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Ielasi L, Tonnini M, Piscaglia F, Serio I. Current guidelines for diagnosis and management of hepatic involvement in hereditary hemorrhagic teleangiectasia. World J Hepatol 2023; 15:675-687. [PMID: 37305373 PMCID: PMC10251273 DOI: 10.4254/wjh.v15.i5.675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/04/2023] [Accepted: 04/12/2023] [Indexed: 05/24/2023] Open
Abstract
Hereditary hemorrhagic teleangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, is the most common cause of hepatic vascular malformations in adults. Different vascular shunts (arteriovenous, arterioportal or portovenous) lead to different clinical manifestations. Even though no hepatic-related symptoms are reported in the majority of cases, the severity of liver disease could lead to refractory medical conditions, in some cases requiring liver transplantation. The aim of this manuscript is to provide an updated overview of the current evidence regarding the diagnosis and treatment of HHT liver involvement and liver-related complications.
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Affiliation(s)
- Luca Ielasi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
- Department of Internal Medicine, Ospedale per gli Infermi di Faenza, Faenza 48018, Italy
| | - Matteo Tonnini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Fabio Piscaglia
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Ilaria Serio
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
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Perioperative Complications and Long-Term Follow-Up of Liver Transplantation in Hemorrhagic Hereditary Telangiectasia: Report of Three Cases and Systematic Review. J Clin Med 2022; 11:jcm11195624. [PMID: 36233492 PMCID: PMC9573297 DOI: 10.3390/jcm11195624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/11/2022] [Accepted: 09/19/2022] [Indexed: 11/17/2022] Open
Abstract
The aim was to describe three patients with hemorrhagic hereditary telangiectasia (HHT) requiring liver transplantation (LT) and to perform a systematic review focusing on surgical complications and long-term follow-up. Unrestricted searches of the Medline and Embase databases were performed through February 2022. Forty-five studies were selected including 80 patients plus the three new reported patients, 68 (81.9%) were female and mean age was 50 (27–72) years. Main indications for LT were high-output cardiac failure (n = 40; 48.2%), ischemic cholangitis (n = 19; 22.9%), and a combination of both conditions (n = 13;15.6%). Mean cold ischemic time and red blood cell units transfused during LT were 554 (300–941) minutes and 11.4 (0–88) units, respectively. Complications within 30 days were described in 28 (33.7%) patients, mainly bleeding complications in 13 patients, hepatic artery (HA) thrombosis in four and hepatic vein thrombosis in one. Mean follow-up was 76.4 (1–288) months, and during it, four new patients developed thrombotic complications in HA, HA aneurysm, celiac artery, and the portal–splenic–mesenteric vein. HHT relapse in the transplant allograft was detected in 13 (17.1%) patients after 1–19 years (including two fatal recurrences). Overall mortality was 12%. In conclusion, previous assessment of HA anatomy and hyperdynamic circulatory state could reduce LT complications. The risk of relapse in the hepatic graft supports a multidisciplinary follow-up for HHT patients with LT.
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Dumortier J, Dupuis-Girod S, Valette PJ, Valent A, Guillaud O, Saurin JC, Hervieu V, Robinson P, Plauchu H, Paliard P, Boillot O, Scoazec JY. Recurrence of Hereditary Hemorrhagic Telangiectasia After Liver Transplantation: Clinical Implications and Physiopathological Insights. Hepatology 2019; 69:2232-2240. [PMID: 30549294 DOI: 10.1002/hep.30424] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 12/03/2018] [Indexed: 02/04/2023]
Abstract
Liver transplantation (LT) has been proposed as a curative treatment in hereditary hemorrhagic telangiectasia (HHT) with severe hepatic involvement. We provide a long-term evaluation of graft status after LT for HHT, with a focus on the risk of recurrence. The present study included all patients prospectively followed up after LT for HHT in the Lyon Liver Transplant Unit from 1993 to 2010, with a survival of more than 1 year. Protocol clinical, radiological, and histological examinations were performed at regular intervals. Fourteen patients were included (13 women and one man). Median age at LT was 52.5 years (range: 33.1-66.7). In eight patients (seven female), disease recurrence was diagnosed by abnormal radiological features, suggestive of microcirculatory disturbances. Typical vascular lesions, including telangiectasia, were demonstrated by liver biopsy in five of these patients. The median interval between LT and diagnosis of recurrence was 127 months (range: 74-184). The risk of recurrence increased over time; estimated cumulative risk was 47.9% at 15 years. Liver tissue analysis found the coexistence of an angiogenic process combined with endothelial microchimerism, as shown by the presence of vascular lining cells of recipient origin. Conclusion: The present data show that disease recurrence occurs, usually after a long delay, in a significant number of patients treated by LT for liver complications of HHT. This strongly supports the necessity of a lifelong follow-up and suggests that therapeutic strategy needs discussion and evaluation, especially of the role of potential adjuvant treatments to LT, such as antiangiogenic medications, when recurrent disease appears.
