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Mengler K, Garbade SF, Gleich F, Thimm E, May P, Lindner M, Lüsebrink N, Marquardt T, Hübner V, Krämer J, Neugebauer J, Beblo S, Gillitzer C, Grünert SC, Hennermann JB, Kamrath C, Marquardt I, Näke A, Murko S, Schmidt S, Schnabel E, Lommer-Steinhoff S, Hoffmann GF, Beime J, Santer R, Kölker S, Mütze U. Treatment Outcomes for Maple Syrup Urine Disease Detected by Newborn Screening. Pediatrics 2024:e2023064370. [PMID: 38957900 DOI: 10.1542/peds.2023-064370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 07/04/2024] Open
Abstract
OBJECTIVE Maple syrup urine disease (MSUD), a life-threatening metabolic disorder, is included in newborn screening (NBS) programs worldwide. The study aims to evaluate the impact of NBS on the long-term outcome of MSUD patients. METHODS We performed a prospective, national, multicenter, observational study. RESULTS In the studied NBS cohort (N = 33; 22 classic MSUD [cMSUD], 11 variant MSUD [vMSUD]; median age at last visit 10.4 years), 32 (97%) patients survived, 58% of them had normal cognitive functions (median IQ 87). Initial peak leucine increased linearly with age in cMSUD (median: 1712 µmol/L), but not in vMSUD. Global IQ correlated inversely with the initial peak leucine concentration (P = .04; β = -0.0081) and the frequency of decompensations (P = .02; β = -9.133). A cluster analysis identified 2 subgroups differing in their long-term metabolic control (median leucine concentration: 162 vs 278 µmol/L; P < .001). In cMSUD, lower leucine concentrations were associated with a higher IQ (95.5 vs 80; P = .008). Liver transplantation (median age 5.8 years) was not associated with better cognitive outcome. NBS is highly sensitive for cMSUD, but vMSUD might be missed (N = 2 missed by NBS). CONCLUSIONS NBS and the early start of treatment improve survival and long-term outcome in individuals with cMSUD. Disease severity is an important modifier of outcome; however, the time to NBS report and the quality of long-term metabolic control had an independent impact on cognitive outcome, highlighting the importance of an early diagnosis and the quality of treatment.
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Affiliation(s)
- Katharina Mengler
- Medical Faculty of Heidelberg, Center for Child and Adolescent Medicine, Division of Child Neurology and Metabolic Medicine, Heidelberg University, Heidelberg, Germany
| | - Sven F Garbade
- Medical Faculty of Heidelberg, Center for Child and Adolescent Medicine, Division of Child Neurology and Metabolic Medicine, Heidelberg University, Heidelberg, Germany
| | - Florian Gleich
- Medical Faculty of Heidelberg, Center for Child and Adolescent Medicine, Division of Child Neurology and Metabolic Medicine, Heidelberg University, Heidelberg, Germany
| | - Eva Thimm
- Department of General Pediatrics, Neonatology, and Pediatric Cardiology, University Children's Hospital
| | - Petra May
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Martin Lindner
- Division of Pediatric Neurology, University Children's Hospital Frankfurt, Frankfurt, Germany
| | - Natalia Lüsebrink
- Division of Pediatric Neurology, University Children's Hospital Frankfurt, Frankfurt, Germany
| | - Thorsten Marquardt
- Department of Pediatrics, University Hospital Muenster, Muenster, Germany
| | - Vanessa Hübner
- Children's Hospital Reutlingen, Klinikum am Steinenberg, Reutlingen, Germany
| | - Johannes Krämer
- Department of Pediatric and Adolescent Medicine, University of Ulm, Ulm, Germany
| | - Julia Neugebauer
- Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Center of Chronically Sick Children, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Skadi Beblo
- Department of Women and Child Health, Hospital for Children and Adolescents, Center for Pediatric Research Leipzig (CPL), University Hospitals, University of Leipzig, Leipzig, Germany
| | - Claus Gillitzer
- Children's Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Sarah C Grünert
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Julia B Hennermann
- Villa Metabolica, Center for Pediatric and Adolescent Medicine, Mainz University Medical Center, Mainz, Germany
| | - Clemens Kamrath
- Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Iris Marquardt
- Department of Child Neurology, Children's Hospital Oldenburg, Oldenburg, Germany
| | - Andrea Näke
- Children's Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Simona Murko
- Department of Pediatrics, University Medical Center Eppendorf, Hamburg, Germany
| | - Sebastian Schmidt
- Clinic for Internal Medicine III, Endocrinology and Metabolic Diseases, University Hospital Jena
| | - Elena Schnabel
- Medical Faculty of Heidelberg, Center for Child and Adolescent Medicine, Division of Child Neurology and Metabolic Medicine, Heidelberg University, Heidelberg, Germany
| | - Svenja Lommer-Steinhoff
- Medical Faculty of Heidelberg, Center for Child and Adolescent Medicine, Division of Child Neurology and Metabolic Medicine, Heidelberg University, Heidelberg, Germany
| | - Georg F Hoffmann
- Medical Faculty of Heidelberg, Center for Child and Adolescent Medicine, Division of Child Neurology and Metabolic Medicine, Heidelberg University, Heidelberg, Germany
| | - Jan Beime
- Department of Pediatrics, University Medical Center Eppendorf, Hamburg, Germany
| | - René Santer
- Department of Pediatrics, University Medical Center Eppendorf, Hamburg, Germany
| | - Stefan Kölker
- Medical Faculty of Heidelberg, Center for Child and Adolescent Medicine, Division of Child Neurology and Metabolic Medicine, Heidelberg University, Heidelberg, Germany
| | - Ulrike Mütze
- Medical Faculty of Heidelberg, Center for Child and Adolescent Medicine, Division of Child Neurology and Metabolic Medicine, Heidelberg University, Heidelberg, Germany
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Choi BH, Hyun S, Koo SH. The role of BCAA metabolism in metabolic health and disease. Exp Mol Med 2024:10.1038/s12276-024-01263-6. [PMID: 38956299 DOI: 10.1038/s12276-024-01263-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 03/11/2024] [Accepted: 03/19/2024] [Indexed: 07/04/2024] Open
