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Uslu A, Çekmen N, Torgay A, Haberal M. Perioperative management in pediatric domino liver transplantation for metabolic disorders: A narrative review. Paediatr Anaesth 2024. [PMID: 38980227 DOI: 10.1111/pan.14967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 06/25/2024] [Accepted: 07/01/2024] [Indexed: 07/10/2024]
Abstract
Domino liver transplantation and domino-auxiliary partial orthotopic liver transplantation are emerging techniques that can expand the liver donor pool and provide hope for children with liver disease. The innovative technique of domino liver transplantation has emerged as a pioneering strategy, capitalizing on structurally preserved livers from donors exhibiting single enzymatic defects within a morphologically normal context, effectively broadening the donor pool. Concurrently, the increasingly prevalent domino-auxiliary partial orthotopic liver transplantation method assumes a critical role in bolstering available donor resources. These advanced transplantation methods present a unique opportunity for pediatric patients who, despite having structurally and functionally intact livers and lacking early signs of portal hypertension or extrahepatic involvement, do not attain priority on conventional transplant lists. Utilizing optimal clinical conditions enhances posttransplant outcomes, benefiting patients who would otherwise endure extended waiting periods for traditional transplantation. The perioperative management of children undergoing these procedures is complex and requires careful consideration of some factors, including clinical and metabolic conditions of the specific metabolic disorder, and the need for tailored perioperative management planning. Furthermore, the prudent consideration of de novo disease development in the recipient assumes paramount significance when selecting suitable donors for domino liver transplantation, as it profoundly influences prognosis, mortality, and morbidity. This narrative review of domino liver transplantation will discuss the pathophysiology, clinical evaluation, perioperative management, and prognostic expectations, focusing on perioperative anesthetic considerations for children undergoing domino liver transplantation.
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Affiliation(s)
- Ahmed Uslu
- Department of Surgical Sciences, Anesthesiology and Intensive Care Medicine, Başkent University, Ankara, Türkiye
| | - Nedim Çekmen
- Department of Surgical Sciences, Anesthesiology and Intensive Care Medicine, Başkent University, Ankara, Türkiye
| | - Adnan Torgay
- Department of Surgical Sciences, Anesthesiology and Intensive Care Medicine, Başkent University, Ankara, Türkiye
| | - Mehmet Haberal
- Department of Surgical Sciences, Organ and Tissue Transplantation Center, Başkent University, Ankara, Türkiye
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Hannah N, Vasic D, Kansal A, Al-Ani A, Hebbard G, Sood S. Serum ammonia does not guide management and is overutilised in patients with cirrhosis in hospital settings. Intern Med J 2023; 53:2057-2064. [PMID: 36891668 DOI: 10.1111/imj.16053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 02/12/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Hepatic encephalopathy is a confusional state associated with cirrhosis. Serum ammonia levels are neither sensitive nor specific for the diagnosis. AIMS We audited the ordering location and hospital unit whilst assessing the impact on management at a major Australian tertiary centre. METHODS We conducted a single-centre retrospective chart review of the ordering of serum ammonia levels between 1 March 2019 and 29 February 2020 at The Royal Melbourne Hospital, a tertiary-referral centre in Melbourne, Victoria. Demographic, medication and pathology results, including serum ammonia measurements, were collected. The main outcomes assessed were ordering location, sensitivity, specificity and impact on management. RESULTS A total of 1007 serum ammonia tests were ordered in 425 patients. Nearly all ammonia ordering was by non-gastroenterologists, 24.2% by the intensive care unit, 23.1% by general medicine and 19.5% by the emergency department (ED). Only 21.6% of patients had a history of cirrhosis, with hepatic encephalopathy diagnosed in 13.6%. On subgroup analysis, 217 ammonia tests were performed in 92 patients with cirrhosis. Cirrhotic patients were older (64 vs 59 years, P = 0.012) and had higher median ammonia levels (64.46 vs 59 μmol/L, P < 0.001) compared with non-cirrhotic patients. In cirrhotic patients, the sensitivity and specificity for serum ammonia and diagnosis of hepatic encephalopathy were 75% and 52.3% respectively. CONCLUSION We affirm the poor utility of serum ammonia levels for guiding management of hepatic encephalopathy within the Australian context. ED and general medical units account for the majority of test ordering within the hospital. Understanding where ordering occurs provides a target for targeted education.
