic acidemia (PA), one glycogen storage disease(GSD) type-1, one GSD type-3, and one Citrullinemia. Post-LT ICU and hospital stays were comparable (p > .05). Patient and graft survival was 100% and 66.6% in the MSUD group and DLT recipients at a mean follow-up of 13.5 and 15 months. There was no death in the MSUD group as compared to four in the DLT group. The amino acid levels rapidly normalized after the LT in the children with MSUD and they tolerated the normal unrestricted diet. No vascular, biliary, or graft-related complications were seen in the post-transplant period. No occurrence of MSUD was noted in DLT recipients. CONCLUSION DLTs have excellent post-surgical outcomes. DLT should be strongly considered and adopted by transplant programs worldwide to circumvent organ shortage.
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Affiliation(s)
- Vikram Kumar
- Department of Pediatric Hepatology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, India
| | - Vipul Gautam
- Department of Pediatric Hepatology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, India
| | - Shaleen Agarwal
- Department of Liver Transplant Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, India
| | - Vijaykant Pandey
- Department of Anesthesiology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, India
| | - Sumit Goyal
- Department of Anesthesiology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, India
| | - Vaibhav Nasa
- Department of Anesthesiology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, India
| | - Shweta A Singh
- Department of Anesthesiology, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, India
| | - Khalid Al-Thihli
- Genetic and Developmental Medicine Clinic, Department of Genetics, Sultan Qaboos University Hospital, Muscat, Oman
| | - Fathiya Al-Murshedi
- Genetic and Developmental Medicine Clinic, Department of Genetics, Sultan Qaboos University Hospital, Muscat, Oman
| | | | - Yusriya Al Rawahi
- Department of Child Health, Sultan Qaboos University Hospital, Muscat, Oman
| | | | - Khoula Al Said
- Department of Pediatrics, The Royal Hospital, Muscat, Oman
| | - Subhash Gupta
- Department of Liver Transplant Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, India
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6
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Skvorak K, Liu J, Kruse N, Mehmood R, Das S, Jenne S, Chng C, Lao UL, Duan D, Asfaha J, Du F, Teadt L, Sero A, Ching C, Riggins J, Pope L, Yan P, Mashiana H, Ismaili MHA, McCluskie K, Huisman G, Silverman AP. Oral enzyme therapy for maple syrup urine disease (MSUD) suppresses plasma leucine levels in intermediate MSUD mice and healthy nonhuman primates. J Inherit Metab Dis 2023; 46:1089-1103. [PMID: 37494004 DOI: 10.1002/jimd.12662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/06/2023] [Accepted: 07/25/2023] [Indexed: 07/27/2023]
Abstract
Maple syrup urine disease (MSUD) is an inborn error of branched-chain amino acid metabolism affecting several thousand individuals worldwide. MSUD patients have elevated levels of plasma leucine and its metabolic product α-ketoisocaproate (KIC), which can lead to severe neurotoxicity, coma, and death. Patients must maintain a strict diet of protein restriction and medical formula, and periods of noncompliance or illness can lead to acute metabolic decompensation or cumulative neurological impairment. Given the lack of therapeutic options for MSUD patients, we sought to develop an oral enzyme therapy that can degrade leucine within the gastrointestinal tract prior to its systemic absorption and thus enable patients to maintain acceptable plasma leucine levels while broadening their access to natural protein. We identified a highly active leucine decarboxylase enzyme from Planctomycetaceae bacterium and used directed evolution to engineer the enzyme for stability to gastric and intestinal conditions. Following high-throughput screening of over 12 000 enzyme variants over 9 iterative rounds of evolution, we identified a lead variant, LDCv10, which retains activity following simulated gastric or intestinal conditions in vitro. In intermediate MSUD mice or healthy nonhuman primates given a whey protein meal, oral treatment with LDCv10 suppressed the spike in plasma leucine and KIC and reduced the leucine area under the curve in a dose-dependent manner. Reduction in plasma leucine correlated with decreased brain leucine levels following oral LDCv10 treatment. Collectively, these data support further development of LDCv10 as a potential new therapy for MSUD patients.
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Affiliation(s)
| | - Joyce Liu
- Codexis, Inc., Redwood City, California, USA
| | - Nikki Kruse
- Codexis, Inc., Redwood City, California, USA
| | | | | | | | | | - U Loi Lao
- Codexis, Inc., Redwood City, California, USA
| | - Da Duan
- Codexis, Inc., Redwood City, California, USA
| | | | - Faye Du
- Codexis, Inc., Redwood City, California, USA
| | - Leann Teadt
- Codexis, Inc., Redwood City, California, USA
| | | | | | | | - Lianne Pope
- Codexis, Inc., Redwood City, California, USA
| | - Ping Yan
- Codexis, Inc., Redwood City, California, USA
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7
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Rossi A, Basilicata S, Borrelli M, Ferreira CR, Blau N, Santamaria F. Clinical and biochemical footprints of inherited metabolic diseases. XIII. Respiratory manifestations. Mol Genet Metab 2023; 140:107655. [PMID: 37517329 DOI: 10.1016/j.ymgme.2023.107655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/17/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023]
Abstract
At any age, respiratory manifestations are a major cause of increased morbidity and mortality of inherited metabolic diseases (IMDs). Type and severity are extremely variable, this depending on the type of the underlying disorder. Symptoms and signs originating from upper or lower airways and/or thoracic wall and/or respiratory muscles involvement can occur either at presentation or in the late clinical course. Acute respiratory symptoms can trigger metabolic decompensation which, in turn, makes airway symptoms worse, creating a vicious circle. We have identified 181 IMDs associated with various types of respiratory symptoms which were classified into seven groups according to the type of clinical manifestations affecting the respiratory system: (i) respiratory failure, (ii) restrictive lung disease, (iii) interstitial lung disease, (iv) lower airway disease, (v) upper airway obstruction, (vi) apnea, and (vii) other. We also provided a list of investigations to be performed based on the respiratory phenotypes and indicated the therapeutic strategies currently available for IMD-associated airway disease. This represents the thirteenth issue in a series of educational summaries providing a comprehensive and updated list of metabolic differential diagnoses according to system involvement.
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Affiliation(s)
- Alessandro Rossi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Simona Basilicata
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Melissa Borrelli
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Carlos R Ferreira
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Nenad Blau
- Division of Metabolism, University Children's Hospital, Zürich, Switzerland.
| | - Francesca Santamaria
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy.
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8
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Deon M, Guerreiro G, Girardi J, Ribas G, Vargas CR. Treatment of maple syrup urine disease: Benefits, risks, and challenges of liver transplantation. Int J Dev Neurosci 2023; 83:489-504. [PMID: 37340513 DOI: 10.1002/jdn.10283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 02/06/2023] [Accepted: 05/21/2023] [Indexed: 06/22/2023] Open
Abstract
Maple syrup urine disease (MSUD) is caused by a deficiency in the activity of the branched-chain α-ketoacid dehydrogenase (BCKD) complex, promoting the accumulation of the branched-chain amino acids (BCAA) leucine, isoleucine, and valine, as well as their respective α-keto acids. MSUD is an autosomal recessive hereditary metabolic disorder characterized by ketoacidosis, ataxia, coma, and mental and psychomotor retardation. The mechanisms involved in the brain damage caused by MSUD are not fully understood. Early diagnosis and treatment, as well as proper control of metabolic decompensation crises, are crucial for patients' survival and for a better prognosis. The recommended treatment consists of a high-calorie diet with restricted protein intake and specific formulas containing essential amino acids, except those accumulated in MSUD. This treatment will be maintained throughout life, being adjusted according to the patients' nutritional needs and BCAA concentration. Because dietary treatment may not be sufficient to prevent neurological damage in MSUD patients, other therapeutic strategies have been studied, including liver transplantation. With transplantation, it is possible to obtain an increase of about 10% of the normal BCKD in the body, an amount sufficient to maintain amino acid homeostasis and reduce metabolic decompensation crises. However, the experience related to this practice is very limited when considering the shortage of liver for transplantation and the risks related to the surgical procedure and immunosuppression. Thus, the purpose of this review is to survey the benefits, risks, and challenges of liver transplantation in the treatment of MSUD.
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Affiliation(s)
- Marion Deon
- Faculdade de Farmácia, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
- Serviço de Genética Médica, HCPA, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
| | - Gilian Guerreiro
- Faculdade de Farmácia, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
- Serviço de Genética Médica, HCPA, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
| | - Julia Girardi
- Residência em Análises Clínicas do Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Graziela Ribas
- Serviço de Genética Médica, HCPA, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
| | - Carmen Regla Vargas
- Faculdade de Farmácia, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
- Serviço de Genética Médica, HCPA, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
- Programa de Pós-Graduação em Ciências Farmacêuticas, Porto Alegre, Rio Grande do Sul, Brazil
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Kasahara M, Hong JC, Dhawan A. Evaluation of living donors for hereditary liver disease (siblings, heterozygotes). J Hepatol 2023; 78:1147-1156. [PMID: 37208102 DOI: 10.1016/j.jhep.2022.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 05/21/2023]
Abstract
Living donor liver transplantation (LDLT) is recognised as an alternative treatment modality to reduce waiting list mortality and expand the donor pool. Over recent decades, there have been an increasing number of reports on the use of LT and specifically LDLT for familial hereditary liver diseases. There are marginal indications and contraindications that should be considered for a living donor in paediatric parental LDLT. No mortality or morbidity related to recurrence of metabolic diseases has been observed with heterozygous donors, except for certain relevant cases, such as ornithine transcarbamylase deficiency, protein C deficiency, hypercholesterolemia, protoporphyria, and Alagille syndrome, while donor human leukocyte antigen homozygosity also poses a risk. It is not always essential to perform preoperative genetic assays for possible heterozygous carriers; however, genetic and enzymatic assays must hereafter be included in the parental donor selection criteria in the aforementioned circumstances.
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Affiliation(s)
- Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan.
| | - Johnny C Hong
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - Anil Dhawan
- Paediatric Liver GI and Nutrition Center and MowatLabs, King's College Hospital, London, UK
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10
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Sugiyama Y, Murayama K. Acute Encephalopathy Caused by Inherited Metabolic Diseases. J Clin Med 2023; 12:jcm12113797. [PMID: 37297992 DOI: 10.3390/jcm12113797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/22/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
Acute encephalopathy is a critical medical condition that typically affects previously healthy children and young adults and often results in death or severe neurological sequelae. Inherited metabolic diseases that can cause acute encephalopathy include urea cycle disorders, amino acid metabolism disorders, organic acid metabolism disorders, fatty acid metabolism disorders, mutations in the thiamine-transporter gene, and mitochondrial diseases. Although each inherited metabolic disease is rare, its overall incidence is reported as 1 in 800-2500 patients. This narrative review presents the common inherited metabolic diseases that cause acute encephalopathy. Since diagnosing inherited metabolic diseases requires specific testing, early metabolic/metanolic screening tests are required when an inherited metabolic disease is suspected. We also describe the symptoms and history associated with suspected inherited metabolic diseases, the various tests that should be conducted in case of suspicion, and treatment according to the disease group. Recent advancements made in the understanding of some of the inherited metabolic diseases that cause acute encephalopathy are also highlighted. Acute encephalopathy due to inherited metabolic diseases can have numerous different causes, and recognition of the possibility of an inherited metabolic disease as early as possible, obtaining appropriate specimens, and proceeding with testing and treatment in parallel are crucial in the management of these diseases.