Abstract
It has long been postulated that dietary restriction is beneficial for ensuring longevity and extending the health span of mammals, including humans. In particular, a reduction in protein consumption has been shown to be specifically linked to the beneficial effect of dietary restriction on metabolic disorders, presumably by reducing the activity of the mechanistic target of rapamycin complex (mTORC) 1 and the reciprocal activation of AMP-activated protein kinase (AMPK) and sirtuin pathways. Although it is widely used as a dietary supplement to delay the aging process in humans, recent evidence suggests that branched-chain amino acids (BCAAs) might be a major cause of the deteriorating effect of a protein diet on aging and related disorders. In this review, we delineate the regulation of metabolic pathways for BCAAs at the tissue-specific level and summarize recent findings regarding the role of BCAAs in the control of metabolic health and disease in mammals.
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Affiliation(s)
| | - Seunghoon Hyun
- Division of Life Sciences, Korea University, Seoul, Korea
| | - Seung-Hoi Koo
- Division of Life Sciences, Korea University, Seoul, Korea.
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3
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Eldredge JA, Hardikar W. Current status and future directions of liver transplantation for metabolic liver disease in children. Pediatr Transplant 2024; 28:e14625. [PMID: 37859572 DOI: 10.1111/petr.14625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/03/2023] [Accepted: 10/08/2023] [Indexed: 10/21/2023]
Abstract
Orthotopic liver transplantation (OLT) in the care of children with inborn errors of metabolism (IEM) is well established and represent the second most common indication for pediatric liver transplantation in most centers worldwide, behind biliary atresia. OLT offers cure of disease when a metabolic defect is confined to the liver, but may still be transformative on a patient's quality of life reducing the chance of metabolic crises causing neurological damage in children be with extrahepatic involvement and no "functional cure." Outcomes post-OLT for inborn errors of metabolism are generally excellent. However, this benefit must be balanced with consideration of a composite risk of morbidity, and commitment to a lifetime of post-transplant chronic disease management. An increasing number of transplant referrals for children with IEM has contributed to strain on graft access in many parts of the world. Pragmatic evaluation of IEM referrals is essential, particularly pertinent in cases where progression of extra-hepatic disease is anticipated, with long-term outcome expected to be poor. Decision to proceed with liver transplantation is highly individualized based on the child's dynamic risk-benefit profile, their family unit, and their treating multidisciplinary team. Also to be considered is the chance of future treatments, such as gene therapies, emerging in the medium term.
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Affiliation(s)
- Jessica A Eldredge
- Department of Gastroenterology, Hepatology and Clinical Nutrition, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Winita Hardikar
- Department of Gastroenterology, Hepatology and Clinical Nutrition, Royal Children's Hospital University of Melbourne, Parkville, Victoria, Australia
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4
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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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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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6
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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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Elserafy N, Thompson S, Dalkeith T, Stormon M, Thomas G, Shun A, Sawyer J, Balasubramanian S, Bhattacharya K, Badawi N, Ellaway C. Liver transplantation in children with inborn errors of metabolism: 30 years experience in NSW, Australia. JIMD Rep 2021; 60:88-95. [PMID: 34258144 PMCID: PMC8260479 DOI: 10.1002/jmd2.12219] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 04/01/2021] [Accepted: 04/06/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Inborn errors of metabolism (IEM) are a diverse group of genetic disorders that can result in significant morbidity and sometimes death. Metabolic management can be challenging and burdensome for families. Liver transplantation (LT) is increasingly being considered a treatment option for some IEMs. IEMs are now considered the second most common reason for pediatric LT. AIM To review the data of all children with an IEM who had LT at The Children's Hospital at Westmead (CHW), NSW, Australia between January 1986 and January 2019. METHODS Retrospective data collected from the medical records and genetic files included patient demographics, family history, parental consanguinity, method of diagnosis of IEM, hospital and intensive care unit admissions, age at LT, graft type, clinical outcomes and metabolic management pre and post-LT. RESULTS Twenty-four LT were performed for 21 patients. IEM diagnoses were MSUD (n = 4), UCD (n = 8), OA (n = 6), TYR type I (n = 2) and GSD Ia (n = 1). Three patients had repeat transplants due to complications. Median age at transplant was 6.21 years (MSUD), 0.87 years (UCD), 1.64 years (OA) and 2.2 years (TYR I). Two patients died peri-operatively early in the series, one died 3 months after successful LT due to septicemia. Eighteen LTs have been performed since 2008 in comparison to six LT prior to 2008. Dietary management was liberalized post LT for all patients. CONCLUSIONS Referral for LT for IEMs has increased over the last 33 years, with the most referrals in the last 10 years. Early LT has resulted in improved clinical outcomes and patient survival.
