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Vasudevan AK, Shanmugam N, Rammohan A, Balakrishnan U, Menon J, Iqbal MAUH, Mohammed GMO, Kaliamoorthy I, Rela M. Long-Term Amino Acid Homeostasis, Neurodevelopmental and Growth Profiles Following Liver Transplantation in Maple Syrup Urine Disease. Pediatr Transplant 2024; 28:e14845. [PMID: 39158064 DOI: 10.1111/petr.14845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 07/02/2024] [Accepted: 08/05/2024] [Indexed: 08/20/2024]
Abstract
INTRODUCTION Maple syrup urine disease (MSUD) is caused by the deficiency of branched-chain keto acid dehydrogenase (BCKAD) and, it is well described that BCKAD contributed by an allograft following liver transplantation (LT) phenotypically normalizes this inborn error of metabolism (IEM). There is, however, a paucity of data especially with regards to the neurodevelopmental aspects and catch-up growth profiles after LT in a resource-challenged setting. We present our series of children under 6 years of age who underwent LT for MSUD particularly focusing on their amino acid homeostasis, neurodevelopmental and somatic growth profiles. METHODS Of 580 consecutive pediatric LT (PLT) performed between January 2011 and December 2022, all children who underwent LT for MSUD were included for analysis. Data accrued included peri-LT details, pre- and post-LT metabolic profile, neurodevelopmental assessment, somatic growth evaluation, and long-term outcomes. RESULTS Six children underwent LT for MSUD with a median age and weight at LT of 20.5 (IQR: 8-60) months and 10.1 (IQR: 6.7-15.8) kg, respectively. One explanted liver was used as a domino graft for Arginase deficiency. Median follow-up period was 52.5 (IQR: 27-94) months. None had vascular or biliary complications. Following LT, all children were started on an unrestricted protein diet and had normalization of BCAA levels. Post-LT height and weight improved by 1 SD but did not achieve the normal profile. None of the children had neuro-deterioration and have achieved new milestones. CONCLUSION This is the first-report presenting the growth aspects, amino acid and neurodevelopmental profiles of children who underwent LT for MSUD within the socio-economic-cultural idiosyncrasies and constraints prevalent in our part of the world.
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Affiliation(s)
- Anu K Vasudevan
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Naresh Shanmugam
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Ashwin Rammohan
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Umamaheswari Balakrishnan
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Jagadeesh Menon
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Mohammed Asrar Ul Huq Iqbal
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Gehan Mohammed Osman Mohammed
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Ilankumaran Kaliamoorthy
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Mohamed Rela
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
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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] [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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K K H, Ajmera P, Agarwal A, Dahiya A, Parripati VK. Maple Syrup Urine Disease: An Uncommon Cause of Neonatal Febrile Seizures. Cureus 2023; 15:e40826. [PMID: 37489218 PMCID: PMC10363028 DOI: 10.7759/cureus.40826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 07/26/2023] Open
Abstract
Maple syrup urine disease (MSUD) is a rare autosomal-recessive disorder. An enzyme complex called branched-chain alpha-keto acid dehydrogenase (BCKAD) metabolizes branched-chain amino acids (BCAAs), such as leucine, isoleucine, and valine, in the body. The deficiency of this enzyme causes the accumulation of BCAAs in cerebrospinal fluid, plasma, and urine. This metabolic illness is defined by abnormal levels of BCAAs. The pathognomonic illness marker alloisoleucine is produced in the absence of the BCKAD enzyme, which is part of a metabolic pathway involving three BCAAs and gets accumulated in the body. Classically, affected neonates present with feeding problems, vomiting, lethargy, and irritability, leading to seizures, coma, and death if left untreated. Blood and urine analysis reveals an accumulation of BCAAs in the plasma and urine. Here, we report the case of a neonate on day 10 of life with febrile seizures and non-acceptance of feeds, who was diagnosed with the classical form of MSUD. This is a classic case of MSUD which was evaluated exhaustively and revealed all classic features clinically and on investigations.