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Affiliation(s)
- Yohei Sugiyama
- Department of Metabolism, Chiba Children's Hospital, Chiba 266-0007, Japan
- Department of Pediatrics, Faculty of Medicine, Juntendo University, Tokyo 113-8431, Japan
| | - Kei Murayama
- Center for Medical Genetics, Chiba Children's Hospital, Chiba 266-0007, Japan
- Diagnostics and Therapeutics of Intractable Diseases, Intractable Disease Research Center, Graduate School of Medicine, Juntendo University, Tokyo 113-8431, Japan
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11
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Aras A, Avanaz A, Inan Aydemir N, Kayaalp E, Ulgen Tekerek N, Kisaoglu A, Demiryilmaz I, Soyucen E, Dursun O, Yilmaz A, Artan R, Aydinli B. Long-term results of liver transplantation for maple syrup urine disease: A single-center experience in Turkey. Pediatr Transplant 2023; 27:e14464. [PMID: 36588190 DOI: 10.1111/petr.14464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 09/25/2022] [Accepted: 12/18/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Maple syrup urine disease (MSUD) is an autosomal recessive inherited disorder. Despite the advances in medical nutrition therapies, classical phenotype causes severe neurological disorders and sudden death. It is known that MSUD patients do not experience metabolic attacks despite their free diet after liver transplantation (LT). This study aims to reveal the long-term results, development, mental, motor, intellectual and nutritional status of MSUD patients who underwent LT. METHODS The data of 12 patients who underwent deceased donor (5 recipients) and living donor liver transplantation (7 recipients) were retrospectively analyzed. The age, genotype, psychometric and mental status, development, BCAA values, type of LT, donor-recipient proximity, complications, and survival were assessed. RESULTS There were 4 (33%) girls and 8 (67%) boys. The mean current age was 9.33 ± 4.58 years. The mean follow-up time was 3 ± 2.5 years. The repeated measures of leucine and isoleucine values revealed that there were no significant differences from the pre-LT to post-LT 1-year. The protein-restricted nutrition was switched to a free diet when oral intake was opened after LT. None of the recipients experienced metabolic attacks after the living donor or deceased donor LT. The 1-, 3-, and 5-year survival rate of the patients is 83.3%. There was no significant difference in survival between living and deceased donor liver transplantation. CONCLUSIONS Liver transplantation is a treatment option for MSUD in proper conditions to save the patient life, increase the quality of life, and provide essential amino acids with free diet intake for growth and development.
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Affiliation(s)
- Arzu Aras
- Department of Pediatric Gastroenterology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Ali Avanaz
- Department of Organ Transplantation, Akdeniz University School of Medicine, Antalya, Turkey
| | - Nurel Inan Aydemir
- Department of Pediatric Gastroenterology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Ece Kayaalp
- Department of Pediatric Nutrition and Metabolism, Akdeniz University School of Medicine, Antalya, Turkey
| | - Nazan Ulgen Tekerek
- Department of Pediatric Intensive Care, Akdeniz University School of Medicine, Antalya, Turkey
| | - Abdullah Kisaoglu
- Department of Organ Transplantation, Akdeniz University School of Medicine, Antalya, Turkey
| | - Ismail Demiryilmaz
- Department of Organ Transplantation, Akdeniz University School of Medicine, Antalya, Turkey
| | - Erdogan Soyucen
- Department of Pediatric Nutrition and Metabolism, Akdeniz University School of Medicine, Antalya, Turkey
| | - Oguz Dursun
- Department of Pediatric Intensive Care, Akdeniz University School of Medicine, Antalya, Turkey
| | - Aygen Yilmaz
- Department of Pediatric Gastroenterology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Reha Artan
- Department of Pediatric Gastroenterology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Bulent Aydinli
- Department of Organ Transplantation, Akdeniz University School of Medicine, Antalya, Turkey
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12
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Soltys K, Mazariegos G, Bucuvalas J. Domino liver transplantation: Don't slip in the pool. Liver Transpl 2022; 28:1829-1830. [PMID: 35981084 DOI: 10.1002/lt.26561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 08/05/2022] [Indexed: 01/13/2023]
Affiliation(s)
- Kyle Soltys
- The Starzl Network for Excellence in Pediatric Transplantation, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Transplant Surgery, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - George Mazariegos
- The Starzl Network for Excellence in Pediatric Transplantation, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Transplant Surgery, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John Bucuvalas
- Jack and Lucy Clark Department of Pediatrics, Mount Sinai Kravis Children's Hospital, Recanati/Miller Transplantation Institute, Mount Sinai Health System, New York, New York, USA
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13
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Cebisli E, Ulgen-Tekerek N, Dursun O, Koker A, Kisaoglu A, Artan R, Soyucen E, Elpek GO. Intestinal Mucormycosis in a Child With Maple Syrup Urine Disease After Orthotopic Liver Transplant. EXP CLIN TRANSPLANT 2022; 21:375-379. [PMID: 36259617 DOI: 10.6002/ect.2021.0257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Mucormycosis can result in serious morbidity and mortality, especially in transplant recipients. In this case report, we present a 3-year-old female patient with maple syrup urine disease who developed mucormycosis infection after deceased donor split liver transplant. Progressive segmental necrosis of the small intestines and new ischemic areas were observed after repeated abdominal surgeries. Microscopic examination of biopsy material revealed mucormycosis. Early recognition is crucial for treatment, and patients with clinical suspicion can be treated empirically with antifungal medicine. However, diagnostic tests with accurate and fast results are needed and more effective therapeutic methods should be developed for better outcomes.
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14
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Baumann U, Karam V, Adam R, Fondevila C, Dhawan A, Sokal E, Jacquemin E, Kelly DA, Grabhorn E, Pawlowska J, D'Antiga L, Jara Vega P, Debray D, Polak WG, de Ville de Goyet J, Verkade HJ. Prognosis of Children Undergoing Liver Transplantation: A 30-Year European Study. Pediatrics 2022; 150:189501. [PMID: 36111446 DOI: 10.1542/peds.2022-057424] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2022] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES The European Liver Transplant Registry has been collecting data on virtually all pediatric liver transplant (PLT) procedures in Europe since 1968. We analyzed patient outcome over time and identified parameters associated with long-term patient outcome. METHODS Participating centers and European organ-sharing organizations provided retrospective data to the European Liver Transplant Registry. To identify trends, data were grouped into consecutive time spans: era A: before 2000, era B: 2000 to 2009, and the current era, era C: since 2010. RESULTS From June 1968 until December 2017, 16 641 PLT were performed on 14 515 children by 133 centers. The children <7 years of age represented 58% in era A, and 66% in the current era (P <.01). The main indications for PLT were congenital biliary diseases (44%) and metabolic diseases (18%). Patient survival at 5 years is currently 86% overall and 97% in children who survive the first year after PLT. The survival rate has improved from 74% in era A to 83% in era B and 85% in era C (P <.0001). Low-volume centers (<5 PLT/year) represented 75% of centers but performed only 19% of PLT and were associated with a decreased survival rate. In the current era, however, survival rates has become irrespective of volume. Infection is the leading cause of death (4.1%), followed by primary nonfunction of the graft (1.4%). CONCLUSIONS PLT has become a highly successful medical treatment that should be considered for all children with end-stage liver disease. The main challenge for further improving the prognosis remains the early postoperative period.
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Affiliation(s)
- Ulrich Baumann
- Hannover Medical School, Divisions of Paediatric Gastroenterology and Hepatology, Department for Paediatric Kidney, Liver, and Metabolic Diseases, Hannover, Germany.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom.,European Liver Transplant Registry, AP-HP Hôpital Paul Brousse, Research Unit "Chronotherapy, cancers and transplantation," University Paris-Saclay, Villejuif, France.,European Liver and Intestine Transplant Association, Padova, Italy.,European Reference Network TransplantChild, La Paz University Hospital, Madrid, Spain
| | - Vincent Karam
- European Liver Transplant Registry, AP-HP Hôpital Paul Brousse, Research Unit "Chronotherapy, cancers and transplantation," University Paris-Saclay, Villejuif, France.,European Liver and Intestine Transplant Association, Padova, Italy
| | - René Adam
- European Liver Transplant Registry, AP-HP Hôpital Paul Brousse, Research Unit "Chronotherapy, cancers and transplantation," University Paris-Saclay, Villejuif, France.,European Liver and Intestine Transplant Association, Padova, Italy
| | - Constantino Fondevila
- European Liver Transplant Registry, AP-HP Hôpital Paul Brousse, Research Unit "Chronotherapy, cancers and transplantation," University Paris-Saclay, Villejuif, France.,Department of General and Digestive Surgery, Hospital Universitario La Paz, IDIPAZ, CIBERehd, Madrid, Spain
| | - Anil Dhawan
- King's College Hospital, London, United Kingdom
| | - Etienne Sokal
- Cliniques Universitaires Saint Luc, Catholic University of Louvain, Brussels, Belgium
| | - Emmanuel Jacquemin
- Pediatric Hepatology and Liver Transplantation Unit, National Reference Centre for Biliary Atresia and Genetic Cholestasis, FILFOIE, ERN RARE LIVER, Bicêtre Hospital, Assistance Publique: Hôpitaux de Paris, University Paris-Saclay, Le Kremlin-Bicêtre; Inserm U1193, Hepatinov, University Paris-Saclay, Orsay, France
| | - Deirdre A Kelly
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - Enke Grabhorn
- European Reference Network TransplantChild, La Paz University Hospital, Madrid, Spain.,Childreńs Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joanna Pawlowska
- European Reference Network TransplantChild, La Paz University Hospital, Madrid, Spain.,Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Lorenzo D'Antiga
- European Reference Network TransplantChild, La Paz University Hospital, Madrid, Spain.,Paediatric Hepatology, Gastroenterology, and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Paloma Jara Vega
- European Reference Network TransplantChild, La Paz University Hospital, Madrid, Spain.,Paediatric Hepatology Service, Coordinator ERN TransplantChild, Hospital Infantil Universitario La Paz, Madrid, Spain
| | - Dominique Debray
- European Reference Network TransplantChild, La Paz University Hospital, Madrid, Spain.,Pediatric Liver Unit and Reference Center for Biliary Atresia and Genetic Cholestasis, APHP-Hôpital Necker, Université de Paris, Paris, France
| | - Wojciech G Polak
- European Liver and Intestine Transplant Association, Padova, Italy.,Department of Surgery, Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jean de Ville de Goyet
- Department for the Treatment and Study of Pediatric Abdominal Diseases and Abdominal Transplantation, ISMETT, Palermo, Italy
| | - Henkjan J Verkade
- European Liver and Intestine Transplant Association, Padova, Italy.,Dept. of Pediatrics, Beatrix Children's Hospital/University Medical Center Groningen, University of Groningen, ERN RareLiver, Groningen, The Netherlands
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15
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Billington CJ, Chapman KA, Leon E, Meltzer BW, Berger SI, Olson M, Figler RA, Hoang SA, Wanxing C, Wamhoff BR, Collado MS, Cusmano‐Ozog K. Genomic and biochemical analysis of repeatedly observed variants in DBT in individuals with maple syrup urine disease of Central American ancestry. Am J Med Genet A 2022; 188:2738-2749. [PMID: 35799415 PMCID: PMC9542135 DOI: 10.1002/ajmg.a.62893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/17/2022] [Accepted: 05/20/2022] [Indexed: 01/25/2023]
Abstract
Maple syrup urine disease (MSUD) is an intoxication-type inherited metabolic disorder in which hyperleucinemia leads to brain swelling and death without treatment. MSUD is caused by branched-chain alpha-ketoacid dehydrogenase deficiency due to biallelic loss of the protein products from the genes BCKDHA, BCKDHB, or DBT, while a distinct but related condition is caused by loss of DLD. In this case series, eleven individuals with MSUD caused by two pathogenic variants in DBT are presented. All eleven individuals have a deletion of exon 2 (delEx2, NM_001918.3:c.48_171del); six individuals are homozygous and five individuals are compound heterozygous with a novel missense variant (NM_001918.5:c.916 T > C [p.Ser306Pro]) confirmed to be in trans. Western Blot indicates decreased amount of protein product in delEx2;c.916 T > C liver cells and absence of protein product in delEx2 homozygous hepatocytes. Ultrahigh performance liquid chromatography-tandem mass spectrometry demonstrates an accumulation of branched-chain amino acids and alpha-ketoacids in explanted hepatocytes. Individuals with these variants have a neonatal-onset, non-thiamine-responsive, classical form of MSUD. Strikingly, the entire cohort is derived from families who immigrated to the Washington, DC, metro area from Honduras or El Salvador suggesting the possibility of a founder effect.