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Affiliation(s)
- Noha Elserafy
- Genetic Metabolic Disorders Service, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Sue Thompson
- Genetic Metabolic Disorders Service, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
| | - Troy Dalkeith
- Genetic Metabolic Disorders Service, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
| | - Michael Stormon
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
- Department of Gastroenterology, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Gordon Thomas
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
- Department of Paediatric Surgery, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Albert Shun
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
- Department of Paediatric Surgery, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Janine Sawyer
- Department of Gastroenterology, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Shanti Balasubramanian
- Genetic Metabolic Disorders Service, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
| | - Kaustuv Bhattacharya
- Genetic Metabolic Disorders Service, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
| | - Nadia Badawi
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
- Grace Centre for Newborn Care, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Carolyn Ellaway
- Genetic Metabolic Disorders Service, The Children's Hospital at WestmeadSydney Children's Hospital NetworkSydneyNew South WalesAustralia
- Paediatric divisonThe University of SydneySydneyNew South WalesAustralia
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8
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Menon J, Vij M, Sachan D, Rammohan A, Shanmugam N, Kaliamoorthy I, Rela M. Pediatric metabolic liver diseases: Evolving role of liver transplantation. World J Transplant 2021; 11:161-179. [PMID: 34164292 PMCID: PMC8218348 DOI: 10.5500/wjt.v11.i6.161] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/13/2021] [Accepted: 06/03/2021] [Indexed: 02/06/2023] Open
Abstract
Metabolic liver diseases (MLD) are the second most common indication for liver transplantation (LT) in children. This is based on the fact that the majority of enzymes involved in various metabolic pathways are present within the liver and LT can cure or at least control the disease manifestation. LT is also performed in metabolic disorders for end-stage liver disease, its sequelae including hepatocellular cancer. It is also performed for preventing metabolic crisis’, arresting progression of neurological dysfunction with a potential to reverse symptoms in some cases and for preventing damage to end organs like kidneys as in the case of primary hyperoxalosis and methyl malonic acidemia. Pathological findings in explant liver with patients with metabolic disease include unremarkable liver to steatosis, cholestasis, inflammation, variable amount of fibrosis, and cirrhosis. The outcome of LT in metabolic disorders is excellent except for patients with mitochondrial disorders where significant extrahepatic involvement leads to poor outcomes and hence considered a contraindication for LT. A major advantage of LT is that in the post-operative period most patients can discontinue the special formula which they were having prior to the transplant and this increases their well-being and improves growth parameters. Auxiliary partial orthotopic LT has been described for patients with noncirrhotic MLD where a segmental graft is implanted in an orthotopic position after partial resection of the native liver. The retained native liver can be the potential target for future gene therapy when it becomes a clinical reality.
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Affiliation(s)
- Jagadeesh Menon
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Mukul Vij
- Department of Pathology, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Deepti Sachan
- Department of Transfusion Medicine, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Ashwin Rammohan
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Naresh Shanmugam
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Ilankumaran Kaliamoorthy
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
| | - Mohamed Rela
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Chennai 600044, Tamil Nadu, India
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9
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Campanholi DRR, Margutti AVB, Silva WA, Garcia DF, Molfetta GA, Marques AA, Schwartz IVD, Cornejo V, Hamilton V, Castro G, Sperb-Ludwig F, Borges ES, Camelo JS. Molecular basis of various forms of maple syrup urine disease in Chilean patients. Mol Genet Genomic Med 2021; 9:e1616. [PMID: 33955723 PMCID: PMC8172190 DOI: 10.1002/mgg3.1616] [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] [Received: 07/10/2020] [Revised: 01/05/2021] [Accepted: 01/13/2021] [Indexed: 12/04/2022] Open
Abstract
Background Maple syrup urine disease (MSUD) is an autosomal recessive inherited metabolic disorder caused by the deficient activity of the branched‐chain α‐keto acid dehydrogenase (BCKD) enzymatic complex. BCKD is a mitochondrial complex encoded by four genes: BCKDHA, BCKDHB, DBT, and DLD. MSUD is predominantly caused by mutations in the BCKDHA, BCKDHB, and DBT genes which encode the E1α, E1β, and E2 subunits of the BCKD complex, respectively. The aim of this study was to characterize the genetic basis of MSUD in a cohort of Chilean MSUD patients by identifying point mutations in the BCKDHA, BCKDHB, and DBT genes and to describe their impact on the phenotypic heterogeneity of these patients. Methods This manuscript describes a cross‐sectional study of 18 MSUD patients carried out using PCR and DNA sequencing. Results Four novel pathogenic mutations were identified: one in BCKDHA (p.Thr338Ile), two in BCKDHB (p.Gly336Ser e p.Pro240Thr), and one in DBT (p.Gly406Asp). Four additional pathogenic mutations found in this study have been described previously. There were no correlations between the genotype and phenotype of the patients. Conclusion If MSUD is diagnosed earlier, with a newborn screening approach, it might be possible to establish genotype‐phenotype relationships more efficiently. This manuscript describes a cross‐sectional study of 18 MSUD patients carried out using PCR and DNA sequencing. Four novel pathogenic mutations were identified: one in BCKDHA (p.Thr338Ile), two in BCKDHB (p.Gly336Ser e p.Pro240Thr), and one in DBT (p.Gly406Asp). Four additional pathogenic mutations found in this study have been described previously. There were no correlations between the genotype and phenotype of the patients.