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Affiliation(s)
- Harshyenee K K
- Radiology, Dr. D. Y. Patil Medical College, Hospital & Research Centre, Pune, IND
| | - Pranav Ajmera
- Radiology, Dr. D. Y. Patil Medical College, Hospital & Research Centre, Pune, IND
| | - Aastha Agarwal
- Radiology, Dr. D. Y. Patil Medical College, Hospital & Research Centre, Pune, IND
| | - Ajay Dahiya
- Radiology, Dr. D. Y. Patil Medical College, Hospital & Research Centre, Pune, IND
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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] [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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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] [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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Puffenberger EG. Mendelian disease research in the Plain populations of Lancaster County, Pennsylvania. Am J Med Genet A 2021; 185:3322-3333. [PMID: 34532947 DOI: 10.1002/ajmg.a.62489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/30/2021] [Accepted: 08/05/2021] [Indexed: 11/07/2022]
Abstract
Founder populations have long contributed to our knowledge of rare disease genes and phenotypes. From the pioneering work of Dr. Victor McKusick to today, research in these groups has shed light on rare recessive phenotypes, expanded the clinical spectrum of disease, and facilitated disease gene identification. Current clinical and research studies in these special groups augment the wealth of knowledge already gained, provide new insights into emerging problems such as variant interpretation and reduced penetrance, and contribute to the development of novel therapies for rare genetic diseases. Clinical developments over the past 30 years have altered the fundamental relationship with the Lancaster Plain communities: research has become more collaborative, and the knowledge imparted by these studies is now being harnessed to provide cutting-edge translational medicine to the very community of vulnerable individuals who need it most.
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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: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [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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Hyperleucinosis during infections in maple syrup urine disease post liver transplantation. Mol Genet Metab Rep 2021; 27:100763. [PMID: 33996492 PMCID: PMC8102797 DOI: 10.1016/j.ymgmr.2021.100763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [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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Sood V, Squires JE, Mazariegos GV, Vockley J, McKiernan PJ. Living Related Liver Transplantation for Metabolic Liver Diseases in Children. J Pediatr Gastroenterol Nutr 2021; 72:11-17. [PMID: 32969959 PMCID: PMC10657650 DOI: 10.1097/mpg.0000000000002952] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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] [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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11
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Domino Liver Transplant in Maple Syrup Urine Disease: Technical Details of Cases in Which the First Surgery Involved a Living Donor. Transplantation 2019; 103:536-543. [PMID: 29847508 DOI: 10.1097/tp.0000000000002300] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [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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12
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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] [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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13
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Vieira TA, Trapp FB, de Souza CFM, Faccini LS, Jardim LB, Schwartz IVD, Riegel M, Vargas CR, Burin MG, Leistner-Segal S, Ashton-Prolla P, Giugliani R. Information and Diagnosis Networks - tools to improve diagnosis and treatment for patients with rare genetic diseases. Genet Mol Biol 2019; 42:155-164. [PMID: 31188934 PMCID: PMC6687351 DOI: 10.1590/1678-4685-gmb-2018-0214] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 12/12/2018] [Indexed: 12/14/2022] Open
Abstract
Brazil is a country of continental dimensions and most genetic services are concentrated in the Southeast and South, including the Medical Genetics Service of the Hospital de Clínicas de Porto Alegre (MGS/HCPA). As many areas on the country do not have adequate medical genetics support, networks were designed to extend the service of the MGS/HCPA reference center. This paper presents the information and diagnosis networks that have their headquarters at MGS/HCPA: SIAT (National Information System on Teratogenic Agents), SIEM (Information Service on Inborn Errors of Metabolism), Alô Genética (Hello Genetics - Medical Genetics Information Service for Primary Health Care Professionals); Rede MPS Brasil (MPS-Mucopolysaccharidosis Brazil Network); Rede EIM Brasil (IEM-Inborn Errors of Metabolism Brazil Network), Rede NPC Brasil (Niemann-Pick C - NPC Brazil Network), Rede DLD Brasil (LSD-Lysosomal Storage Disorders Brazil Network), Rede DXB (MSUD-Maple Syrup Urine Disease Network), RedeBRIM (Brazilian Network of Reference and Information in Microdeletion Syndromes Project), Rede Neurogenética (Neurogenetics Network), and Rede Brasileira de Câncer Hereditário (Brazilian Hereditary Cancer Network). These tools are very useful to provide access to a qualified information and/or diagnostic service for specialized and non-specialized health services, bypassing difficulties that preclude patients to access reference centers.