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Affiliation(s)
- Charles J. Billington
- Children's National Rare Disease InstituteWashingtonDistrict of ColumbiaUSA
- Department of PediatricsUniversity of MinnesotaMinneapolisMinnesotaUSA
| | | | - Eyby Leon
- Children's National Rare Disease InstituteWashingtonDistrict of ColumbiaUSA
| | - Beatrix W. Meltzer
- Laboratory Medicine, Children's National HospitalWashingtonDistrict of ColumbiaUSA
| | - Seth I. Berger
- Children's National Rare Disease InstituteWashingtonDistrict of ColumbiaUSA
| | - Matthew Olson
- HemoShear Therapeutics, Inc.CharlottesvilleVirginiaUSA
| | | | | | - Cui Wanxing
- Georgetown University HospitalWashingtonDistrict of ColumbiaUSA
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16
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Ghasemzad M, Hashemi M, Lavasani ZM, Hossein-khannazer N, Bakhshandeh H, Gramignoli R, Keshavarz Alikhani H, Najimi M, Nikeghbalian S, Vosough M. Novel Gene-Correction-Based Therapeutic Modalities for Monogenic Liver Disorders. Bioengineering (Basel) 2022; 9:392. [PMID: 36004917 PMCID: PMC9404740 DOI: 10.3390/bioengineering9080392] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/04/2022] [Accepted: 08/10/2022] [Indexed: 11/17/2022] Open
Abstract
The majority of monogenic liver diseases are autosomal recessive disorders, with few being sex-related or co-dominant. Although orthotopic liver transplantation (LT) is currently the sole therapeutic option for end-stage patients, such an invasive surgical approach is severely restricted by the lack of donors and post-transplant complications, mainly associated with life-long immunosuppressive regimens. Therefore, the last decade has witnessed efforts for innovative cellular or gene-based therapeutic strategies. Gene therapy is a promising approach for treatment of many hereditary disorders, such as monogenic inborn errors. The liver is an organ characterized by unique features, making it an attractive target for in vivo and ex vivo gene transfer. The current genetic approaches for hereditary liver diseases are mediated by viral or non-viral vectors, with promising results generated by gene-editing tools, such as CRISPR-Cas9 technology. Despite massive progress in experimental gene-correction technologies, limitations in validated approaches for monogenic liver disorders have encouraged researchers to refine promising gene therapy protocols. Herein, we highlighted the most common monogenetic liver disorders, followed by proposed genetic engineering approaches, offered as promising therapeutic modalities.
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17
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Pontoizeau C, Simon-Sola M, Gaborit C, Nguyen V, Rotaru I, Tual N, Colella P, Girard M, Biferi MG, Arnoux JB, Rötig A, Ottolenghi C, de Lonlay P, Mingozzi F, Cavazzana M, Schiff M. Neonatal gene therapy achieves sustained disease rescue of maple syrup urine disease in mice. Nat Commun 2022; 13:3278. [PMID: 35672312 PMCID: PMC9174284 DOI: 10.1038/s41467-022-30880-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 05/17/2022] [Indexed: 11/21/2022] Open
Abstract
Maple syrup urine disease (MSUD) is a rare recessively inherited metabolic disorder causing accumulation of branched chain amino acids leading to neonatal death, if untreated. Treatment for MSUD represents an unmet need because the current treatment with life-long low-protein diet is challenging to maintain, and despite treatment the risk of acute decompensations and neuropsychiatric symptoms remains. Here, based on significant liver contribution to the catabolism of the branched chain amino acid leucine, we develop a liver-directed adeno-associated virus (AAV8) gene therapy for MSUD. We establish and characterize the Bckdha (branched chain keto acid dehydrogenase a)−/− mouse that exhibits a lethal neonatal phenotype mimicking human MSUD. Animals were treated at P0 with intravenous human BCKDHA AAV8 vectors under the control of either a ubiquitous or a liver-specific promoter. BCKDHA gene transfer rescued the lethal phenotype. While the use of a ubiquitous promoter fully and sustainably rescued the disease (long-term survival, normal phenotype and correction of biochemical abnormalities), liver-specific expression of BCKDHA led to partial, though sustained rescue. Here we show efficacy of gene therapy for MSUD demonstrating its potential for clinical translation. Maple syrup urine disease (MSUD) is a rare inborn error of metabolism, which is currently treated with life-long low-protein diet that can be challenging to maintain. Here the authors develop an AAV8-directed gene therapy providing sustainable disease rescue in a mouse model of MSUD.
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Affiliation(s)
- Clément Pontoizeau
- Necker Hospital, APHP, Biochemistry, Metabolomics Unit, Paris Cité University, Paris, France. .,Necker Hospital, APHP, Reference Center for Inborn Error of Metabolism, Pediatrics Department, Paris Cité University, Filière G2M, Paris, France. .,Inserm UMR_S1163, Institut Imagine, Paris, France.
| | | | | | | | - Irina Rotaru
- Inserm UMR_S1163, Institut Imagine, Paris, France
| | - Nolan Tual
- Inserm UMR_S1163, Institut Imagine, Paris, France
| | | | - Muriel Girard
- Necker Hospital, APHP, Pediatric Hepatology Unit, Pediatrics Department, Paris Cité University, Paris, France.,Inserm U1151, Institut Necker Enfants Malades, Paris, France
| | - Maria-Grazia Biferi
- Sorbonne University, Inserm, Institute of Myology, Centre of Research in Myology, Paris, France
| | - Jean-Baptiste Arnoux
- Necker Hospital, APHP, Reference Center for Inborn Error of Metabolism, Pediatrics Department, Paris Cité University, Filière G2M, Paris, France
| | - Agnès Rötig
- Inserm UMR_S1163, Institut Imagine, Paris, France
| | - Chris Ottolenghi
- Necker Hospital, APHP, Biochemistry, Metabolomics Unit, Paris Cité University, Paris, France.,Necker Hospital, APHP, Reference Center for Inborn Error of Metabolism, Pediatrics Department, Paris Cité University, Filière G2M, Paris, France.,Inserm UMR_S1163, Institut Imagine, Paris, France
| | - Pascale de Lonlay
- Necker Hospital, APHP, Reference Center for Inborn Error of Metabolism, Pediatrics Department, Paris Cité University, Filière G2M, Paris, France.,Inserm U1151, Institut Necker Enfants Malades, Paris, France
| | | | - Marina Cavazzana
- Inserm UMR_S1163, Institut Imagine, Paris, France.,Necker Hospital, APHP, Biotherapies Department, Paris Cité University, Paris, France
| | - Manuel Schiff
- Necker Hospital, APHP, Reference Center for Inborn Error of Metabolism, Pediatrics Department, Paris Cité University, Filière G2M, Paris, France. .,Inserm UMR_S1163, Institut Imagine, Paris, France.
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18
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Spiekerkoetter U, Krude H. Target Diseases for Neonatal Screening in Germany. Dtsch Arztebl Int 2022; 119:306-316. [PMID: 35140012 PMCID: PMC9450505 DOI: 10.3238/arztebl.m2022.0075] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 04/12/2021] [Accepted: 11/11/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Neonatal screening in Germany currently comprises 19 congenital diseases, 13 of which are metabolic diseases. Approximately one in 1300 newborns suffers from one of these target diseases. Early diagnosis and treatment enable the affected children to undergo better development and even, in many cases, to have a normal life. METHODS This review is based on pertinent publications retrieved by a selective search in the PubMed and Embase databases. RESULTS Positive screening findings are confirmed in approximately one out of five newborns. The prompt evaluation of suspected diagnoses is essential, as treatment for some of these diseases must be initiated immediately after birth to prevent longterm sequelae. The most commonly identified diseases are primary hypothyroidism (1:3338), phenylketonuria/hyperphenylalaninemia (1 : 5262), cystic fibrosis (1 : 5400), and medium-chain acyl-CoA dehydrogenase deficiency (1 : 10 086). Patient numbers are rising as new variants of the target diseases are being identified, and treatments must be adapted to their heterogeneous manifestations. Precise diagnosis and the planning of treatment, which is generally lifelong, are best carried out in a specialized center. CONCLUSION Improved diagnosis and treatment now prolong the lives of many patients with congenital diseases. The provision of appropriate long-term treatment extending into adulthood will be a central structural task for screening medicine in the future.
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Affiliation(s)
- Ute Spiekerkoetter
- General Pediatrics, Adolescent Medicine and Neonatology, University Medical Center, Medical Faculty, University of Freiburg
| | - Heiko Krude
- Institute of Experimental Pediatric Endocrinology, Charité—University Medical Center Berlin
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19
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Shimizu S, Sakamoto S, Fukuda A, Yanagi Y, Uchida H, Mimori K, Nakao T, Sun C, Horikawa R, Kasahara M. Surgical technique and the long-term outcomes of pediatric living donor domino liver transplantation from patients with maple syrup urine disease. Pediatr Transplant 2022; 26:e14174. [PMID: 34687480 DOI: 10.1111/petr.14174] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/29/2021] [Accepted: 10/11/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND The native liver of patients with maple syrup urine disease (MSUD) (1st recipients) can be used as a graft for non-MSUD patients with end-stage liver disease (2nd recipients). This study aimed to demonstrate the optimal operational procedures and the long-term outcomes of 2nd recipients. METHODS Six 2nd recipients of living donor domino liver transplantation (LD-DLT) (age: 42.5 [22-169] months at DLT) received a native liver as a graft from an MSUD patient at our hospital between June 2014 and April 2020. We reviewed the operational procedures and outcomes of 2nd recipients after LD-DLT. RESULTS The 2nd recipients' original diseases included biliary atresia, congenital hepatic fibrosis, congenital protein C deficiency, familial hypercholesterolemia, hepatoblastoma, and mitochondrial hepatopathy. Five of the six recipients had a whole liver and one had a right lobe graft. The site at which the vessels of the MSUD liver were dissected prioritized the safety of the 1st recipient. At the end of follow-up, all recipients were doing well without surgical complications. The mean serum amino acid values of the 2nd recipients did not exceed the upper limit of the reference values during the long-term observation period. All patients showed normal growth while maintaining the same z-score of height and weight after LD-DLT as the preoperative level. CONCLUSION The liver of patients with MSUD can be used safely without concern regarding long-term complications or de novo MSUD development. LD-DLT using the MSUD liver can expand the donor pool as an alternative graft in pediatric LT.
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Affiliation(s)
- Seiichi Shimizu
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Yusuke Yanagi
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kotaro Mimori
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Toshimasa Nakao
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Chao Sun
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Reiko Horikawa
- Department of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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20
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Affiliation(s)
- Laura L Guilder
- Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jonathan B Kronick
- Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
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21
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Moreira-Silva H, Ferreira S, Almeida M, Gonçalves I, Cipriano MA, Vizcaíno JR, Santos-Silva E, Gomes-Martins E. Case report: NAFLD and maple syrup urine disease: Is there an interplay between branched-chain amino acids and fructose consumption? Front Pediatr 2022; 10:933081. [PMID: 36299693 PMCID: PMC9589422 DOI: 10.3389/fped.2022.933081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 09/02/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The worldwide increase in pediatric overweight and obesity, in parallel with the global increase in the consumption of sucrose and fructose, is associated with non-alcoholic fatty liver disease (NAFLD). Elevated branched-chain amino acids (BCAAs) are a metabolic feature related to obesity and an early risk factor for insulin resistance and NAFLD. However, few studies have assessed metabolic risk factors and nutritional status in maple syrup urine disease (MSUD) patients under restricted BCAA and high carbohydrate diets. METHODS AND RESULTS Herein, we present a pilot report of a 17-year-old boy with classic MSUD with poor diet compliance and high fructose consumption, mainly during early adolescence. At that time, he was overweight and developed features of metabolic syndrome, including persistently elevated liver enzymes and hepatic steatosis. He underwent liver transplantation at the age of 13 years to prevent the risk of progressive cognitive impairment. Two months later, NAFLD relapsed in the graft, despite a better BCAA balance and weight loss. Nevertheless, 6 months after dietary restriction of fructose consumption, NAFLD had sustainably improved. CONCLUSION Childhood overweight and fructose overconsumption are wellestablished driving forces in the development of pediatric NAFLD. However, their role in the early onset and progression of NAFLD in the allograft remains to be established. Furthermore, it is not known whether the dysmetabolic state associated with elevated BCAAs may be contributory. Further studies are required with a cohort of MSUD subjects to validate our findings and to ascertain the possible interaction between a BCAA imbalance and dietary intake in the development of NAFLD.
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Affiliation(s)
- Helena Moreira-Silva
- Pediatric Gastroenterology Unit, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Sandra Ferreira
- Hepatology and Pediatric Liver Transplantation Unit, Hospital Pediátrico de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Manuela Almeida
- Pediatric Metabolic Diseases Unit, Centro de Referência de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Isabel Gonçalves
- Hepatology and Pediatric Liver Transplantation Unit, Hospital Pediátrico de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | | | - J R Vizcaíno
- Anatomic Pathology Service, Pathology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ermelinda Santos-Silva
- Pediatric Gastroenterology Unit, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Esmeralda Gomes-Martins
- Pediatric Metabolic Diseases Unit, Centro de Referência de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto, Porto, Portugal
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22
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Raghu VK, Carr-Boyd PD, Squires JE, Vockley J, Goldaracena N, Mazariegos GV. Domino transplantation for pediatric liver recipients: Obstacles, challenges, and successes. Pediatr Transplant 2021; 25:e14114. [PMID: 34448327 PMCID: PMC9759994 DOI: 10.1111/petr.14114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/23/2021] [Accepted: 07/27/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Domino liver transplantation aims to address the need to increase the liver donor supply. In a domino liver transplant, the domino recipient receives the explanted liver from the recipient of a traditional liver transplant. The domino donor typically requires liver transplant to correct a metabolic disorder; the explanted liver thus has a single gene defect but otherwise normal structure and function. METHODS In this review, we detail the history of domino liver transplantation, appropriate domino donor indications, the technical advances to the surgical approach, current outcomes, and future opportunities. RESULTS Development of de novo disease in the domino recipient has relegated adult domino liver transplant to be considered a source of marginal donor livers. However, pediatric domino liver transplant has leveraged certain metabolic disorders, especially maple syrup urine disease, in which the liver enzyme deficiency can be compensated by the systemic presence of sufficient enzyme. Advances in the surgical aspects of assuring adequate length of vasculature have improved the safety of the procedure in both domino donors and recipients. CONCLUSIONS Pediatric domino liver transplant utilizing domino donors with specific metabolic liver diseases should be considered a viable live donor option for children awaiting liver transplant.