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Affiliation(s)
| | | | - Wilson A Silva
- Genetics Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.,Ribeirão Preto Regional Center of Hematology, National Institute of Science and Technology in Cell Therapy and Cell Therapy Center, Ribeirão Preto, Brazil.,Clinical Hospital Genomic Center, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Daniel F Garcia
- Genetics Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.,Ribeirão Preto Regional Center of Hematology, National Institute of Science and Technology in Cell Therapy and Cell Therapy Center, Ribeirão Preto, Brazil
| | - Greice A Molfetta
- Ribeirão Preto Regional Center of Hematology, National Institute of Science and Technology in Cell Therapy and Cell Therapy Center, Ribeirão Preto, Brazil.,Clinical Hospital Genomic Center, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Adriana A Marques
- Ribeirão Preto Regional Center of Hematology, National Institute of Science and Technology in Cell Therapy and Cell Therapy Center, Ribeirão Preto, Brazil
| | | | - V Cornejo
- Nutrition and Food Technology Institute, Chile University, Santiago, Chile
| | - Valerie Hamilton
- Nutrition and Food Technology Institute, Chile University, Santiago, Chile
| | - Gabriela Castro
- Nutrition and Food Technology Institute, Chile University, Santiago, Chile
| | | | - Ester S Borges
- School of Medicine, Federal University of São Carlos, São Carlos, Brazil
| | - José S Camelo
- Pediatrics Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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10
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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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11
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Whole-body metabolic fate of branched-chain amino acids. Biochem J 2021; 478:765-776. [PMID: 33626142 DOI: 10.1042/bcj20200686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 12/12/2022]
Abstract
Oxidation of branched-chain amino acids (BCAAs) is tightly regulated in mammals. We review here the distribution and regulation of whole-body BCAA oxidation. Phosphorylation and dephosphorylation of the rate-limiting enzyme, branched-chain α-ketoacid dehydrogenase complex directly regulates BCAA oxidation, and various other indirect mechanisms of regulation also exist. Most tissues throughout the body are capable of BCAA oxidation, and the flux of oxidative BCAA disposal in each tissue is influenced by three key factors: 1. tissue-specific preference for BCAA oxidation relative to other fuels, 2. the overall oxidative activity of mitochondria within a tissue, and 3. total tissue mass. Perturbations in BCAA oxidation have been implicated in many disease contexts, underscoring the importance of BCAA homeostasis in overall health.
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12
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Current update in domino liver transplantation. Int J Surg 2020; 82S:163-168. [PMID: 32244002 DOI: 10.1016/j.ijsu.2020.03.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 03/09/2020] [Accepted: 03/12/2020] [Indexed: 12/14/2022]
Abstract
Orthotopic liver transplantation is an established treatment for end stage liver diseases as well as for some severe metabolic disorders. With increasing number of patients on the waiting list and the ongoing shortage of livers available, domino liver transplantation (DLT) became an option to further expand the organ donor pool. DLT utilizes the explanted liver of one liver transplant recipient as a donor graft in another patient. Despite being a surgically, and logistically demanding procedure, excellent results could be achieved in experienced high-volume transplant centers. In this review we present the current world status of DLT.
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13
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Differential Intraoperative Effect of Liver Transplant in Different Inborn Errors of Metabolism. J Pediatr Gastroenterol Nutr 2019; 69:160-162. [PMID: 30964822 DOI: 10.1097/mpg.0000000000002354] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Liver transplant (LT) is a therapeutic option for a growing number of inborn errors of metabolism (IEM), including some disorders not confined to the liver. Clinical advantages of LT in maple syrup urine disease (MSUD), methylmalonic acidemia (MMA), and argininosuccinic aciduria (ASA) have been reported. However, no information on the early metabolic effect of LT after portal reperfusion is available in these disorders. Here we describe the intraoperative differential metabolic outcome of LT in MSUD, MMA, and ASA. In these IEM, LT promptly cleared toxic metabolites to safe concentrations. In MSUD, leucine concentration reached physiological concentration within 12 hours after portal reperfusion. In MMA and ASA, LT allowed faster clearance of methylmalonate and argininosuccinate, respectively, both dropping by ∼90% within the first hour after portal reperfusion. The early biochemical benefits of LT in MSUD, MMA, and ASA demonstrate its immediate effectiveness in protecting patients from intercurrent metabolic decompensations.