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Affiliation(s)
- Nicholas Hannah
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Dubravka Vasic
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Abhik Kansal
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Aysha Al-Ani
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Geoff Hebbard
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Siddharth Sood
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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Phillips SM, Pouch SM, Lo DJ, Kandiah S, Lomashvili KA, Subramanian RA, Moran P, Killian A, Kandiah PA. A Case of "Cryptammonia": Disseminated Cryptococcal Infection Generating Profound Hyperammonemia in a Liver Transplant Recipient. J Investig Med High Impact Case Rep 2022; 10:23247096221129467. [PMID: 36214295 PMCID: PMC9549096 DOI: 10.1177/23247096221129467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Mycoplasma and Ureaplasma infections have been
described as a cause of hyperammonemia syndrome leading to devastating
neurological injury in the post-transplant period, most commonly in lung
transplant recipients. The occurrence of significant hyperammonemia caused by
other urease-producing organisms remains unclear. We describe a case of
disseminated cryptococcosis presenting with profound hyperammonemia in a
55-year-old orthotopic liver transplant recipient. Through a process of
elimination, other potential causes for hyperammonemia were excluded revealing a
probable association between hyperammonemia and disseminated cryptococcosis.
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Affiliation(s)
- Steven M. Phillips
- Emory University, Atlanta, GA,
USA,Steven M. Phillips, DO, University of
Nebraska Medical Center, 988440 Nebraska Medical Center, Omaha, NE 68198-8440,
USA.
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Kamel AY, Emtiazjoo AM, Adkins L, Shahmohammadi A, Alnuaimat H, Pelaez A, Machuca T, Pipkin M, Lee HW, Weiner ID, Chandrashekaran S. Hyperammonemia After Lung Transplantation: Systematic Review and a Mini Case Series. Transpl Int 2022; 35:10433. [PMID: 35620675 PMCID: PMC9128545 DOI: 10.3389/ti.2022.10433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 03/18/2022] [Indexed: 11/21/2022]
Abstract
Background: Hyperammonemia after lung transplantation (HALT) is a rare but serious complication with high mortality. This systematic review delineates possible etiologies of HALT and highlights successful strategies used to manage this fatal complication. Methods: Seven biomedical databases and grey literature sources were searched using keywords relevant to hyperammonemia and lung transplantation for publications between 1995 and 2020. Additionally, we retrospectively analyzed HALT cases managed at our institution between January 2016 and August 2018. Results: The systematic review resulted in 18 studies with 40 individual cases. The mean peak ammonia level was 769 μmol/L at a mean of 14.1 days post-transplant. The mortality due to HALT was 57.5%. In our cohort of 120 lung transplants performed, four cases of HALT were identified. The mean peak ammonia level was 180.5 μmol/L at a mean of 11 days after transplantation. HALT in all four patients was successfully treated using a multimodal approach with an overall mortality of 25%. Conclusion: The incidence of HALT (3.3%) in our institution is comparable to prior reports. Nonetheless, ammonia levels in our cohort were not as high as previously reported and peaked earlier. We attributed these significant differences to early recognition and prompt institution of multimodal treatment approach.
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Affiliation(s)
- Amir Y. Kamel
- Department of Pharmacy, UF Health Shands Hospital, College of Pharmacy, University of Florida, Gainesville, FL, United States
- *Correspondence: Amir Y. Kamel,
| | - Amir M. Emtiazjoo
- Division of Pulmonary, Critical Care and Sleep Medicine, UF Lung Transplant Program, College of Medicine, University of Florida Health Hospital, Gainesville, FL, United States
| | - Lauren Adkins
- College of Pharmacy Liaison Librarian, Health Science Center Libraries, Gainesville, FL, United States
| | - Abbas Shahmohammadi
- Division of Pulmonary, Critical Care and Sleep Medicine, UF Lung Transplant Program, College of Medicine, University of Florida Health Hospital, Gainesville, FL, United States
| | - Hassan Alnuaimat
- Division of Pulmonary, Critical Care and Sleep Medicine, UF Lung Transplant Program, College of Medicine, University of Florida Health Hospital, Gainesville, FL, United States
| | - Andres Pelaez
- Division of Pulmonary, Critical Care and Sleep Medicine, UF Lung Transplant Program, College of Medicine, University of Florida Health Hospital, Gainesville, FL, United States
| | - Tiago Machuca
- Division of Cardiothoracic Surgery, UF Lung Transplant Program, University of Florida Health Hospital, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Mauricio Pipkin
- Division of Cardiothoracic Surgery, UF Lung Transplant Program, University of Florida Health Hospital, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Hyun-wook Lee
- Division of Nephrology, Hypertension and Renal Transplantation, College of Medicine, University of Florida, Gainesville, FL, United States
| | - I. David Weiner
- Division of Nephrology, Hypertension and Renal Transplantation, College of Medicine, University of Florida, Gainesville, FL, United States
- North Florida/South Georgia Veterans Health System, Gainesville, FL, United States
| | - Satish Chandrashekaran