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Affiliation(s)
- Jérôme Dumortier
- Unité de Transplantation Hépatique, Hôpital Edouard Herriot, Hospices Civils de Lyon, and Université Claude Bernard Lyon 1, Lyon, France
| | - Sophie Dupuis-Girod
- Service de Génétique and Centre de Référence Pour la Maladie de Rendu-Osler, Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Bron, France
| | - Pierre-Jean Valette
- Service de Radiologie Digestive, Hôpital Edouard Herriot, Hospices Civils de Lyon, and Université Claude Bernard Lyon 1, Lyon, France
| | - Alexander Valent
- Département de Biologie et Pathologie Médicales, Service de Pathologie Moléculaire, Gustave Roussy Cancer Campus, Villejuif, France
| | - Olivier Guillaud
- Unité de Transplantation Hépatique, Hôpital Edouard Herriot, Hospices Civils de Lyon, and Université Claude Bernard Lyon 1, Lyon, France
| | - Jean-Christophe Saurin
- Service d'Hépato-gastroentérologie, Hospices Civils de Lyon, Hôpital Edouard Herriot, and Université Claude Bernard Lyon 1, Lyon, France
| | - Valérie Hervieu
- Service Central d'Anatomie et Cytologie Pathologiques, Hôpital Edouard Herriot, Hospices Civils de Lyon, and Université Claude Bernard Lyon 1, Lyon, France
| | - Philip Robinson
- Direction de la Recherche Clinique et de l'Innovation, Hospices Civils de Lyon, Lyon, France
| | - Henri Plauchu
- Service de Génétique and Centre de Référence Pour la Maladie de Rendu-Osler, Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Bron, France
| | - Pierre Paliard
- Service d'Hépato-gastroentérologie, Hospices Civils de Lyon, Hôpital Edouard Herriot, and Université Claude Bernard Lyon 1, Lyon, France
| | - Olivier Boillot
- Unité de Transplantation Hépatique, Hôpital Edouard Herriot, Hospices Civils de Lyon, and Université Claude Bernard Lyon 1, Lyon, France
| | - Jean-Yves Scoazec
- Département de Biologie et Pathologie Médicales, Service de Pathologie Moléculaire, Gustave Roussy Cancer Campus, Villejuif, France.,Service Central d'Anatomie et Cytologie Pathologiques, Hôpital Edouard Herriot, Hospices Civils de Lyon, and Université Claude Bernard Lyon 1, Lyon, France
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Shovlin CL, Buscarini E, Hughes JMB, Allison DJ, Jackson JE. Long-term outcomes of patients with pulmonary arteriovenous malformations considered for lung transplantation, compared with similarly hypoxaemic cohorts. BMJ Open Respir Res 2017; 4:e000198. [PMID: 29071074 PMCID: PMC5652477 DOI: 10.1136/bmjresp-2017-000198] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 05/03/2017] [Accepted: 05/18/2017] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Pulmonary arteriovenous malformations (PAVMs) may not be amenable to treatment by embolisation or surgical resection, and many patients are left with significant hypoxaemia. Lung transplantation has been undertaken. There is no guidance on selection criteria. METHODS To guide transplantation listing assessments, the outcomes of the six patients who had been considered for transplantation were compared with a similarly hypoxaemic patient group recruited prospectively between 2005 and 2016 at the same UK institution. RESULTS Six patients had been formally considered for lung transplantation purely for PAVMs. One underwent a single lung transplantation for diffuse PAVMs and died within 4 weeks of surgery. The other five were not transplanted, in four cases at the patients' request. Their current survival ranges from 16 to 27 (median 21) years post-transplant assessment. Of 444 consecutive patients with PAVMs recruited between 2005 and 2016, 42 were similarly hypoxaemic to the 'transplant-considered' cohort (SaO2 <86.5%). Hypoxaemic cohorts maintained arterial oxygen content (CaO2) through secondary erythrocytosis and higher haemoglobin. The 'transplant-considered' cohort had similar CaO2 to the hypoxaemic comparator group, but higher Medical Research Council (MRC) dyspnoea scores (p=0.023), higher rates of cerebral abscesses (p=0.0043) and higher rates of venous thromboemboli (p=0.0009) that were evident before and after the decision to list for transplantation. CONCLUSIONS The non-transplanted patients demonstrated marked longevity. Symptoms and comorbidities were better predictors of health than oxygen measurements. While a case-by-case decision, weighing survival estimates and quality of life will help patients in their decision making, the data suggest a very strong case must be made before lung transplantation is considered.