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14
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Herden U, Grabhorn E, Santer R, Li J, Nadalin S, Rogiers X, Scherer MN, Braun F, Beime J, Lenhartz H, Muntau AC, Fischer L. Surgical Aspects of Liver Transplantation and Domino Liver Transplantation in Maple Syrup Urine Disease: Analysis of 15 Donor-Recipient Pairs. Liver Transpl 2019; 25:889-900. [PMID: 30712285 DOI: 10.1002/lt.25423] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 12/09/2018] [Indexed: 02/07/2023]
Abstract
Liver transplantation (LT) has been shown to be a feasible treatment in patients with severe forms of maple syrup urine disease (MSUD). Because of a sufficient extrahepatic enzyme activity in non-MSUD individuals, the organ of MSUD patients can be used as a domino graft. We performed a retrospective data collection of all LTs for MSUD carried out at the University Medical Center Hamburg-Eppendorf (2016-2018). Moreover, data from all consecutive domino LTs of the MSUD grafts either transplanted at our institution or allocated to other transplant centers were analyzed. During the study period, 15 LTs in MSUD patients were performed (12 children, 3 adults; median age, 10.9 years; range, 0.3-26.1 years). Biliary complications occurred in 20%, and 13.3% suffered from bleeding complications. No further surgical problems occurred. At present, all MSUD patients are alive with a well-functioning liver graft and on an unrestricted diet. In total, 14 consecutive domino LTs were performed. No surgical complications requiring intervention occurred. One patient died because of HCC relapse, and all other patients are alive with good liver graft function. In conclusion, the use of MSUD livers as domino grafts is safe and allows application of LT in MSUD patients without net extraction of a liver graft from the limited donor pool.
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Affiliation(s)
- Uta Herden
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Enke Grabhorn
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - René Santer
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jun Li
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Xavier Rogiers
- Department of Solid Organ Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Marcus N Scherer
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Felix Braun
- Department of General, Visceral, Thoracic, Transplantation and Pediatric Surgery, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Jan Beime
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henning Lenhartz
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ania C Muntau
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lutz Fischer
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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15
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Liu YD, Chu X, Liu RH, Sun Y, Kong QX, Li QB. Paroxysmal spasticity of lower extremities as the initial symptom in two siblings with maple syrup urine disease. Mol Med Rep 2019; 19:4872-4880. [PMID: 30957186 PMCID: PMC6522870 DOI: 10.3892/mmr.2019.10133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 04/01/2019] [Indexed: 12/28/2022] Open
Abstract
Maple syrup urine disease (MSUD) is a rare autosomal recessive metabolic disorder caused by mutations in genes that encode subunits of the branched‑chain α‑ketoacid dehydrogenase (BCKD) complex. Impairment of the BCKD complex results in an abnormal accumulation of branched‑chain amino acids and their corresponding branched‑chain keto acids in the blood and cerebrospinal fluid, which are neurovirulent and may become life‑threatening. An 11‑day‑old boy was admitted to the hospital with paroxysmal spasticity of lower extremities. Of note, his 10‑year‑old sister presented similar symptoms during the neonatal period, and her condition was diagnosed as MSUD when she was 1.5 years old. Genetic screening was performed, and the boy and his sister exhibited two novel compound heterozygous mutations in the branched chain keto acid dehydrogenase E1 subunit β (BCKDHB) gene: A substitution from guanine to adenine in the coding region at position 1,076 (c.1,076G>A) in exon 10 and a deletion of a thymine at position 705 (c.705delT) in exon 6. The missense mutation c.1076G>A results in an amino acid substitution from arginine to lysine at position 359 (p.Arg359Lys), whereas the mutation c.705delT results in the replacement of a cysteine at position 235 with a stop codon (p.Cys235Ter). Neither of the BCKDHB alleles in the compound heterozygote patients is able to generate normal E1β subunits, resulting in a possible impairment of the activity of the BCKD complex. In the present study, it was hypothesized that the two novel heterozygous mutations in the BCKDHB gene found in the Chinese family may be responsible for the phenotype of the two siblings with MSUD.
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Affiliation(s)
- Yi-Dan Liu
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Xu Chu
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, Shandong 272000, P.R. China
| | - Rui-Hua Liu
- Department of Pediatrics, Affiliated Hospital of Jining Medical University, Jining, Shandong 272000, P.R. China
| | - Ying Sun
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Qing-Xia Kong
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, Shandong 272000, P.R. China
| | - Qiu-Bo Li
- Department of Pediatrics, Affiliated Hospital of Jining Medical University, Jining, Shandong 272000, P.R. China
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16
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Abstract
Branched chain amino acids (BCAAs) are building blocks for all life-forms. We review here the fundamentals of BCAA metabolism in mammalian physiology. Decades of studies have elicited a deep understanding of biochemical reactions involved in BCAA catabolism. In addition, BCAAs and various catabolic products act as signaling molecules, activating programs ranging from protein synthesis to insulin secretion. How these processes are integrated at an organismal level is less clear. Inborn errors of metabolism highlight the importance of organismal regulation of BCAA physiology. More recently, subtle alterations of BCAA metabolism have been suggested to contribute to numerous prevalent diseases, including diabetes, cancer, and heart failure. Understanding the mechanisms underlying altered BCAA metabolism and how they contribute to disease pathophysiology will keep researchers busy for the foreseeable future.