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Affiliation(s)
- Taiane Alves Vieira
- Medical Genetics Service, Hospital de Clinicas de Porto
Alegre, Porto Alegre, RS, Brazil
- Research and Postgraduate Group - Hospital de Clinicas de
Porto Alegre, Porto Alegre, RS, Brazil
| | | | | | - Lavínia Schuler Faccini
- Medical Genetics Service, Hospital de Clinicas de Porto
Alegre, Porto Alegre, RS, Brazil
- Department of Genetics – Universidade Federal do Rio Grande do
Sul, Porto Alegre, RS, Brazil
| | - Laura Bannach Jardim
- Medical Genetics Service, Hospital de Clinicas de Porto
Alegre, Porto Alegre, RS, Brazil
- Department of Internal Medicine - Universidade Federal do Rio
Grande do Sul, Porto Alegre, RS, Brazil
| | - Ida Vanessa Doederlein Schwartz
- Medical Genetics Service, Hospital de Clinicas de Porto
Alegre, Porto Alegre, RS, Brazil
- Department of Genetics – Universidade Federal do Rio Grande do
Sul, Porto Alegre, RS, Brazil
| | - Mariluce Riegel
- Medical Genetics Service, Hospital de Clinicas de Porto
Alegre, Porto Alegre, RS, Brazil
| | - Carmen Regla Vargas
- Medical Genetics Service, Hospital de Clinicas de Porto
Alegre, Porto Alegre, RS, Brazil
| | - Maira Graeff Burin
- Medical Genetics Service, Hospital de Clinicas de Porto
Alegre, Porto Alegre, RS, Brazil
| | - Sandra Leistner-Segal
- Medical Genetics Service, Hospital de Clinicas de Porto
Alegre, Porto Alegre, RS, Brazil
| | - Patrícia Ashton-Prolla
- Medical Genetics Service, Hospital de Clinicas de Porto
Alegre, Porto Alegre, RS, Brazil
- Research and Postgraduate Group - Hospital de Clinicas de
Porto Alegre, Porto Alegre, RS, Brazil
- Department of Genetics – Universidade Federal do Rio Grande do
Sul, Porto Alegre, RS, Brazil
| | - Roberto Giugliani
- Medical Genetics Service, Hospital de Clinicas de Porto
Alegre, Porto Alegre, RS, Brazil
- Department of Genetics – Universidade Federal do Rio Grande do
Sul, Porto Alegre, RS, Brazil
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14
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Abstract
Due to the widening gap between supply and demand, patients who need a liver transplant due to metabolic disease may be asked to serve as domino liver donors-to have their native liver transplanted into another candidate. We here analyze the ethical problems surrounding informed consent for the implant and explant procedures in transplant candidates who will serve as domino donors, using the case of a child with maple syrup urine disease. We discuss the need for 2 distinct consent processes separated in time to ensure that potential domino donors (or their surrogates) give a truly voluntary consent. We propose a Domino Donor Advocate-based on the concept of the independent living donor advocate to help the patient and/or his or her surrogates consider the risks, benefits and alternatives. Finally, we evaluate the Organ Procurement and Transplantation Network policy regarding "therapeutic organ donation" and propose several modifications to ensure that the decision by the potential domino donor (and/or his or her surrogate) is voluntary and informed.