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Affiliation(s)
- Vikram K. Raghu
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Peter D. Carr-Boyd
- Hillman Center for Pediatric Transplantation, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James E. Squires
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jerry Vockley
- Division of Medical Genetics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nicolas Goldaracena
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - George V. Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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23
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Vimalesvaran S, Dhawan A. Liver transplantation for pediatric inherited metabolic liver diseases. World J Hepatol 2021; 13:1351-1366. [PMID: 34786171 PMCID: PMC8568579 DOI: 10.4254/wjh.v13.i10.1351] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/23/2021] [Accepted: 08/20/2021] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) remains the gold standard treatment for end stage liver disease in the pediatric population. For liver based metabolic disorders (LBMDs), the decision for LT is predicated on a different set of paradigms. With improved outcomes post-transplantation, LT is no longer merely life saving, but has the potential to also significantly improve quality of life. This review summarizes the clinical presentation, medical treatment and indications for LT for some of the common LBMDs. We also provide a practical update on the dilemmas and controversies surrounding the indications for transplantation, surgical considerations and prognosis and long terms outcomes for pediatric LT in LBMDs. Important progress has been made in understanding these diseases in recent years and with that we outline some of the new therapies that have emerged.
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Affiliation(s)
- Sunitha Vimalesvaran
- Paediatric Liver GI and Nutrition Center, King's College Hospital, London SE5 9RS, United Kingdom
| | - Anil Dhawan
- Paediatric Liver GI and Nutrition Center, King's College Hospital, London SE5 9RS, United Kingdom
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24
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Ewing CB, Soltys KA, Strauss KA, Sindhi R, Vockley J, McKiernan P, Squires RH, Bond G, Ganoza A, Khanna A, Mazariegos GV, Squires JE. Metabolic Control and "Ideal" Outcomes in Liver Transplantation for Maple Syrup Urine Disease. J Pediatr 2021; 237:59-64.e1. [PMID: 34153280 PMCID: PMC9795541 DOI: 10.1016/j.jpeds.2021.06.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/12/2021] [Accepted: 06/15/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To assess outcomes following liver transplantation for maple syrup urine disease by determining attainment and sustainability of metabolic control and apply an "ideal" outcome composite in long-term survivors. STUDY DESIGN A single center, retrospective review collected clinical data including branched-chain amino acid (leucine, isoleucine, and valine) levels following liver transplant and determined achievement of an ideal long-term outcome profile of a first allograft stable on immunosuppression monotherapy, normal growth, and absence of common transplant-related sequelae. RESULTS Of 77 patients meeting inclusion criteria identified, 23 were long-term (≥10-year) survivors and were additionally assessed for ideal outcome attainment. Patient and graft survival were 100% and 99%, respectively, and all patients were on an unrestricted protein intake diet. Although significant variation was noted in mean isoleucine (P < .01) and leucine (P < .05) levels postliver transplantation, no difference was seen in valine (P = .29) and overall clinical impact was likely negligible as metabolic stability was achieved and sustained beyond 3 years postliver transplantation and no metabolic crises were identified. Of 23 long-term survivors with available data, 9 (39%) achieved all composite metrics determined to define "ideal" outcomes in pediatric postliver transplantation populations. CONCLUSIONS Liver transplant enables long-term metabolic stability for patients with maple syrup urine disease. A combination of experience and improvement in both pre- and postliver transplantation care has enabled excellent survival and minimal comorbidities following transplant.
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Affiliation(s)
| | - Kyle A. Soltys
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh
| | | | - Rakesh Sindhi
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh
| | - Jerry Vockley
- Center for Rare Disease Therapy, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Patrick McKiernan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Robert H. Squires
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Geoffrey Bond
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh
| | - Armando Ganoza
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh
| | - Ajai Khanna
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh
| | - George V. Mazariegos
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh
| | - James E. Squires
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, PA
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Greig JA, Jennis M, Dandekar A, Chorazeczewski JK, Smith MK, Ashley SN, Yan H, Wilson JM. Muscle-directed AAV gene therapy rescues the maple syrup urine disease phenotype in a mouse model. Mol Genet Metab 2021; 134:139-146. [PMID: 34454844 DOI: 10.1016/j.ymgme.2021.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/04/2021] [Accepted: 08/07/2021] [Indexed: 11/19/2022]
Abstract
Maple syrup urine disease (MSUD) is a rare, inherited metabolic disorder characterized by a dysfunctional mitochondrial enzyme complex, branched-chain alpha-keto acid dehydrogenase (BCKDH), which catabolizes branched-chain amino acids (BCAAs). Without functional BCKDH, BCAAs and their neurotoxic alpha-keto intermediates can accumulate in the blood and tissues. MSUD is currently incurable and treatment is limited to dietary restriction or liver transplantation, meaning there is a great need to develop new treatments for MSUD. We evaluated potential gene therapy applications for MSUD in the intermediate MSUD (iMSUD) mouse model, which harbors a mutation in the dihydrolipoamide branched-chain transacylase E2 (DBT) subunit of BCKDH. Systemic delivery of an adeno-associated virus (AAV) vector expressing DBT under control of the liver-specific TBG promoter to the liver did not sufficiently ameliorate all aspects of the disease phenotype. These findings necessitated an alternative therapeutic strategy. Muscle makes a larger contribution to BCAA metabolism than liver in humans, but a muscle-specific approach involving a muscle-specific promoter for DBT expression delivered via intramuscular (IM) administration only partially rescued the MSUD phenotype in mice. Combining the muscle-tropic AAV9 capsid with the ubiquitous CB7 promoter via IM or IV injection, however, substantially increased survival across all assessed doses. Additionally, near-normal serum BCAA levels were achieved and maintained in the mid- and high-dose cohorts throughout the study; this approach also protected these mice from a lethal high-protein diet challenge. Therefore, administration of a gene therapy vector that expresses in both muscle and liver may represent a viable approach to treating patients with MSUD.
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Affiliation(s)
- Jenny A Greig
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew Jennis
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Aditya Dandekar
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joanna K Chorazeczewski
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Melanie K Smith
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Scott N Ashley
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hanying Yan
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - James M Wilson
- Gene Therapy Program, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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26
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Elserafy N, Thompson S, Dalkeith T, Stormon M, Thomas G, Shun A, Sawyer J, Balasubramanian S, Bhattacharya K, Badawi N, Ellaway C. Liver transplantation in children with inborn errors of metabolism: 30 years experience in NSW, Australia. JIMD Rep 2021; 60:88-95. [PMID: 34258144 PMCID: PMC8260479 DOI: 10.1002/jmd2.12219] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 04/01/2021] [Accepted: 04/06/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Inborn errors of metabolism (IEM) are a diverse group of genetic disorders that can result in significant morbidity and sometimes death. Metabolic management can be challenging and burdensome for families. Liver transplantation (LT) is increasingly being considered a treatment option for some IEMs. IEMs are now considered the second most common reason for pediatric LT. AIM To review the data of all children with an IEM who had LT at The Children's Hospital at Westmead (CHW), NSW, Australia between January 1986 and January 2019. METHODS Retrospective data collected from the medical records and genetic files included patient demographics, family history, parental consanguinity, method of diagnosis of IEM, hospital and intensive care unit admissions, age at LT, graft type, clinical outcomes and metabolic management pre and post-LT. RESULTS Twenty-four LT were performed for 21 patients. IEM diagnoses were MSUD (n = 4), UCD (n = 8), OA (n = 6), TYR type I (n = 2) and GSD Ia (n = 1). Three patients had repeat transplants due to complications. Median age at transplant was 6.21 years (MSUD), 0.87 years (UCD), 1.64 years (OA) and 2.2 years (TYR I). Two patients died peri-operatively early in the series, one died 3 months after successful LT due to septicemia. Eighteen LTs have been performed since 2008 in comparison to six LT prior to 2008. Dietary management was liberalized post LT for all patients. CONCLUSIONS Referral for LT for IEMs has increased over the last 33 years, with the most referrals in the last 10 years. Early LT has resulted in improved clinical outcomes and patient survival.
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Affiliation(s)
- Noha Elserafy
- Genetic Metabolic Disorders Service, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Sue Thompson
- Genetic Metabolic Disorders Service, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
| | - Troy Dalkeith
- Genetic Metabolic Disorders Service, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
| | - Michael Stormon
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
- Department of Gastroenterology, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Gordon Thomas
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
- Department of Paediatric Surgery, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Albert Shun
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
- Department of Paediatric Surgery, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Janine Sawyer
- Department of Gastroenterology, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Shanti Balasubramanian
- Genetic Metabolic Disorders Service, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
| | - Kaustuv Bhattacharya
- Genetic Metabolic Disorders Service, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
| | - Nadia Badawi
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
- Grace Centre for Newborn Care, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Carolyn Ellaway
- Genetic Metabolic Disorders Service, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
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Menon J, Vij M, Sachan D, Rammohan A, Shanmugam N, Kaliamoorthy I, Rela M. Pediatric metabolic liver diseases: Evolving role of liver transplantation. World J Transplant 2021; 11:161-179. [PMID: 34164292 PMCID: PMC8218348 DOI: 10.5500/wjt.v11.i6.161] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/13/2021] [Accepted: 06/03/2021] [Indexed: 02/06/2023] Open
Abstract
Metabolic liver diseases (MLD) are the second most common indication for liver transplantation (LT) in children. This is based on the fact that the majority of enzymes involved in various metabolic pathways are present within the liver and LT can cure or at least control the disease manifestation. LT is also performed in metabolic disorders for end-stage liver disease, its sequelae including hepatocellular cancer. It is also performed for preventing metabolic crisis’, arresting progression of neurological dysfunction with a potential to reverse symptoms in some cases and for preventing damage to end organs like kidneys as in the case of primary hyperoxalosis and methyl malonic acidemia. Pathological findings in explant liver with patients with metabolic disease include unremarkable liver to steatosis, cholestasis, inflammation, variable amount of fibrosis, and cirrhosis. The outcome of LT in metabolic disorders is excellent except for patients with mitochondrial disorders where significant extrahepatic involvement leads to poor outcomes and hence considered a contraindication for LT. A major advantage of LT is that in the post-operative period most patients can discontinue the special formula which they were having prior to the transplant and this increases their well-being and improves growth parameters. Auxiliary partial orthotopic LT has been described for patients with noncirrhotic MLD where a segmental graft is implanted in an orthotopic position after partial resection of the native liver. The retained native liver can be the potential target for future gene therapy when it becomes a clinical reality.
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Affiliation(s)
- Jagadeesh Menon
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Mukul Vij
- Department of Pathology, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Deepti Sachan
- Department of Transfusion Medicine, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Ashwin Rammohan
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Naresh Shanmugam
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Ilankumaran Kaliamoorthy
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Mohamed Rela
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
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Takano C, Grubbs BH, Ishige M, Ogawa E, Morioka I, Hayakawa S, Miki T. Clinical perspective on the use of human amniotic epithelial cells to treat congenital metabolic diseases with a focus on maple syrup urine disease. Stem Cells Transl Med 2021; 10:829-835. [PMID: 33547875 PMCID: PMC8133340 DOI: 10.1002/sctm.20-0225] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/18/2020] [Accepted: 12/20/2020] [Indexed: 12/16/2022] Open
Abstract
Congenital metabolic diseases are a group of hereditary disorders caused by the deficiency of a single specific enzyme activity. Without appropriate therapy, affected patients suffer severe neurologic disability and eventual death. The current mainstays of management attempt to slow disease progression, but are not curative. Several of these diseases have demonstrated significant benefits from liver transplantation; however, this approach is limited by the morbidity associated with this invasive procedure and a shortage of donor organs. Therefore, there is a need to establish a new strategy for improving the quality of a life for these patients. One potential solution is regenerative therapy using hepatocytes generated from stem cells. Herein, we discuss pertinent issues necessary for clinical application of the human amniotic epithelial cell, a type of placental stem cell. Focusing on maple syrup urine disease as an example, where liver replacement is an effective therapy, we explore this approach from a clinician's perspective.