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Affiliation(s)
- Michael Neinast
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA;
| | - Danielle Murashige
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA;
| | - Zoltan Arany
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA;
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17
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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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18
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Vara R, Dhawan A, Deheragoda M, Grünewald S, Pierre G, Heaton ND, Vilca-Melendez H, Hadžić N. Liver transplantation for neonatal-onset citrullinemia. Pediatr Transplant 2018; 22:e13191. [PMID: 29726081 DOI: 10.1111/petr.13191] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2018] [Indexed: 12/27/2022]
Abstract
Citrullinemia or ASS deficiency in its classical form presents in the neonatal period with poor feeding, hyperammonemia, encephalopathy, seizures, and if untreated can be fatal. Despite advances in medical therapy, neurocognitive outcomes remain suboptimal. LT has emerged as a potential management option. A retrospective single-center review identified 7 children with a median age of 1.1 years (range, 0.6-5.8) at referral. Five children presented clinically, and 2 were treated prospectively from birth due to positive family history. All patients received standard medical and dietary therapy prior to LT. The indications for LT were frequent metabolic decompensations in 4, elective in 2, and ALF in 1. The median age at LT was 2.4 years (range, 1.3-6.5). Five patients received 6 left lateral segment grafts, one a live unrelated donor left lateral segment as an APOLT graft, and one a cadaveric whole liver graft as APOLT. One child required retransplantation due to hepatic artery thrombosis. Graft and patient survival were 86% and 100%, respectively. Median follow-up is 3.1 years (range, 0.1-4.1), and the median age at follow-up is 5.5 years (range, 4.0-9.8). There have been no metabolic decompensations in 6 children, while 1 patient (with APOLT) developed asymptomatic hyperammonemia with no clinical or histological signs of liver injury, requiring additional medical therapy. Our medium-term experience following LT in citrullinemia is favorable, demonstrating a positive transformation of the clinical phenotype.
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Affiliation(s)
- Roshni Vara
- Department of Inherited Metabolic Disease, Evelina London Children's Hospital, London, UK.,Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
| | - Maesha Deheragoda
- Liver Histopathology, Institute of Liver Studies, King's College Hospital, London, UK
| | - Stephanie Grünewald
- Department of Paediatric Inherited Metabolic Disease, Institute of Child Health, Great Ormond Street Hospital for Children, UCL, London, UK
| | - Germaine Pierre
- Department of Paediatric Inherited Metabolic Disease, Bristol Children's Hospital, Bristol, UK
| | - Nigel D Heaton
- Liver Transplantation, Institute of Liver Studies, King's College Hospital, London, UK
| | - Hector Vilca-Melendez
- Liver Transplantation, Institute of Liver Studies, King's College Hospital, London, UK
| | - Nedim Hadžić
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
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19
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Baştürk A, Keçeli M, Erbiş H, Soyucen E, Aliosmanoğlu İ, Dinçkan A, Yılmaz A, Artan R. Liver transplantation from a live donor to a patient with maple syrup urine disease: Two case reports. Turk Arch Pediatr 2018; 53:113-116. [PMID: 30116132 DOI: 10.5152/turkpediatriars.2018.3710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 01/11/2017] [Indexed: 11/22/2022]
Abstract
Liver transplantation were reported in patients with classic maple syrup urine disease in the literature. Branched chain alpha keto acid dehydrogenase activity can be improved in patients after transplant, and a protein-restricted diet is usually not needed. The first patient was a boy aged 2,5 years who presented with frequent ketosis attacks and epileptic seizures, and the second patient was an 11-month-old boy who also presented with frequent ketosis episodes, both despite adherence to diet therapy. Both patients received liver transplantations from live donors. A low protein diet was no longer required and no decline in cognitive functions was observed in either patient in the follow-up. We wanted to present these cases to show that despite a normal diet, plasma levels of branched- chain amino acids remained normal without any decline in cognitive function after liver transplantation in patients with classic maple syrup urine disease patients.
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Affiliation(s)
- Ahmet Baştürk
- Department of Pediatrics, Division of Pediatric Gastroenterology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Meryem Keçeli
- Department of Pediatrics, Division of Pediatric Gastroenterology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Halil Erbiş
- Department of General Surgery, Akdeniz University School of Medicine, Transplantation Institute, Antalya, Turkey
| | - Erdoğan Soyucen
- Department of Pediatrics, Division of Pediatric Nutrition and Metabolism, Akdeniz University School of Medicine, Antalya, Turkey
| | - İbrahim Aliosmanoğlu
- Department of General Surgery, Akdeniz University School of Medicine, Transplantation Institute, Antalya, Turkey
| | - Ayhan Dinçkan
- Department of General Surgery, Akdeniz University School of Medicine, Transplantation Institute, Antalya, Turkey
| | - Aygen Yılmaz
- Department of Pediatrics, Division of Pediatric Gastroenterology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Reha Artan