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15
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Geyer ED, Burrier C, Tumin D, Hayes D, Black SM, Washburn WK, Tobias JD. Outcomes of domino liver transplantation compared to deceased donor liver transplantation: a propensity-matching approach. Transpl Int 2018; 31:1200-1206. [PMID: 29907976 DOI: 10.1111/tri.13291] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 06/01/2018] [Accepted: 06/10/2018] [Indexed: 01/09/2023]
Abstract
Domino liver transplantation (DLT) utilizes the explanted liver of one liver transplant recipient as a donor graft in another patient. While there may be unique risks associated with DLT, it is unclear if DLT has less favorable long-term outcomes than deceased donor liver transplantation (DDLT). We used a propensity score matching approach to compare the outcomes of DLT recipients to DDLT recipients. The United Network for Organ Sharing (UNOS) registry was queried for patients undergoing DLT or DDLT in 2002-2016. Each DLT recipient was matched to a unique DDLT recipient to compare mortality and graft failure. There were 126 DLT and 62 835 DDLT recipients meeting inclusion criteria. After propensity score matching on recipient pre-transplant characteristics, 123 DLT cases were matched to DDLT controls from the same UNOS region. On stratified Cox proportional hazards regression, DLT incurred no increase in the hazard of mortality [hazard ratio (HR) = 1.4; 95% confidence interval (CI): 0.8, 2.7; P = 0.265] or graft failure (HR = 1.2; 95% CI: 0.7, 2.1; P = 0.556) compared to DDLT. Using a large national registry, a propensity-matched analysis found no increased risk of mortality or graft failure associated with DLT compared to DDLT.
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Affiliation(s)
- Emily D Geyer
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Candice Burrier
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Dmitry Tumin
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Don Hayes
- Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Respiratory and Critical Care Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sylvester M Black
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - W Kenneth Washburn
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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16
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Blackburn PR, Gass JM, Vairo FPE, Farnham KM, Atwal HK, Macklin S, Klee EW, Atwal PS. Maple syrup urine disease: mechanisms and management. APPLICATION OF CLINICAL GENETICS 2017; 10:57-66. [PMID: 28919799 PMCID: PMC5593394 DOI: 10.2147/tacg.s125962] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Maple syrup urine disease (MSUD) is an inborn error of metabolism caused by defects in the branched-chain α-ketoacid dehydrogenase complex, which results in elevations of the branched-chain amino acids (BCAAs) in plasma, α-ketoacids in urine, and production of the pathognomonic disease marker, alloisoleucine. The disorder varies in severity and the clinical spectrum is quite broad with five recognized clinical variants that have no known association with genotype. The classic presentation occurs in the neonatal period with developmental delay, failure to thrive, feeding difficulties, and maple syrup odor in the cerumen and urine, and can lead to irreversible neurological complications, including stereotypical movements, metabolic decompensation, and death if left untreated. Treatment consists of dietary restriction of BCAAs and close metabolic monitoring. Clinical outcomes are generally good in patients where treatment is initiated early. Newborn screening for MSUD is now commonplace in the United States and is included on the Recommended Uniform Screening Panel (RUSP). We review this disorder including its presentation, screening and clinical diagnosis, treatment, and other relevant aspects pertaining to the care of patients.
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Affiliation(s)
- Patrick R Blackburn
- Center for Individualized Medicine.,Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | | | - Filippo Pinto E Vairo
- Center for Individualized Medicine.,Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | | | - Sarah Macklin
- Department of Clinical Genomics, Mayo Clinic, Jacksonville, FL
| | - Eric W Klee
- Center for Individualized Medicine.,Department of Health Sciences Research, Mayo Clinic, Rochester, MN.,Department of Clinical Genomics, Mayo Clinic, Jacksonville, FL.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Paldeep S Atwal
- Center for Individualized Medicine.,Department of Clinical Genomics, Mayo Clinic, Jacksonville, FL
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17
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Takano C, Ishige M, Ogawa E, Usui H, Kagawa R, Tajima G, Fujiki R, Fukao T, Mizuta K, Fuchigami T, Takahashi S. A case of classical maple syrup urine disease that was successfully managed by living donor liver transplantation. Pediatr Transplant 2017; 21. [PMID: 28612395 DOI: 10.1111/petr.12948] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2017] [Indexed: 11/28/2022]
Abstract
Classical MSUD is often fatal without appropriate medical interventions because of metabolic crisis. There are numerous reports suggesting the therapeutic potential of deceased donor liver transplantation for MSUD. However, the usefulness of LDLT for MSUD is unknown. We report a case of classical MSUD, which was successfully managed by LDLT from the patient's father at 1 year of age. Abnormal brain findings, which were cured with effective treatment, gradually disappeared after LDLT. The patient then developed normally. Findings from this case suggest the importance of LDLT for maintaining low leucine levels and subsequent normal neurological development. Although LDLT involves a modest surgical insult, LDLT with a related donor achieves acceptable leucine levels for life.