- Division of Pulmonary, Critical Care and Sleep Medicine, UF Lung Transplant Program, College of Medicine, University of Florida Health Hospital, Gainesville, FL, United States
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Successful living donor liver transplantation plus domino-auxiliary partial orthotopic liver transplantation for pediatric patients with metabolic disorders. Pediatr Surg Int 2020; 36:1443-1450. [PMID: 33040172 DOI: 10.1007/s00383-020-04756-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE To investigate the efficacy of living donor liver transplantation (LDLT) plus domino-auxiliary partial orthotopic liver transplantation (D-APOLT) in pediatric patients with metabolic disorders. METHODS From May 2017 to October 2018, two patients with ornithine aminotransferase deficiency (OTCD) and one patient with type I Crigler-Najjar syndrome (CNS1) received LDLT, their livers were prepared as donors for D-APOLT. Two patients with CNS1 received domino liver grafts from OTCD patients; one OTCD patient received a domino liver graft from a CNS1 patient. RESULTS The mean follow-up was 26.6 months. The liver function and ammonia remained in the normal range at the end of the follow-up in all recipients. One D-APOLT patient experienced portal vein thrombosis 2 days after transplantation and required reoperation, this patient presented an imbalance of portal blood perfusion between the native and the domino liver at 8 months after liver transplant. The imbalance was improved by interventional radiology treatment. Two LDLT patients experienced early mild acute rejection. CONCLUSIONS The non-cirrhotic livers from pediatric patients with metabolic liver disease can be used as domino donor grafts for selected pediatric patients with different metabolic liver disease. D-APOLT achieves ideal recipient outcomes and provides a strategy to expand donor source for children.
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Lee CH, Ellaway C, Shun A, Thomas G, Nair P, O'Neill J, Shakel N, Stormon MO. Split-graft liver transplantation from an adult donor with an unrecognized UCD to a pediatric and adult recipient. Pediatr Transplant 2018; 22. [PMID: 29044911 DOI: 10.1111/petr.13073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2017] [Indexed: 12/01/2022]
Abstract
We report the outcomes of an adult and pediatric split liver transplant from an adult male donor who died due to an unrecognized UCD, OTC deficiency. Recognizing inborn errors of metabolism can be challenging, especially in adult centers where such disorders are rarely encountered. Shortage of donors for liver transplantation has led to procedures to maximize donor utilization, such as split and live donor grafts. The cause of death should be ascertained before accepting a cadaveric donor organ.
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Affiliation(s)
- C H Lee
- Department of Gastroenterology and Hepatology, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - C Ellaway
- Genetic Metabolic Disorders Service, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - A Shun
- Department of Surgery, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - G Thomas
- Department of Surgery, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - P Nair
- Intensive Care Unit, St Vincent's Hospital, Sydney, NSW, Australia
| | - J O'Neill
- Department of Neurology, St Vincent's Hospital, Sydney, NSW, Australia
| | - N Shakel
- Department of Gastroenterology and Hepatology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - M O Stormon
- Department of Gastroenterology and Hepatology, The Children's Hospital at Westmead, Westmead, NSW, Australia
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Schielke A, Conti F, Goumard C, Perdigao F, Calmus Y, Scatton O. Liver transplantation using grafts with rare metabolic disorders. Dig Liver Dis 2015; 47:261-70. [PMID: 25498135 DOI: 10.1016/j.dld.2014.11.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 10/26/2014] [Accepted: 11/06/2014] [Indexed: 12/11/2022]
Abstract
Metabolic diseases that involve the liver represent a heterogeneous group of disorders. Apart from the metabolic defect, the subject's liver functions may be normal. With the increasing need for organs, livers from donors with metabolic diseases other than familial amyloid polyneuropathy might be possibly used for transplantation. However, whether such livers qualify as grafts and how they might impact recipient outcome are still unanswered questions. This review of the literature summarizes current experience in the use of such grafts in the context of cadaveric, domino, and living-related liver transplantation.
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Affiliation(s)
- Astrid Schielke
- AP-HP, Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital La Pitié - Salpêtrière, Paris, France.
| | - Filomena Conti
- AP-HP, Department of Hepatogastroenterology, Hôpital La Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France; Université Pierre et Marie Curie, 4 Place Jussieu, Paris, France.
| | - Claire Goumard
- AP-HP, Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital La Pitié - Salpêtrière, Paris, France.
| | - Fabiano Perdigao
- AP-HP, Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital La Pitié - Salpêtrière, Paris, France.
| | - Yvon Calmus
- AP-HP, Department of Hepatogastroenterology, Hôpital La Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France; Université Pierre et Marie Curie, 4 Place Jussieu, Paris, France.
| | - Olivier Scatton
- AP-HP, Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital La Pitié - Salpêtrière, Paris, France; Université Pierre et Marie Curie, 4 Place Jussieu, Paris, France.