- Department of Pediatrics, Division of Pediatric Gastroenterology, Akdeniz University School of Medicine, Antalya, Turkey
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20
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Kenneson A, Osara Y, Pringle T, Youngborg L, Singh RH. Natural history of children and adults with maple syrup urine disease in the NBS-MSUD Connect registry. Mol Genet Metab Rep 2018; 15:22-27. [PMID: 30023285 PMCID: PMC6047058 DOI: 10.1016/j.ymgmr.2018.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 01/08/2018] [Indexed: 12/19/2022] Open
Affiliation(s)
- Aileen Kenneson
- Metabolic Genetics and Nutrition Program, Emory University, Atlanta, GA, USA
| | - Yetsa Osara
- Metabolic Genetics and Nutrition Program, Emory University, Atlanta, GA, USA
| | - Theresa Pringle
- Metabolic Genetics and Nutrition Program, Emory University, Atlanta, GA, USA
| | - Lauren Youngborg
- Metabolic Genetics and Nutrition Program, Emory University, Atlanta, GA, USA
| | - Rani H Singh
- Metabolic Genetics and Nutrition Program, Emory University, Atlanta, GA, USA
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21
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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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22
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Roilides I, Xinias I, Mavroudi A, Ioannou H, Savopoulou P, Imvrios G. Heterozygous liver transplantation for maple syrup urine disease: First European reported case. Pediatr Transplant 2016; 20:846-50. [PMID: 27357264 DOI: 10.1111/petr.12736] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/11/2016] [Indexed: 11/30/2022]
Abstract
MSUD is an autosomal recessive metabolic disorder that results from a defect in the BCKDH enzyme. This enzyme is essential for the second step in the metabolism of the branched-chain amino acids, leucine, isoleucine, and valine. Patients with MSUD are subject to severe, irreversible neurologic injury unless closely managed with a specialized metabolic formula and a diet restricted in leucine throughout their lifetime. During times of illness, patients with MSUD can suffer from severe metabolic derangement, acute cerebral edema, and untimely death. Deceased donor liver transplant restores the ability to metabolize branched-chain amino acids, even on an unrestricted diet, and prevents metabolic derangements during times of illness. We report a successful case of living donor (parental) transplant for a child with MSUD. The donor was the child's father. This approach has been controversial as parents of children with MSUD are obligate heterozygotes for the condition and have diminished levels of BCKDH activity. If effective, living-related donor transplant provides a promising alternative for deceased donor liver transplant, which often requires a prolonged waiting period and may not be feasible in areas with limited medical resources.
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Affiliation(s)
- I Roilides
- 3rd Department of Pediatrics, Hippocration Hospital, Aristotle University, Thessaloniki, Greece
| | - I Xinias
- 3rd Department of Pediatrics, Hippocration Hospital, Aristotle University, Thessaloniki, Greece
| | - A Mavroudi
- 3rd Department of Pediatrics, Hippocration Hospital, Aristotle University, Thessaloniki, Greece
| | - H Ioannou
- 1st Department of Pediatrics, Hippocration Hospital, Aristotle University, Thessaloniki, Greece
| | - P Savopoulou
- 1st Department of Pediatrics, Hippocration Hospital, Aristotle University, Thessaloniki, Greece
| | - G Imvrios
- Transplantation Unit, Hippocration Hospital, Aristotle University, Thessaloniki, Greece
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23
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Couce ML, Ramos F, Bueno MA, Díaz J, Meavilla S, Bóveda MD, Fernández-Marmiesse A, García-Cazorla A. Evolution of maple syrup urine disease in patients diagnosed by newborn screening versus late diagnosis. Eur J Paediatr Neurol 2015; 19:652-9. [PMID: 26232051 DOI: 10.1016/j.ejpn.2015.07.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 06/14/2015] [Accepted: 07/02/2015] [Indexed: 02/02/2023]
Abstract
Maple syrup urine disease (MSUD) is a rare metabolic disorder for which the newborn screening (NBS) is possible but it has not been yet implemented for most Spanish regions. In the present study, we assess the clinical features and outcome of 14 MSUD Spanish patients with similar treatment protocol diagnosed either by NBS or by clinical symptoms. Eight patients were detected by NBS, four classic and four moderate MSUD. The average age at detection was 4.6 days, the mean plasmatic concentration of leucine at diagnosis was 1807 μM; the average number of days with leucine >1000 μM was 0.7 (0-4) and the mean number of total hospitalizations was 1.6 (0-5). Mean follow-up time was 70 months. They had good evolution: all remain asymptomatic, but 2 patients have attention deficit and hyperactivity disorder. Six patients with late diagnosis of classic MSUD were followed during 41 months. All presented with acute encephalopathy during the first month of life, mean leucine levels of 2355 μM, mean number of days with leucine >1000 μM of 6.6 (1-13) and mean number of total hospitalizations of 5.3 (4-7). Only two patients have a psychomotor development index in the lower limit (80 and 83). For all patients a good genotype-phenotype correlation was found and four novel mutations were identified: p.A311H, p.T84S, p.T397L, pL398P. Our study support that NBS improves prognosis of MSUD patients. But early diagnosis and an aggressive treatment together with a close monitoring of leucine levels improve neurological evolution in MSUD patients, even for those not detected by NBS.