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Affiliation(s)
- Chika Takano
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Mika Ishige
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Erika Ogawa
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Hiromi Usui
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Reiko Kagawa
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, Hiroshima, Japan
| | - Go Tajima
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, Hiroshima, Japan.,Division of Neonatal Screening, Research Institute, National Center for Child Health and Development, Tokyo, Japan
| | - Ryoji Fujiki
- Department of Technology Development, Kazusa DNA Research Institute, Chiba, Japan
| | - Toshiyuki Fukao
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Koichi Mizuta
- Transplant Surgery Division, Department of Surgery, Jichi Medical University, Tochigi, Japan
| | - Tatsuo Fuchigami
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Shori Takahashi
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
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18
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Yasui T, Suzuki T, Hara F, Watanabe S, Uga N, Naoe A, Yoshikawa T, Ito T, Nakajima Y, Miura H, Sugioka A, Kato Y, Tokoro T, Tanahashi Y, Kasahara M, Fukuda A, Kurahashi H. Successful living donor liver transplantation for classical maple syrup urine disease. Pediatr Transplant 2016; 20:707-710. [PMID: 27319399 DOI: 10.1111/petr.12738] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2016] [Indexed: 11/28/2022]
Abstract
MSUD is an autosomal recessive condition characterized by a deficiency in the enzyme, BCKDH, which catalyzes the breakdown of BCAAs. If left untreated, MSUD can result in mental retardation, central nervous system disorders, and even death. Most patients with MSUD are treated with a restricted protein diet and milk from which BCAAs have been removed. LT has been shown effective in patients with MSUD. This report describes the case of a 15-month-old boy who received a liver graft from his mother. Transplantation was successful, and the patient was then able to ingest a normal diet. Despite episodes of acute rejection, chylous ascites, and high fever (40 °C), he has shown no evidence of MSUD recurrence. These findings indicate that patients with MSUD can be successfully treated by LDLT, even when the donor is a heterozygous carrier of a mutated BCKDH gene.
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Affiliation(s)
- Toshihiro Yasui
- Department of Pediatric Surgery, Fujita Health University, Aichi, Japan
| | - Tatsuya Suzuki
- Department of Pediatric Surgery, Fujita Health University, Aichi, Japan
| | - Fujio Hara
- Department of Pediatric Surgery, Fujita Health University, Aichi, Japan
| | - Shunsuke Watanabe
- Department of Pediatric Surgery, Fujita Health University, Aichi, Japan
| | - Naoko Uga
- Department of Pediatric Surgery, Fujita Health University, Aichi, Japan
| | - Atsuki Naoe
- Department of Pediatric Surgery, Fujita Health University, Aichi, Japan
| | | | - Tetsuya Ito
- Department of Pediatric, Fujita Health University, Aichi, Japan
| | - Yoko Nakajima
- Department of Pediatric, Fujita Health University, Aichi, Japan
| | - Hiroki Miura
- Department of Pediatric, Fujita Health University, Aichi, Japan
| | - Atsushi Sugioka
- Department of Surgery, Fujita Health University, Aichi, Japan
| | - Yutaro Kato
- Department of Surgery, Fujita Health University, Aichi, Japan
| | - Takamasa Tokoro
- Department of Surgery, Fujita Health University, Aichi, Japan
| | | | - Mureo Kasahara
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akinari Fukuda
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroki Kurahashi
- Division of Molecular Genetics, Institute for Comprehensive Medical Science, Fujita Health University, Aichi, Japan
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19
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Celik N, Squires RH, Vockley J, Sindhi R, Mazariegos G. Liver transplantation for maple syrup urine disease: A global domino effect. Pediatr Transplant 2016; 20:350-1. [PMID: 27038300 DOI: 10.1111/petr.12697] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Neslihan Celik
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Robert H Squires
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Jerry Vockley
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Rakesh Sindhi
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - George Mazariegos
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.
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