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Živković SA. Neurologic complications after liver transplantation. World J Hepatol 2013; 5:409-416. [PMID: 24023979 PMCID: PMC3767839 DOI: 10.4254/wjh.v5.i8.409] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 06/21/2013] [Accepted: 07/13/2013] [Indexed: 02/06/2023] Open
Abstract
Neurologic complications are relatively common after solid organ transplantation and affect 15%-30% of liver transplant recipients. Etiology is often related to immunosuppressant neurotoxicity and opportunistic infections. Most common complications include seizures and encephalopathy, and occurrence of central pontine myelinolysis is relatively specific for liver transplant recipients. Delayed allograft function may precipitate hepatic encephalopathy and neurotoxicity of calcineurin inhibitors typically manifests with tremor, headaches and encephalopathy. Reduction of neurotoxic immunosuppressants or conversion to an alternative medication usually result in clinical improvement. Standard preventive and diagnostic protocols have helped to reduce the prevalence of opportunistic central nervous system (CNS) infections, but viral and fungal CNS infections still affect 1% of liver transplant recipients, and the morbidity and mortality in the affected patients remain fairly high. Critical illness myopathy may also affect up to 7% of liver transplant recipients. Liver insufficiency is also associated with various neurologic disorders which may improve or resolve after successful liver transplantation. Accurate diagnosis and timely intervention are essential to improve outcomes, while advances in clinical management and extended post-transplant survival are increasingly shifting the focus to chronic post-transplant complications which are often encountered in a community hospital and an outpatient setting.
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Brown JH, Tellez J, Wilson V, Mackie IJ, Scully M, Tredger MM, Moore I, McDougall NI, Strain L, Marchbank KJ, Sheerin NS, O'Grady J, Harris CL, Goodship THJ. Postpartum aHUS secondary to a genetic abnormality in factor H acquired through liver transplantation. Am J Transplant 2012; 12:1632-6. [PMID: 22420623 DOI: 10.1111/j.1600-6143.2012.03991.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We report here a young female who underwent a successful deceased donor liver transplant for hepatic vein thrombosis. Five years after transplantation she developed postpartum atypical hemolytic uremic syndrome (aHUS). She did not recover renal function. Mutation screening of complement genes in her DNA did not show any abnormality. Mutation screening of DNA available from the donor showed a nonsense CFH mutation leading to factor H deficiency. Genotyping of the patient showed that she was homozygous for an aHUS CD46 at-risk haplotype. In this individual, the development of aHUS has been facilitated by the combination of a trigger (pregnancy), an acquired rare genetic variant (CFH mutation) and a common susceptibility factor (CD46 haplotype).
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Affiliation(s)
- J H Brown
- Renal Unit, Belfast City Hospital, Belfast Health and Social Care Trust, Belfast, United Kingdom
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Bercovitch L, Martin L, Chassaing N, Hefferon TW, Bessis D, Vanakker O, Terry SF. Acquired pseudoxanthoma elasticum presenting after liver transplantation. J Am Acad Dermatol 2011; 64:873-8. [PMID: 21397982 DOI: 10.1016/j.jaad.2010.03.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2009] [Revised: 03/25/2010] [Accepted: 03/30/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pseudoxanthoma elasticum (PXE) is thought to be a metabolic disorder resulting from mutations in the gene encoding the cellular transporter, ABCC6, which is primarily expressed in liver and kidney. We encountered 3 patients who developed clinical and histopathological evidence of PXE after liver transplantation, suggesting that PXE could have been acquired from the transplanted organ. OBJECTIVE We sought to delineate the clinical features and screen each patient and samples of donor liver for mutations in the ABCC6 gene. METHODS Each patient underwent full clinical examination, skin biopsy, and ophthalmologic examination, and whole genome sequencing using standard techniques. Fixed samples of donor liver tissue were available for mutation analysis in two patients and of donor kidney tissue in one. RESULTS All 3 patients had unequivocal clinical and histopathologic evidence of PXE. No patient (or family member available for screening) had evidence of mutations in ABCC6. Neither liver specimen nor the single available kidney specimen showed evidence of mutations in ABCC6. LIMITATIONS Liver tissue was not available from one patient and DNA was of poor quality in another, resulting in limited screening. Genetic testing does not detect ABCC6 mutations in 10% of patients with confirmed PXE. CONCLUSION Although we were unable to demonstrate ABCC6 mutations in limited screening of fixed donor livers, the absence of any PXE mutations in the affected patients, the timing of onset of PXE, and the known acquisition of other metabolic disorders and coagulopathies from donor livers suggest that PXE was likely acquired via liver transplantation.
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Affiliation(s)
- Lionel Bercovitch
- Department of Dermatology, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island 02903, USA.
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