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Affiliation(s)
- Chika Takano
- Division of Microbiology, Department of Pathology and MicrobiologyNihon University School of MedicineTokyoJapan
- Department of Pediatrics and Child HealthNihon University School of MedicineTokyoJapan
| | - Brendan H. Grubbs
- Department of Obstetrics and GynecologyKeck School of Medicine, University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Mika Ishige
- Department of Pediatrics and Child HealthNihon University School of MedicineTokyoJapan
| | - Erika Ogawa
- Department of Pediatrics and Child HealthNihon University School of MedicineTokyoJapan
| | - Ichiro Morioka
- Department of Pediatrics and Child HealthNihon University School of MedicineTokyoJapan
| | - Satoshi Hayakawa
- Division of Microbiology, Department of Pathology and MicrobiologyNihon University School of MedicineTokyoJapan
| | - Toshio Miki
- Department of PhysiologyNihon University School of MedicineTokyoJapan
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29
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Molema F, Martinelli D, Hörster F, Kölker S, Tangeraas T, de Koning B, Dionisi‐Vici C, Williams M. Liver and/or kidney transplantation in amino and organic acid-related inborn errors of metabolism: An overview on European data. J Inherit Metab Dis 2021; 44:593-605. [PMID: 32996606 PMCID: PMC8247334 DOI: 10.1002/jimd.12318] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/29/2020] [Accepted: 09/25/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND This study provides a general overview on liver and/or kidney transplantation in patients with an amino and organic acid-related disorder (AOA) with the aim to investigate patient characteristics and global outcome in Europe. This study was an initiative of the E-IMD and the AOA subnetwork of MetabERN. METHODS A questionnaire was sent to all clinically active European Society for the Study of Inborn Errors of Metabolism (SSIEM) members. The questionnaire focused on transplanted individuals with methylmalonic acidemia (MMA), propionic acidemia (PA), maple syrup urine disease (MSUD), and urea-cycle disorders (UCDs). RESULTS We identified 280 transplanted AOA patients (liver transplantation in 20 MMA, 37 PA, 47 MSUD, and 111 UCD patients, kidney or combined liver and kidney transplantation in 57 MMA patients and undefined transplantation type in 8 MMA patients), followed by 51 metabolic centers. At a median follow-up of 3.5 years, posttransplant survival ranged between 78% and 100%, being the lowest in PA patients. Overall, the risk of mortality was highest within 14 days posttransplantation. Neurological complications were mainly reported in Mut0 type MMA (n = 8). Nonneurological complications occurred in MMA (n = 28), PA (n = 7), and UCD (n = 14) patients, while it was virtually absent in MSUD patients. Only 116/280 patients were psychologically tested. In all, except MSUD patients, the intelligence quotient (IQ) remained unchanged in the majority (76/94, 81%). Forty-one percentage (9/22) of MSUD patient showed improved IQ. CONCLUSION The survival in AOA individuals receiving liver and/or kidney transplantation seems satisfactory. Evidence-based guidelines, systematic data collection, and improved cooperation between transplantation centers and European Reference Networks are indispensable to improve patient care and outcomes.
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Affiliation(s)
- Femke Molema
- Department of Pediatrics, Center for Lysosomal and Metabolic DiseasesErasmus MC University Medical Center, AOA subgroup MetabERNRotterdamThe Netherlands
- Subnetwork for Amino and Organic Acid‐Related Disorders (AOA)European Reference Network for Hereditary Metabolic Disorders (MetabERN)UdineItaly
| | - Diego Martinelli
- Subnetwork for Amino and Organic Acid‐Related Disorders (AOA)European Reference Network for Hereditary Metabolic Disorders (MetabERN)UdineItaly
- U.O.C. Patologia MetabolicaOspedale Pediatrico Bambino Gesù, AOA Subgroup MetabERNRomeItaly
| | - Friederike Hörster
- Subnetwork for Amino and Organic Acid‐Related Disorders (AOA)European Reference Network for Hereditary Metabolic Disorders (MetabERN)UdineItaly
- Centre for Child and Adolescent Medicine, Division of Neuropaediatrics and Metabolic MedicineUniversity Hospital Heidelberg, AOA Subgroup MetabERNHeidelbergGermany
| | - Stefan Kölker
- Subnetwork for Amino and Organic Acid‐Related Disorders (AOA)European Reference Network for Hereditary Metabolic Disorders (MetabERN)UdineItaly
- Centre for Child and Adolescent Medicine, Division of Neuropaediatrics and Metabolic MedicineUniversity Hospital Heidelberg, AOA Subgroup MetabERNHeidelbergGermany
| | - Trine Tangeraas
- Subnetwork for Amino and Organic Acid‐Related Disorders (AOA)European Reference Network for Hereditary Metabolic Disorders (MetabERN)UdineItaly
- Department of Paediatric and Adolescent Medicine, AOA subgroup MetabERNOslo University Hospital RikshospitaletOsloNorway
| | - Barbara de Koning
- Department of Paediatric Gastro‐EnterologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Carlo Dionisi‐Vici
- Subnetwork for Amino and Organic Acid‐Related Disorders (AOA)European Reference Network for Hereditary Metabolic Disorders (MetabERN)UdineItaly
- U.O.C. Patologia MetabolicaOspedale Pediatrico Bambino Gesù, AOA Subgroup MetabERNRomeItaly
| | - Monique Williams
- Department of Pediatrics, Center for Lysosomal and Metabolic DiseasesErasmus MC University Medical Center, AOA subgroup MetabERNRotterdamThe Netherlands
- Subnetwork for Amino and Organic Acid‐Related Disorders (AOA)European Reference Network for Hereditary Metabolic Disorders (MetabERN)UdineItaly
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Guilder L, Prada CE, Saenz S, Jain-Ghai S, Karp N, Mazariegos G, Ratko S, Salvarinova R, Mercimek-Andrews S. Hyperleucinosis during infections in maple syrup urine disease post liver transplantation. Mol Genet Metab Rep 2021; 27:100763. [PMID: 33996492 DOI: 10.1016/j.ymgmr.2021.100763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/19/2021] [Accepted: 04/19/2021] [Indexed: 11/29/2022] Open
Abstract
Maple syrup urine disease (MSUD) is due to biallelic variants in one of the three genes: BCKDHA, BCKDHB, and DBT. Branched-chain alpha-ketoacid dehydrogenase complex deficiency and elevated leucine, valine, isoleucine and alloisoleucine in body fluids are the results. We report hyperleucinosis during intercurrent illnesses in six patients with MSUD post liver transplantation. Patient charts were retrospectively reviewed. Data was entered into an Excel Database. Literature was reviewed. Six patients with MSUD were included who had post liver transplantation hyperleucinosis during an intercurrent illness. Five had encephalopathy. One received hemodialysis for the management of hyperleucinosis. All patients had unrestricted diet. Additionally, there were five patients (one patient included into the current study) reported in the literature. We suggested management considerations for the follow-up of patients with MSUD post liver transplantation after the first episode of unexplained encephalopathy or signs of acute hyperleucinosis during intercurrent illness due to our clinical experience: 1) Healthy: Unrestricted diet and monitoring of leucine levels; 2) Illness: a) home illness management: increased carbohydrate intake b) illness management at hospital: intravenous dextrose, intravenous lipid and daily plasma amino acid monitoring. We report hyperleucinosis and/or encephalopathy as a rare event post liver transplantation in MSUD as a multicenter case series. Hyperleucinosis and/or encephalopathy may occur in both related and unrelated donor liver transplantation. Based on the long-term follow-up of those patients, these suggested management considerations may be revised as per the patients' needs. Patients with MSUD can present with hyperleucinosis during intercurrent illness post liver transplantation. Hyperleucinosis in MSUD post liver transplantation can occur in related and unrelated donor liver transplantation. Monitoring of patients with MSUD is required after their first episode of hyperleucinosis post liver transplantation.
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Akin EÖ, Pekcici BB, Eminoglu FT. International classification of functioning, disability and health framework (ICF) based adaptive functioning outcomes of children with organic acidemias from a middle-income country. Brain Dev 2021; 43:389-395. [PMID: 33309492 DOI: 10.1016/j.braindev.2020.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/24/2020] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The World Health Organization International Classification of Functioning, Disability and Health Framework (ICF) states that a child's health conditions, functions, activities, participation in life and contextual factors shape disability. Research on the development of children with organic acidemias (OA) mostly focused on cognitive and medical outcomes. This study aimed to examine adaptive functioning of children with OAs based on ICF. METHODS In this cross-sectional study, children with propionic academia, methylmalonic acidemia and maple syrup urine disease receiving care at Ankara University School of Medicine, Department of Pediatrics, Pediatric Metabolism Division were recruited. Comprehensive developmental assessments included ICF-based methods. Adaptive functioning was measured with Vineland Adaptive Behavior Scales-Second Edition. RESULTS The sample comprised 22 children with a median age of 47.5 months (IQR: 35-73.5). Most mothers (64%) had less than 5 years of education, half had depression. Two children (9%) were attending to school, 14 (64%) were not regularly playing with friends. Fourteen children (64%) had significant communication delays, 12 (55%) had significant problems in daily living skills, and 12 (55%) in social skills. Mean adaptive behavior composite score was 65.5 ± 16.8 (low), children with feeding disorders had significantly more low adaptive behavior composite scores than children with no feeding disorder diagnosis (p = 0.001). CONCLUSIONS Our results imply that children with OAs from Turkey, a middle-income country had major difficulties in functioning, activities, participation and contextual factors. Feeding problems appeared as a risk factor for lower adaptive functioning. ICF-based assessments and interventions are urgently needed in the management of children with OAs.
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Affiliation(s)
- Ezgi Özalp Akin
- Ankara University School of Medicine, Department of Pediatrics, Developmental-Behavioral Pediatrics Division, Turkey.
| | - Bahar Bingoler Pekcici
- Ankara University School of Medicine, Department of Pediatrics, Developmental-Behavioral Pediatrics Division, Turkey
| | - Fatma Tuba Eminoglu
- Ankara University School of Medicine, Department of Pediatrics, Pediatric Metabolism Division, Turkey
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Takano C, Ishige M, Ogawa E, Nagano N, Morohashi T, Okahashi A, Kawakami K, Komatsu A, Kawana K, Urakami T, Morioka I. Nutrient management in the intrapartum period in maternal maple syrup urine disease. Mol Genet Metab Rep 2021; 26:100711. [PMID: 33552905 DOI: 10.1016/j.ymgmr.2021.100711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 11/22/2022] Open
Abstract
Women with congenital amino acid disorders, including maple syrup urine disease (MSUD), are at risk of metabolic crisis at delivery. There are still only a few case reports of maternal MSUD globally, and we are the first to report the successful perinatal management of a woman with classical MSUD in Japan. A healthy baby was delivered by scheduled cesarean section despite the presence of several uterine fibroids. With precise diet therapy and accurate preparation, she completed the postpartum period without metabolic decompensation. Although her clinical outcome was favorable, she experienced hypoproteinemia at delivery because the available branched-chain amino acid-free medical food did not contain sufficient protein to meet the recommended nutrient intake. Therefore, this case also indicates a potential issue regarding a shortage of variations in specific amino acid-free medical food in Japan, which should be addressed to achieve a better nutrient status of adults with MSUD and other amino acid disorders.
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Abstract
ABSTRACT Metabolic liver diseases (MLDs) are a heterogeneous group of inherited conditions for which liver transplantation can provide definitive treatment. The limited availability of deceased donor organs means some who could benefit from transplant do not have this option. Living related liver transplant (LrLT) using relatives as donors has emerged as one solution to this problem. This technique is established worldwide, especially in Asian countries, with shorter waiting times and patient and graft survival rates equivalent to deceased donor liver transplantation. However, living donors are underutilized for MLDs in many western countries, possibly due to the fear of limited efficacy using heterozygous donors. We have reviewed the published literature and shown that the use of heterozygous donors for liver transplantation is safe for the majority of MLDs with excellent metabolic correction. The use of LrLT should be encouraged to complement deceased donor liver transplantation (DDLT) for treatment of MLDs.
