FAP World Transplant Register and domino/sequential register update

Liver transplantation for familial amyloidotic polyneuropathy (FAP): a single-center experience over 16 years

Orthotopic liver transplantation (LTx) is currently the only available treatment that has been proven to halt the progress of familial amyloidotic polyneuropathy (FAP). The aim of this study was to assess mortality and symptomatic response to LTx for FAP. All 86 FAP patients transplanted at our hospital between April 1990 and November 2005 were included in the study. Five patients underwent retransplantation. The 1-, 3- and 5-year patient survival rates in patients transplanted during 1996-2005 were 94.6%, 92.3% and 92.3%, respectively, a significant difference from the rates of 76.7%, 66.7% and 66.7%, respectively, during 1990-1995 (p = 0.0003). Multivariate analysis revealed that the age at the time of LTx (>or=40 years), duration of the disease (>or=7 years) and modified body mass index (mBMI) (<600) were independent prognostic factors for patient survival. A halt in the progress of symptoms was noted in most patients, but only a minority experienced an improvement after LTx. To optimize the posttransplant prognosis, LTx should be performed in the early stages of the disease, and close post-LTx monitoring of heart function by echocardiography and of heart arrhythmia by Holter ECG is mandatory.

The systemic amyloidoses

PURPOSE OF REVIEW

Clinical management of the amyloidoses has historically been the province of rheumatologists, because of the relation to long-standing inflammation in rheumatoid arthritis, ankylosing spondylitis, and juvenile chronic arthritis. Currently, nephrologists, hematologist-oncologists, neurologists, and transplant surgeons all have a diagnostic or therapeutic interest. Current advances, using the tools of physical biochemistry, cell biology, and genetics, have begun to impact the diagnosis and clinical management of these disorders and raise questions regarding our notions of protein conformation in vivo and how nonnatively folded proteins may produce disease.

RECENT FINDINGS

It appears that all amyloidogenic precursors undergo some degree of misfolding that allows them to populate an immediate precursor pool from which they rapidly aggregate. Depending on the particular protein, a variety of mechanisms appear operative, some of which involve nonphysiologic proteolysis, defective physiologic proteolysis, mutations involving changes in thermodynamic or kinetic properties, and pathways that are yet to be defined. Whatever the particular process, the result is a tendency toward oligomeric aggregation followed by the assembly of higher order structures that become insoluble under physiologic conditions. Detailed analyses have been described for transthyretin (senile systemic amyloidosis and familial amyloid polyneuropathy), immunoglobulin light chains (light-chain amyloid), beta2 microglobulin (dialysis-related amyloid), and apolipoprotein A1, and are in process for others. SUMMARY Therapies have been proposed based on precursor stabilization (transthyretin), elimination of the synthesizing cell (light-chain amyloid), fibril disruption and immunization to induce host-mediated aggregate clearance (Alzheimer disease, light-chain amyloid, prions), and aggressive therapy of a primary inflammatory process (amyloid A). During the next decade, the value of these therapies, and others, suggested by studies on the basic properties of cells and proteins, will become clear.

Review article: hepatocellular carcinoma: indications for liver transplantation

The role of liver transplantation for hepatocellular carcinoma has evolved over the years and currently is one of the curative therapies for small tumours. The survival rates are similar with those for nonmalignant liver disease after transplantation. The treatment of small tumours eligible for both resection and transplantation depends on the experience of the transplant centre and the waiting time for a liver graft. With waiting times for liver transplant becoming gradually longer, prioritization of the tumour patients has been suggested. Adjuvant therapies may delay the tumour progression while patients wait for a transplant. The living donor and the domino liver transplantation are useful alternatives given the shortage of organs but the experience is still limited in the Western world and the selection for the domino livers is fairly restricted.

Liver transplantation for hepatocellular carcinoma

The surgical management for hepatocellular carcinoma (HCC) is multiplicity. In Japan, liver resection has generally been considered to be the only curative treatment for HCC. The resectability of a tumor in cirrhotic patients, however, is limited by the diminished functional reserve of the cirrhotic liver and the attendant risk for intraoperative bleeding and postoperative liver failure. In cirrhotic patients, liver transplantation has been considered as the indication for HCC in many countries except Japan. Although the survival rate of patients with HCC who received liver transplants was poor in the early period, it later moved to the same level as for patients with other liver diseases. In 1993, living donor adult liver transplantation was started in Japan and it became an additional option for the treatment of HCC. A shortage of liver donors means that new methods of liver procurement must be explored. Domino liver transplantation using the livers of patients with familial amyloid polyneuropathy was also another option for advanced HCC. For the prevention of a recurrence of HCC, pre-, intra-, and postoperative chemotherapy have been performed after both liver resection and liver transplantation. We should also try to minimize intraoperative dissemination by surgical manipulation. Recently, potential gene therapies for HCC have been studied. Electroporation-mediated IL-12 gene therapy for HCC was found to be effective for both mIL-12-transferred HCC and for distant HCC. For patients with HCC accompanied by liver cirrhosis, liver transplantation remains the ultimate curative therapy. Immunologic and oncologic approaches to HCC can help prevent tumor recurrence and also help us to obtain better results after liver transplantation.