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Affiliation(s)
- Claire L Shovlin
- NHLI Vascular Science, Imperial College London, London, UK
- Respiratory Medicine, and VASCERN HHT European Reference Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Elisabetta Buscarini
- Gastroenterology Department, and VASCERN HHT European Reference Centre, Maggiore Hospital, ASST Crema, Crema, Italy
| | | | - David J Allison
- Department of Imaging, Imperial College Healthcare NHS Trust, London, UK
| | - James E Jackson
- Department of Imaging, and VASCERN HHT European Reference Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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Chen B, Wang W, Tam MD, Quintini C, Fung JJ, Li X. Transjugular intrahepatic portosystemic shunt in liver transplant recipients: indications, feasibility, and outcomes. Hepatol Int 2015; 9:391-8. [DOI: 10.1007/s12072-015-9632-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 04/06/2015] [Indexed: 12/11/2022]
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Ha J, Son BK, Ahn SB, Jo YK, Kim SH, Jo YJ, Park YS, Jung YY. Osler-Weber-Rendu disease presenting as recurrent portosystemic encephalopathy in a 75-year-old female patient. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2015; 65:57-61. [PMID: 25603856 DOI: 10.4166/kjg.2015.65.1.57] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Osler-Weber-Rendu disease is a rare autosomal dominant disorder of fibrovascular tissues, characterized by a classic triad of mucocutaneous telangiectasias, recurrent hemorrhages, and a familial occurrence. Portosystemic encephalopathy in a patient with Osler-Weber-Rendu disease is rare, but we experienced a case presenting with recurrent portosystemic encephalopathy in Osler-Weber-Rendu disease. We report on a case of a 75-year-old female presenting with an altered mentality. Initial studies including brain imaging study did not reveal any specific cause for her mental status. She was diagnosed with the rare disease after a series of tests and received conservative treatment. Her neurological status recovered fully without complication after conservative treatment and she was discharged after 18 hospital days. This case demonstrated an extremely rare case of Osler-Weber-Rendu disease presenting as portosystemic encephalopathy treated successfully with conservative treatment. For patients who have shown hepatic encephalopathy without a definite cause, we recommend evaluation for the possibility of Osler-Weber-Rendu disease. Conservative treatment based on treatment of advanced liver cirrhosis could be an alternative solution.
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Affiliation(s)
- Junghoon Ha
- Departments of Internal Medicine and Radiology, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea
| | - Byoung Kwan Son
- Departments of Internal Medicine, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea
| | - Sang Bong Ahn
- Departments of Internal Medicine, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea
| | - Young Kwan Jo
- Departments of Internal Medicine, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea
| | - Seong Hwan Kim
- Departments of Internal Medicine, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea
| | - Yun Ju Jo
- Departments of Internal Medicine, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea
| | - Young Sook Park
- Departments of Internal Medicine, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea
| | - Yoon Young Jung
- Departments of Radiology, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea
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Abstract
Hereditary haemorrhagic telangiectasia, inherited as an autosomal dominant trait, affects approximately 1 in 5000 people. The abnormal vascular structures in HHT result from mutations in genes (most commonly endoglin or ACVRL1) whose protein products influence TGF-ß superfamily signalling in vascular endothelial cells. The cellular mechanisms underlying the generation of HHT telangiectasia and arteriovenous malformations are being unravelled, with recent data focussing on a defective response to angiogenic stimuli in particular settings. For affected individuals, there is often substantial morbidity due to sustained and repeated haemorrhages from telangiectasia in the nose and gut. Particular haematological clinical challenges include the management of severe iron deficiency anaemia; handling the intricate balance of antiplatelet or anticoagulants for HHT patients in whom there are often compelling clinical reasons to use such agents; and evaluation of apparently attractive experimental therapies promoted in high profile publications when guidelines and reviews are quickly superseded. There is also a need for sound screening programmes for silent arteriovenous malformations. These occur commonly in the pulmonary, cerebral, and hepatic circulations, may haemorrhage, but predominantly result in more complex pathophysiology due to consequences of defective endothelium, or shunts that bypass specific capillary beds. This review will focus on the new evidence and concepts in this complex and fascinating condition, placing these in context for both clinicians and scientists, with a particular emphasis on haematological settings.
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Affiliation(s)
- Claire L Shovlin
- NHLI Cardiovascular Sciences, Imperial College London, UK and HHTIC London, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.
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