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Affiliation(s)
- Vikrant Sood
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - George V. Mazariegos
- Division of Pediatric Transplantation, Hillman Center for Pediatric Transplantation
| | - Jerry Vockley
- Center for Rare Disease Therapy, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
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Margutti AVB, Silva WA, Garcia DF, de Molfetta GA, Marques AA, Amorim T, Prazeres VMG, Boy da Silva RT, Miura IK, Seda Neto J, Santos EDS, Santos MLSF, Lourenço CM, Tonon T, Sperb-Ludwig F, de Souza CFM, Schwartz IVD, Camelo JS. Maple syrup urine disease in Brazilian patients: variants and clinical phenotype heterogeneity. Orphanet J Rare Dis 2020; 15:309. [PMID: 33131499 PMCID: PMC7603684 DOI: 10.1186/s13023-020-01590-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 10/15/2020] [Indexed: 11/14/2022] Open
Abstract
Background Maple syrup urine disease (MSUD) is an autosomal recessive inherited metabolic disease caused by deficient activity of the branched-chain α-keto acid dehydrogenase (BCKD) enzymatic complex. BCKD is a mitochondrial complex encoded by BCKDHA, BCKDHB, DBT, and DLD genes. MSUD is predominantly caused by Variants in BCKDHA, BCKDHB, and DBT genes encoding the E1α, E1β, and E2 subunits of BCKD complex, respectively. The aim of this study was to characterize the genetic basis of MSUD by identifying the point variants in BCKDHA, BCKDHB, and DBT genes in a cohort of Brazilian MSUD patients and to describe their phenotypic heterogeneity. It is a descriptive cross-sectional study with 21 MSUD patients involving molecular genotyping by Sanger sequencing. Results Eight new variants predicted as pathogenic were found between 30 variants (damaging and non-damaging) identified in the 21 patients analyzed: one in the BCKDHA gene (p.Tyr120Ter); five in the BCKDHB gene (p.Gly131Val, p.Glu146Glnfs * 13, p.Phe149Cysfs * 9, p.Cys207Phe, and p.Lys211Asn); and two in the DBT gene (p.Glu148Ter and p.Glu417Val). Seventeen pathogenic variants were previously described and five variants showed no pathogenicity according to in silico analysis.
Conclusion Given that most of the patients received late diagnoses, the study results do not allow us to state that the molecular features of MSUD variant phenotypes are predictive of clinical severity.
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Affiliation(s)
- Ana Vitoria Barban Margutti
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Bandeirantes Av., 3900 - HC Criança - off D506, Ribeirão Prêto, SP, 14049-900, Brazil
| | - Wilson Araújo Silva
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.,National Institute of Science and Technology in Stem Cell, and Cell Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto, SP, Brazil.,Center for Medical Genomics at Clinics Hospital of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Daniel Fantozzi Garcia
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.,National Institute of Science and Technology in Stem Cell, and Cell Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Greice Andreotti de Molfetta
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.,National Institute of Science and Technology in Stem Cell, and Cell Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto, SP, Brazil.,Center for Medical Genomics at Clinics Hospital of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Adriana Aparecida Marques
- National Institute of Science and Technology in Stem Cell, and Cell Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Tatiana Amorim
- Associação de Pais e Amigos dos Excepcionais of Salvador, Salvador, BA, Brazil.,Department of Life Sciences, Bahia State University, Salvador, BA, Brazil
| | | | - Raquel Tavares Boy da Silva
- Department of Pediatrics, Medical Sciences School, Rio de Janeiro State University, Rio de Janeiro, RJ, Brazil
| | | | | | | | | | | | - Tássia Tonon
- Posgraduate Programme in Medicine - Medical Sciences, Federal University of Rio Grande Do Sul, Porto Alegre, RS, Brazil
| | - Fernanda Sperb-Ludwig
- Department of Genetics, Federal University of Rio Grande Do Sul, Porto Alegre, RS, Brazil.,BRAIN Laboratory (Basic Research and Advanced Investigations in Neurosciences), Clinics Hospital of Porto Alegre, Porto Alegre, RS, Brazil
| | - Carolina Fischinger Moura de Souza
- Medical Genetics Service, Clinics Hospital of Porto Alegre, Department of Genetics, Federal University of Rio Grande Do Sul, Porto Alegre, RS, Brazil
| | - Ida Vanessa Döederlein Schwartz
- Medical Genetics Service, Clinics Hospital of Porto Alegre, Department of Genetics, Federal University of Rio Grande Do Sul, Porto Alegre, RS, Brazil
| | - José Simon Camelo
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Bandeirantes Av., 3900 - HC Criança - off D506, Ribeirão Prêto, SP, 14049-900, Brazil.
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Abstract
Although orthotopic liver transplantation remains the only proven treatment for end-stage liver disease and inherited metabolic liver disease, its application has been limited by the scarcity of donor organs available for transplantation. Among feasible approaches developed to expand the donor organ pool, domino liver transplantation is a strategy in which explanted genetically defective livers of liver transplant recipients are used as grafts in other patients. Another promising therapeutic strategy is hepatocyte transplantation, an alternative to liver transplantation for certain groups of patients. However, the availability of primary hepatocytes is also hindered by the shortage of donor liver tissues. Against this background, domino hepatocyte transplantation, a strategy that utilizes the hepatocytes derived from the explanted livers of liver transplant recipients with noncirrhotic inherited metabolic liver diseases as the source of primary hepatocytes, may help increase the supply of liver cells available for transplantation. In this review, we focus on the status quo of domino liver transplantation and domino hepatocyte transplantation. We also describe recent innovative transplant strategies based on domino transplantation.
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Affiliation(s)
- Guang-Peng Zhou
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Li-Ying Sun
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China,Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Xu J, Jakher Y, Ahrens-Nicklas RC. Brain Branched-Chain Amino Acids in Maple Syrup Urine Disease: Implications for Neurological Disorders. Int J Mol Sci 2020; 21:E7490. [PMID: 33050626 DOI: 10.3390/ijms21207490] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/02/2020] [Accepted: 10/09/2020] [Indexed: 12/16/2022] Open
Abstract
Maple syrup urine disease (MSUD) is an autosomal recessive disorder caused by decreased activity of the branched-chain α-ketoacid dehydrogenase complex (BCKDC), which catalyzes the irreversible catabolism of branched-chain amino acids (BCAAs). Current management of this BCAA dyshomeostasis consists of dietary restriction of BCAAs and liver transplantation, which aims to partially restore functional BCKDC activity in the periphery. These treatments improve the circulating levels of BCAAs and significantly increase survival rates in MSUD patients. However, significant cognitive and psychiatric morbidities remain. Specifically, patients are at a higher lifetime risk for cognitive impairments, mood and anxiety disorders (depression, anxiety, and panic disorder), and attention deficit disorder. Recent literature suggests that the neurological sequelae may be due to the brain-specific roles of BCAAs. This review will focus on the derangements of BCAAs observed in the brain of MSUD patients and will explore the potential mechanisms driving neurologic dysfunction. Finally, we will discuss recent evidence that implicates the relevance of BCAA metabolism in other neurological disorders. An understanding of the role of BCAAs in the central nervous system may facilitate future identification of novel therapeutic approaches in MSUD and a broad range of neurological disorders.
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Tsai HY, Wu SC, Li JC, Chen YM, Chan CC, Chen CH. Loss of the Drosophila branched-chain α-ketoacid dehydrogenase complex results in neuronal dysfunction. Dis Model Mech 2020; 13:dmm044750. [PMID: 32680850 PMCID: PMC7473638 DOI: 10.1242/dmm.044750] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 07/06/2020] [Indexed: 12/28/2022] Open
Abstract
Maple syrup urine disease (MSUD) is an inherited error in the metabolism of branched-chain amino acids (BCAAs) caused by a severe deficiency of the branched-chain α-ketoacid dehydrogenase (BCKDH) complex, which ultimately leads to neurological disorders. The limited therapies, including protein-restricted diets and liver transplants, are not as effective as they could be for the treatment of MSUD due to the current lack of molecular insights into the disease pathogenesis. To address this issue, we developed a Drosophila model of MSUD by knocking out the dDBT gene, an ortholog of the human gene encoding the dihydrolipoamide branched chain transacylase (DBT) subunit of BCKDH. The homozygous dDBT mutant larvae recapitulate an array of MSUD phenotypes, including aberrant BCAA accumulation, developmental defects, poor mobile behavior and disrupted L-glutamate homeostasis. Moreover, the dDBT mutation causes neuronal apoptosis during the developmental progression of larval brains. The genetic and functional evidence generated by in vivo depletion of dDBT expression in the eye indicates severe impairment of retinal rhabdomeres. Further, the dDBT mutant shows elevated oxidative stress and higher lipid peroxidation accumulation in the larval brain. Therefore, we conclude from in vivo evidence that the loss of dDBT results in oxidative brain damage that may lead to neuronal cell death and contribute to aspects of MSUD pathology. Importantly, when the dDBT mutants were administrated with Metformin, the aberrances in BCAA levels and motor behavior were ameliorated. This intriguing outcome strongly merits the use of the dDBT mutant as a platform for developing MSUD therapies.This article has an associated First Person interview with the joint first authors of the paper.
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Affiliation(s)
- Hui-Ying Tsai
- Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zhunan, Miaoli 35053, Taiwan
- Institute of Molecular and Cellular Biology, National Taiwan University, Taipei 10090, Taiwan
- National Mosquito-Borne Diseases Control Research Center, National Health Research Institutes, Zhunan, Miaoli 35053, Taiwan
| | - Shih-Cheng Wu
- National Mosquito-Borne Diseases Control Research Center, National Health Research Institutes, Zhunan, Miaoli 35053, Taiwan
| | - Jian-Chiuan Li
- Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zhunan, Miaoli 35053, Taiwan
| | - Yu-Min Chen
- Institute of Molecular and Cellular Biology, National Taiwan University, Taipei 10090, Taiwan
- National Mosquito-Borne Diseases Control Research Center, National Health Research Institutes, Zhunan, Miaoli 35053, Taiwan
| | - Chih-Chiang Chan
- Graduate Institute of physiology, National Taiwan University College of Medicine, Taipei 10051, Taiwan
| | - Chun-Hong Chen
- Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zhunan, Miaoli 35053, Taiwan
- Institute of Molecular and Cellular Biology, National Taiwan University, Taipei 10090, Taiwan
- National Mosquito-Borne Diseases Control Research Center, National Health Research Institutes, Zhunan, Miaoli 35053, Taiwan
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Strauss KA, Ahlfors CE, Soltys K, Mazareigos GV, Young M, Bowser LE, Fox MD, Squires JE, McKiernan P, Brigatti KW, Puffenberger EG, Carson VJ, Vreman HJ. Crigler-Najjar Syndrome Type 1: Pathophysiology, Natural History, and Therapeutic Frontier. Hepatology 2020; 71:1923-1939. [PMID: 31553814 PMCID: PMC7909716 DOI: 10.1002/hep.30959] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 09/04/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS We describe the pathophysiology, treatment, and outcome of Crigler-Najjar type 1 syndrome (CN1) in 28 UGT1A1 c.222C>A homozygotes followed for 520 aggregate patient-years. APPROACH AND RESULTS Unbound ("free") bilirubin (Bf ) was measured in patient sera to characterize the binding of unconjugated bilirubin (BT ) to albumin (A) and validate their molar concentration ratio (BT /A) as an index of neurological risk. Two custom phototherapy systems were constructed from affordable materials to provide high irradiance in the outpatient setting; light dose was titrated to keep BT /A at least 30% below intravascular BT binding capacity (i.e., BT /A = 1.0). Categorical clinical outcomes were ascertained by chart review, and a measure (Lf ) was used to quantify liver fibrosis. Unbound bilirubin had a nonlinear relationship to BT (R2 = 0.71) and BT /A (R2 = 0.76), and Bf as a percentage of BT correlated inversely to the bilirubin-albumin equilibrium association binding constant (R2 = 0.69), which varied 10-fold among individuals. In newborns with CN1, unconjugated bilirubin increased 4.3 ± 1.1 mg/dL per day. Four (14%) neonates developed kernicterus between days 14 and 45 postnatal days of life; peak BT ≥ 30 mg/dL and BT /A ≥ 1.0 mol:mol were equally predictive of perinatal brain injury (sensitivity 100%, specificity 93.3%, positive predictive value 88.0%), and starting phototherapy after age 13 days increased this risk 3.5-fold. Consistent phototherapy with 33-103 µW/cm2 •nm for 9.2 ± 1.1 hours/day kept BT and BT /A within safe limits throughout childhood, but BT increased 0.46 mg/dL per year to reach dangerous concentrations by 18 years of age. Liver transplantation (n = 17) normalized BT and eliminated phototherapy dependence. Liver explants showed fibrosis ranging from mild to severe. CONCLUSION Seven decades after its discovery, CN1 remains a morbid and potentially fatal disorder.
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Affiliation(s)
- Kevin A. Strauss
- Clinic for Special Children, Strasburg, PA,Penn-Lancaster General Hospital, Lancaster, PA,Departments of Pediatrics and Molecular, Cell & Cancer Biology, University of Massachusetts School of Medicine, Worcester, MA
| | - Charles E. Ahlfors
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Kyle Soltys
- Department of Surgery, Division of Pediatric Transplantation, Hillman Center for Pediatric Transplantation, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - George V. Mazareigos
- Department of Surgery, Division of Pediatric Transplantation, Hillman Center for Pediatric Transplantation, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | | | | | - Michael D. Fox
- Clinic for Special Children, Strasburg, PA,Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA,Diagnostic Referral Division, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - James E. Squires
- Division of Gastroenterology and Hepatology, Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Patrick McKiernan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, UPMC Children’s Hospital of Pittsburgh and Pittsburgh Liver Research Center, Pittsburgh, PA
| | | | | | | | - Hendrik J. Vreman
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
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Marques HP, Barros I, Li J, Murad SD, di Benedetto F. Current update in domino liver transplantation. Int J Surg 2020; 82S:163-8. [PMID: 32244002 DOI: 10.1016/j.ijsu.2020.03.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 03/09/2020] [Accepted: 03/12/2020] [Indexed: 12/14/2022]
Abstract
Orthotopic liver transplantation is an established treatment for end stage liver diseases as well as for some severe metabolic disorders. With increasing number of patients on the waiting list and the ongoing shortage of livers available, domino liver transplantation (DLT) became an option to further expand the organ donor pool. DLT utilizes the explanted liver of one liver transplant recipient as a donor graft in another patient. Despite being a surgically, and logistically demanding procedure, excellent results could be achieved in experienced high-volume transplant centers. In this review we present the current world status of DLT.
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40
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Strauss KA, Carson VJ, Soltys K, Young ME, Bowser LE, Puffenberger EG, Brigatti KW, Williams KB, Robinson DL, Hendrickson C, Beiler K, Taylor CM, Haas-Givler B, Chopko S, Hailey J, Muelly ER, Shellmer DA, Radcliff Z, Rodrigues A, Loeven K, Heaps AD, Mazariegos GV, Morton DH. Branched-chain α-ketoacid dehydrogenase deficiency (maple syrup urine disease): Treatment, biomarkers, and outcomes. Mol Genet Metab 2020; 129:193-206. [PMID: 31980395 DOI: 10.1016/j.ymgme.2020.01.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 01/11/2020] [Accepted: 01/13/2020] [Indexed: 12/26/2022]
Abstract
Over the past three decades, we studied 184 individuals with 174 different molecular variants of branched-chain α-ketoacid dehydrogenase activity, and here delineate essential clinical and biochemical aspects of the maple syrup urine disease (MSUD) phenotype. We collected data about treatment, survival, hospitalization, metabolic control, and liver transplantation from patients with classic (i.e., severe; n = 176), intermediate (n = 6) and intermittent (n = 2) forms of MSUD. A total of 13,589 amino acid profiles were used to analyze leucine tolerance, amino acid homeostasis, estimated cerebral amino acid uptake, quantitative responses to anabolic therapy, and metabolic control after liver transplantation. Standard instruments were used to measure neuropsychiatric outcomes. Despite advances in clinical care, classic MSUD remains a morbid and potentially fatal disorder. Stringent dietary therapy maintains metabolic variables within acceptable limits but is challenging to implement, fails to restore appropriate concentration relationships among circulating amino acids, and does not fully prevent cognitive and psychiatric disabilities. Liver transplantation eliminates the need for a prescription diet and safeguards patients from life-threatening metabolic crises, but is associated with predictable morbidities and does not reverse pre-existing neurological sequelae. There is a critical unmet need for safe and effective disease-modifying therapies for MSUD which can be implemented early in life. The biochemistry and physiology of MSUD and its response to liver transplantation afford key insights into the design of new therapies based on gene replacement or editing.
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Affiliation(s)
- Kevin A Strauss
- Clinic for Special Children, Strasburg, PA, USA; Department of Pediatrics, Penn Medicine-Lancaster General Hospital, Lancaster, PA, USA; Departments of Pediatrics and Molecular, Cell & Cancer Biology, University of Massachusetts School of Medicine, Worcester, MA, USA.
| | - Vincent J Carson
- Clinic for Special Children, Strasburg, PA, USA; Department of Pediatrics, Penn Medicine-Lancaster General Hospital, Lancaster, PA, USA
| | - Kyle Soltys
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | | | | | | | | | | | | | | | | | - Cora M Taylor
- Geisinger Autism & Developmental Medicine Institute, Lewisburg, PA, USA
| | | | - Stephanie Chopko
- Department of Pediatrics, Nemours Alfred I. duPont Hospital for Children, Wilmington, DE, USA; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Emilie R Muelly
- Department of Internal Medicine, The Permanente Medical Group, Santa Clara, CA, USA
| | - Diana A Shellmer
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Zachary Radcliff
- Department of Pediatrics, Nemours Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | | | | | | | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - D Holmes Morton
- Clinic for Special Children, Strasburg, PA, USA; Department of Pediatrics, Penn Medicine-Lancaster General Hospital, Lancaster, PA, USA; Central Pennsylvania Clinic, Belleville, PA, USA
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41
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Jain-Ghai S, Joffe AR, Bond GY, Siriwardena K, Chan A, Yap JYK, Hajihosseini M, Dinu IA, Acton BV, Robertson CMT. Pre-school neurocognitive and functional outcomes after liver transplant in children with early onset urea cycle disorders, maple syrup urine disease, and propionic acidemia: An inception cohort matched-comparison study. JIMD Rep 2020; 52:43-54. [PMID: 32154059 PMCID: PMC7052695 DOI: 10.1002/jmd2.12095] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 12/20/2019] [Accepted: 01/07/2020] [Indexed: 12/23/2022] Open
Abstract
Background Urea cycle disorders (UCD) and organic acid disorders classically present in the neonatal period. In those who survive, developmental delay is common with continued risk of regression. Liver transplantation improves the biochemical abnormality and patient survival is good. We report the neurocognitive and functional outcomes post‐transplant for nine UCD, three maple syrup urine disease, and one propionic acidemia patient. Methods Thirteen inborn errors of metabolism (IEM) patients were individually one‐to‐two matched to 26 non‐IEM patients. All patients received liver transplant. Wilcoxon rank sum test was used to compare full‐scale intelligence‐quotient (FSIQ) and Adaptive Behavior Assessment System‐II General Adaptive Composite (GAC) at age 4.5 years. Dichotomous outcomes were reported as percentages. Results FSIQ and GAC median [IQR] was 75 [54, 82.5] and 62.0 [47.5, 83] in IEM compared with 94.5 [79.8, 103.5] and 88.0 [74.3, 97.5] in matched patients (P‐value <.001), respectively. Of IEM patients, 6 (46%) had intellectual disability (FSIQ and GAC <70), 5 (39%) had autism spectrum disorder, and 1/13 (8%) had cerebral palsy, compared to 1/26 (4%), 0, 0, and 0% of matched patients, respectively. In the subgroup of nine with UCDs, FSIQ (64[54, 79]), and GAC (56[45, 75]) were lower than matched patients (100.5 [98.5, 101] and 95 [86.5, 99.5]), P = .005 and .003, respectively. Conclusion This study evaluated FSIQ and GAC at age 4.5 years through a case‐comparison between IEM and matched non‐IEM patients post‐liver transplantation. The neurocognitive and functional outcomes remained poor in IEM patients, particularly in UCD. This information should be included when counselling parents regarding post‐transplant outcome.
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Affiliation(s)
- Shailly Jain-Ghai
- Department of Medical Genetics University of Alberta Edmonton Alberta Canada
| | - Ari R Joffe
- Department of Pediatrics University of Alberta Edmonton Alberta Canada
| | - Gwen Y Bond
- Department of Pediatrics Glenrose Rehabilitation Hospital Edmonton Alberta Canada
| | - Komudi Siriwardena
- Department of Medical Genetics University of Alberta Edmonton Alberta Canada
| | - Alicia Chan
- Department of Medical Genetics University of Alberta Edmonton Alberta Canada
| | - Jason Y K Yap
- University of Melbourne The Royal Children's Hospital Melbourne Australia
| | - Morteza Hajihosseini
- School of Public Health (Biostatistics) University of Alberta Edmonton Alberta Canada
| | - Irina A Dinu
- School of Public Health (Biostatistics) University of Alberta Edmonton Alberta Canada
| | - Bryan V Acton
- Department of Psychology University of Saskatchewan Saskatoon Saskatchewan Canada
| | - Charlene M T Robertson
- Department of Pediatrics University of Alberta Edmonton Alberta Canada.,Department of Pediatrics Glenrose Rehabilitation Hospital Edmonton Alberta Canada
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Affiliation(s)
- James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
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Celik N, Kelly B, Soltys K, Squires JE, Vockley J, Shellmer DA, Strauss K, McKiernan P, Ganoza A, Sindhi R, Bond G, Mazariegos G, Khanna A. Technique and outcome of domino liver transplantation from patients with maple syrup urine disease: Expanding the donor pool for live donor liver transplantation. Clin Transplant 2019; 33:e13721. [PMID: 31556146 DOI: 10.1111/ctr.13721] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/22/2019] [Accepted: 08/31/2019] [Indexed: 01/26/2023]
Abstract
AIM/BACKGROUND Domino liver transplantation (DLT) using liver allografts from patients with metabolic disorders enhances organ utilization. Short- and long-term course and outcome of these patients can impact the decision to offer this procedure to patients, especially those with diseases that can potentially be cured with liver transplant. We reviewed the outcomes of DLT from maple syrup urine disease (MSUD) patients in our large academic pediatric and adult transplant program. METHODS All patients receiving DLT were analyzed retrospectively with a minimum of one-year follow-up period for patient and donor characteristics, early and late postoperative complications and patient and graft survival with their MSUD donors in terms of age, weight, MELD/PELD scores, cold ischemia time, postoperative leucine levels, and peak ALT (alanine aminotransferase) levels during the first 48 postoperative hours. RESULTS Between 2006 and May 2019, 21 patients underwent domino liver transplantation with live donor allografts from MSUD patients. Four patients transplanted for different metabolic diseases are focus of a separate report. Seventeen patients with minimum one-year follow-up period are reported herein. The indications were primary sclerosing cholangitis (PSC, n = 4), congenital hepatic fibrosis (CHF, n = 2), alpha-1 antitrypsin deficiency (A-1 ATD, n = 2), progressive familial intrahepatic cholestasis (PFIC, n = 2), cystic fibrosis (n = 1), primary biliary cirrhosis (PBC, n = 1), neonatal hepatitis (n = 1), embryonal sarcoma (n = 1), Caroli disease (n = 1), hepatocellular carcinoma (HCC, n = 1), and chronic rejection after liver transplantations for PSC (n = 1). All patients and grafts survived at median follow-up of 6.4 years (range 1.2-12.9 years). Median domino recipient age was 16.2 years (range 0.6-64.6 years) and median MSUD recipient age was 17.6 years (range 4.8-32.1 years). There were no vascular complications during the early postoperative period, one patient had portal vein thrombosis 3 years after DLT and a meso-Rex bypass was successfully performed. Small for size syndrome (SFSS) occurred in reduced left lobe DLT recipient and was managed successfully with conservative management. Biliary stricture developed in 2 patients and was resolved by stenting. Comparison between DLT and MSUD recipients' peak postoperative ALT results and PELD/MELD scores showed lower levels in DLT group (P-value <.05). CONCLUSIONS Patient and graft survival in DLT from MSUD donors was excellent at short- and long-term follow-up. Metabolic functions have been normal in all recipients on a normal unrestricted protein diet. Ischemia preservation injury based on peak ALT was significantly decreased in DLT recipients. Domino transplantation from pediatric and adult recipients with selected metabolic diseases should be increasingly considered as an excellent option and alternative to deceased donor transplantation, thereby expanding the living donor pool. This, to date, is the largest world experience in DLT utilizing livers from patients with MSUD.
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Affiliation(s)
- Neslihan Celik
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Thomas E. Starzl Transplant Institute, Pittsburgh, PA, USA
| | - Beau Kelly
- DCI Donor Services Inc, Sacramento, CA, USA
| | - Kyle Soltys
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Thomas E. Starzl Transplant Institute, Pittsburgh, PA, USA
| | - James E Squires
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Thomas E. Starzl Transplant Institute, Pittsburgh, PA, USA
| | - Jerry Vockley
- Center for Rare Disease Therapy, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Diana A Shellmer
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Thomas E. Starzl Transplant Institute, Pittsburgh, PA, USA
| | - Kevin Strauss
- Pediatric Hepatology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.,Clinic for Special Children, Strasburg, PA, USA
| | - Patrick McKiernan
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Thomas E. Starzl Transplant Institute, Pittsburgh, PA, USA
| | - Armando Ganoza
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Thomas E. Starzl Transplant Institute, Pittsburgh, PA, USA
| | - Rakesh Sindhi
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Thomas E. Starzl Transplant Institute, Pittsburgh, PA, USA
| | - Geoffrey Bond
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Thomas E. Starzl Transplant Institute, Pittsburgh, PA, USA
| | - George Mazariegos
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Thomas E. Starzl Transplant Institute, Pittsburgh, PA, USA
| | - Ajai Khanna
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Thomas E. Starzl Transplant Institute, Pittsburgh, PA, USA
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Conti F, Mochel F, Calmus Y. Domino liver transplantation: the risk of disease recurrence. Clin Res Hepatol Gastroenterol 2019; 43:510-2. [PMID: 30773354 DOI: 10.1016/j.clinre.2019.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 01/21/2019] [Indexed: 02/04/2023]
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Roda KMO, Vincenzi R, Fonseca EA, Benavides M, Turine P, Afonso RC, Tonon T, Schwartz I, Miura IK, Pugliese R, Porta G, Chapchap P, Seda Neto J. Domino Liver Transplant in Maple Syrup Urine Disease: Technical Details of Cases in Which the First Surgery Involved a Living Donor. Transplantation 2019; 103:536-43. [PMID: 29847508 DOI: 10.1097/TP.0000000000002300] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Data describing the technical aspects of living donor (LD) domino liver transplantation (DLT) in maple syrup urine disease (MSUD) are limited. The largest published series includes only 3 cases. One great challenge of this procedure is to ensure adequate vascular stumps for the LD, the MSUD patient, and the recipient of the domino graft. Here, we describe our experience in 11 cases of LD-DLT in MSUD, highlighting the technical aspects of LD-DLT. METHODS From September 2012 to September 2017, 11 patients with MSUD underwent LD liver transplantation at our institution, and MSUD livers were used as domino grafts in 11 children. RESULTS (1) MSUD patients: 10 patients received a left lateral segment. The donor's left hepatic vein (HV) was anastomosed to the confluence of the recipient's 3 HVs. No vascular grafts (VG) were required for portal vein (PV) anastomosis. Single arterial anastomosis was performed with microsurgery in 10 of 11 patients. (2) MSUD graft recipients: In 8 cases, HV reconstruction was performed between the graft's HV confluence and the recipient's HV confluence, and in 3 cases, a vena cava triangulation was necessary; 6 MSUD grafts required HV venoplasty. No VG were needed for HV reconstruction. VG were used for PV reconstruction in 3 cases due to sclerotic PV. In 2 cases, double arterial anastomoses were performed in the MSUD liver. All patients remain alive and well. CONCLUSIONS Living donor liver transplantation followed by DLT for MSUD is a complex procedure and demands technical refinement. Special attention must be paid to vascular reconstruction.
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Porta F, Romagnoli R, Busso M, Tandoi F, Spada M. Differential Intraoperative Effect of Liver Transplant in Different Inborn Errors of Metabolism. J Pediatr Gastroenterol Nutr 2019; 69:160-2. [PMID: 30964822 DOI: 10.1097/MPG.0000000000002354] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Liver transplant (LT) is a therapeutic option for a growing number of inborn errors of metabolism (IEM), including some disorders not confined to the liver. Clinical advantages of LT in maple syrup urine disease (MSUD), methylmalonic acidemia (MMA), and argininosuccinic aciduria (ASA) have been reported. However, no information on the early metabolic effect of LT after portal reperfusion is available in these disorders. Here we describe the intraoperative differential metabolic outcome of LT in MSUD, MMA, and ASA. In these IEM, LT promptly cleared toxic metabolites to safe concentrations. In MSUD, leucine concentration reached physiological concentration within 12 hours after portal reperfusion. In MMA and ASA, LT allowed faster clearance of methylmalonate and argininosuccinate, respectively, both dropping by ∼90% within the first hour after portal reperfusion. The early biochemical benefits of LT in MSUD, MMA, and ASA demonstrate its immediate effectiveness in protecting patients from intercurrent metabolic decompensations.
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Celik N, Squires JE, Soltys K, Vockley J, Shellmer DA, Chang W, Strauss K, McKiernan P, Ganoza A, Sindhi R, Bond G, Mazariegos G, Khanna A. Domino liver transplantation for select metabolic disorders: Expanding the living donor pool. JIMD Rep 2019; 48:83-89. [PMID: 31392117 PMCID: PMC6606984 DOI: 10.1002/jmd2.12053] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 05/17/2019] [Accepted: 05/21/2019] [Indexed: 01/20/2023] Open
Abstract
Domino liver transplantation (DLT) involves transplanting liver from a patient with metabolic disease into a patient with end-stage liver disease with the expectation that the recipient will not develop the metabolic syndrome or the recurrent syndrome will have minimal affect. The domino donor gets a deceased donor or a segment of live-donor liver through the deceased donor organ allocation system. Waitlist mortality for the domino recipient exceeds morbidity associated with getting the donor disease. Between 2015 and 2017, four patients with three metabolic disorders at UPMC Children's Hospital of Pittsburgh underwent DLT with domino allografts from maple syrup urine disease (MSUD) patients. These included patients with propionic acidemia (PA) (n = 1), Crigler-Najjar (CN) syndrome type-1 (n = 2), and carbamoyl phosphate synthetase deficiency (CPSD) (n = 1). Mean follow-up was 1.6 years (range 1.1-2.1 years). Total bilirubin levels normalized postoperatively in both CN patients and they maintain normal allograft function. The PA patient had normal to minimal elevations of isoleucine and leucine, and no other abnormalities on low protein diet supplemented with a low methionine and valine free formula. No metabolic crises have occurred. The patient with CPSD takes normal baby food. No elevation in ammonia levels have been observed in any of the patients. DLT for a select group of metabolic diseases alleviated the recipients of their metabolic defect with minimal evidence of transferrable-branched chain amino acid elevations or clinical MSUD despite increased protein intake. DLT using allografts with MSUD expands the live donor liver pool and should be considered for select metabolic diseases that may have a different enzymatic deficiency.
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Affiliation(s)
- Neslihan Celik
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMCThomas E. Starzl Transplantation Institute, University of Pittsburgh School of MedicinePittsburghPennsylvania
| | - James E. Squires
- Pediatric HepatologyChildren's Hospital of Pittsburgh of UPMCPittsburghPennsylvania
| | - Kyle Soltys
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMCThomas E. Starzl Transplantation Institute, University of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Jerry Vockley
- Division of Medical GeneticsUniversity of Pittsburgh School of Medicine, Center for Rare Disease Therapy, Children's Hospital of Pittsburgh of UPMCPittsburghPennsylvania
| | - Diana A. Shellmer
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMCThomas E. Starzl Transplantation Institute, University of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Wonbae Chang
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMCThomas E. Starzl Transplantation Institute, University of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Kevin Strauss
- Division of Medical GeneticsUniversity of Pittsburgh School of Medicine, Center for Rare Disease Therapy, Children's Hospital of Pittsburgh of UPMCPittsburghPennsylvania
| | - Patrick McKiernan
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMCThomas E. Starzl Transplantation Institute, University of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Armando Ganoza
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMCThomas E. Starzl Transplantation Institute, University of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Rakesh Sindhi
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMCThomas E. Starzl Transplantation Institute, University of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Geoffrey Bond
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMCThomas E. Starzl Transplantation Institute, University of Pittsburgh School of MedicinePittsburghPennsylvania
| | - George Mazariegos
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMCThomas E. Starzl Transplantation Institute, University of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Ajai Khanna
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMCThomas E. Starzl Transplantation Institute, University of Pittsburgh School of MedicinePittsburghPennsylvania
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Castells AA, Gueraldi D, Balada R, Tristán-Noguero A, Cortès-Saladelafont E, Ramos F, Meavilla S, De Los Santos M, Garcia-Volpe C, Colomé R, Couce ML, Sierra C, Ormazábal A, Batllori M, Artuch R, Armstrong J, Alcántara S, Garcia-Cazorla À. Discovery of Biomarker Panels for Neural Dysfunction in Inborn Errors of Amino Acid Metabolism. Sci Rep 2019; 9:9128. [PMID: 31235756 DOI: 10.1038/s41598-019-45674-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 06/07/2019] [Indexed: 12/11/2022] Open
Abstract
Patients with inborn errors of amino acid metabolism frequently show neuropsychiatric symptoms despite accurate metabolic control. This study aimed to gain insight into the underlying mechanisms of neural dysfunction. Here we analyzed the expression of brain-derived neurotrophic factor (BDNF) and 10 genes required for correct brain functioning in plasma and blood of patients with Urea Cycle Disorders (UCD), Maple Syrup Urine Disease (MSUD) and controls. Receiver-operating characteristic (ROC) analysis was used to evaluate sensitivity and specificity of potential biomarkers. CACNA2D2 (α2δ2 subunit of voltage-gated calcium channels) and MECP2 (methyl-CpG binding protein 2) mRNA and protein showed an excellent neural function biomarker signature (AUC ≥ 0,925) for recognition of MSUD. THBS3 (thrombospondin 3) mRNA and AABA gave a very good biomarker signature (AUC 0,911) for executive-attention deficits. THBS3, LIN28A mRNA, and alanine showed a perfect biomarker signature (AUC 1) for behavioral and mood disorders. Finally, a panel of BDNF protein and at least two large neural AAs showed a perfect biomarker signature (AUC 1) for recognition of psychomotor delay, pointing to excessive protein restriction as central causative of psychomotor delay. To conclude, our study has identified promising biomarker panels for neural function evaluation, providing a base for future studies with larger samples.
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Spada M, Angelico R, Dionisi-Vici C. Maple Syrup Urine Disease and Domino Liver Transplantation: When and How? Liver Transpl 2019; 25:827-828. [PMID: 31038782 DOI: 10.1002/lt.25481] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 04/25/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Marco Spada
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Roberta Angelico
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Carlo Dionisi-Vici
- Division of Metabolism, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
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Herden U, Grabhorn E, Santer R, Li J, Nadalin S, Rogiers X, Scherer MN, Braun F, Beime J, Lenhartz H, Muntau AC, Fischer L. Surgical Aspects of Liver Transplantation and Domino Liver Transplantation in Maple Syrup Urine Disease: Analysis of 15 Donor-Recipient Pairs. Liver Transpl 2019; 25:889-900. [PMID: 30712285 DOI: 10.1002/lt.25423] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 12/09/2018] [Indexed: 02/07/2023]
Abstract
Liver transplantation (LT) has been shown to be a feasible treatment in patients with severe forms of maple syrup urine disease (MSUD). Because of a sufficient extrahepatic enzyme activity in non-MSUD individuals, the organ of MSUD patients can be used as a domino graft. We performed a retrospective data collection of all LTs for MSUD carried out at the University Medical Center Hamburg-Eppendorf (2016-2018). Moreover, data from all consecutive domino LTs of the MSUD grafts either transplanted at our institution or allocated to other transplant centers were analyzed. During the study period, 15 LTs in MSUD patients were performed (12 children, 3 adults; median age, 10.9 years; range, 0.3-26.1 years). Biliary complications occurred in 20%, and 13.3% suffered from bleeding complications. No further surgical problems occurred. At present, all MSUD patients are alive with a well-functioning liver graft and on an unrestricted diet. In total, 14 consecutive domino LTs were performed. No surgical complications requiring intervention occurred. One patient died because of HCC relapse, and all other patients are alive with good liver graft function. In conclusion, the use of MSUD livers as domino grafts is safe and allows application of LT in MSUD patients without net extraction of a liver graft from the limited donor pool.
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Affiliation(s)
- Uta Herden
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Enke Grabhorn
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - René Santer
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jun Li
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Xavier Rogiers
- Department of Solid Organ Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Marcus N Scherer
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Felix Braun
- Department of General, Visceral, Thoracic, Transplantation and Pediatric Surgery, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Jan Beime
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henning Lenhartz
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ania C Muntau
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lutz Fischer
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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