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Affiliation(s)
- M L Couce
- Metabolic Unit, Servei of Neonatology, Department of Pediatrics, Hospital Clínico Universitario de Santiago, IDIS, CIBERER, ISCIII, Santiago de Compostela, Spain.
| | - F Ramos
- Department of Neurology, Neurometabolic Unit, Hospital Sant Joan de Déu, and CIBERER, ISCIII, Barcelona, Spain
| | - M A Bueno
- Metabolic and Dismorphology Unit, Department of Pediatrics, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - J Díaz
- Gastroenterolgy, Nutrition and Metabolic Unit, Hospital Central de Asturias, Spain
| | - S Meavilla
- Department of Gastroenterology and Nutrition, Metabolic Unit, Hospital Sant Joan de Déu, Barcelona, Spain
| | - M D Bóveda
- Metabolic Unit, Servei of Neonatology, Department of Pediatrics, Hospital Clínico Universitario de Santiago, IDIS, CIBERER, ISCIII, Santiago de Compostela, Spain
| | - A Fernández-Marmiesse
- Metabolic Unit, Servei of Neonatology, Department of Pediatrics, Hospital Clínico Universitario de Santiago, IDIS, CIBERER, ISCIII, Santiago de Compostela, Spain
| | - A García-Cazorla
- Department of Neurology, Neurometabolic Unit, Hospital Sant Joan de Déu, and CIBERER, ISCIII, Barcelona, Spain
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24
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Li X, Ding Y, Liu Y, Ma Y, Song J, Wang Q, Li M, Qin Y, Yang Y. Eleven novel mutations of the BCKDHA, BCKDHB and DBT genes associated with maple syrup urine disease in the Chinese population: Report on eight cases. Eur J Med Genet 2015; 58:617-23. [PMID: 26453840 DOI: 10.1016/j.ejmg.2015.10.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 09/30/2015] [Accepted: 10/03/2015] [Indexed: 12/01/2022]
Abstract
Maple syrup urine disease (MSUD) is a rare autosomal recessive disorder that affects the degradation of branched chain amino acids (BCAAs). Only a few cases of MSUD have been documented in Mainland China, and prenatal diagnosis has not been performed so far. In this report, 8 patients (4 girls and 4 boys) with MSUD from 8 unrelated Chinese families were diagnosed at the age of 9 days to 1 year and 8 months. The diagnosis was confirmed by serum BCAAs and genetic analyses. Among the 8 patients, only one was detected by newborn screening. The remaining 7 patients were admitted because of neurological disorders and underwent selective screening. Significantly elevated BCAAs were observed in 7 patients. One patient was diagnosed by post-mortem study. 12 mutations were found in the BCKDHA, BCKDHB and DBT genes. 11 of these mutations were novel: c.178G > T, c.491T > C, c.740A > G, c.1214_1219dupCCAACC and IVS6+1delG in BCKDHA; c.482T > G, c.508C > T, c.767A > G, c.768C > G and IVS4,-2A > C in BCKDHB; and c.1A > G in DBT. Only one mutation, c.659C > T in the BCKDHA gene, had been previously reported. 7 patients were treated by dietary intervention and symptomatic therapy. 6 of them showed clinical improvement. The mother of one patient who died from MSUD underwent amniocentesis during her second pregnancy. The BCAAs level in her amniotic fluid was normal. Only one heterozygous mutation, IVS4,-2A > C in the BCKDHB gene, was detected in the cultured amniocytes. The results revealed that the fetus was not affected by MSUD. Normal development and the blood BCAAs profile confirmed the prenatal diagnosis after birth. Thus, we identified eleven novel mutations associated with MSUD in the Chinese population. Prenatal diagnosis of MSUD was successfully performed on one fetus by genetic analysis of the cultured amniocytes.
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Affiliation(s)
- Xiyuan Li
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Yuan Ding
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Yupeng Liu
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Yanyan Ma
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Jinqing Song
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | - Qiao Wang
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
| | | | | | - Yanling Yang
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China.
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25
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Chin HL, Aw MM, Quak SH, Huang J, Hart CE, Prabhakaran K, Goh DL. Two consecutive partial liver transplants in a patient with Classic Maple Syrup Urine Disease. Mol Genet Metab Rep 2015; 4:49-52. [PMID: 26937410 PMCID: PMC4750575 DOI: 10.1016/j.ymgmr.2015.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 06/11/2015] [Accepted: 06/11/2015] [Indexed: 11/21/2022] Open
Abstract
Maple syrup urine disease is caused by a deficiency in the branched chain ketoacid dehydrogenase (BCKAD) complex. This results in the accumulation of branched chain amino acids (BCAA) and branched chain ketoacids in the body. Even when aggressively treated with dietary restriction of BCAA, patients experience long term cognitive, neurological and psychosocial problems. Liver transplantation from deceased donors has been shown to be an effective modality in introducing adequate BCKAD activity, attaining a metabolic cure for patients. Here, we report the clinical course of the first known patient with classic MSUD who received two consecutive partial liver grafts from two different living non-carrier donors and his five year outcome posttransplant. We also show that despite the failure of the first liver graft, and initial acute cellular rejection of the second liver graft in our patient, his metabolic control remained good without metabolic decompensation.
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Affiliation(s)
- H L Chin
- Department of Paediatrics, National University Hospital, National University Health Systems, Singapore
| | - M M Aw
- Department of Paediatrics, National University Hospital, National University Health Systems, Singapore; Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - S H Quak
- Department of Paediatrics, National University Hospital, National University Health Systems, Singapore; Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - J Huang
- Department of Paediatrics, National University Hospital, National University Health Systems, Singapore
| | - C E Hart
- Biochemical Genetics and National Expanded Newborn Screening, Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, Singapore
| | - K Prabhakaran
- Department of Paediatric Surgery, National University Hospital, National University Health Systems, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Paediatric Solid Organ Transplantation, National University Hospital, National University Health Systems, Singapore
| | - D L Goh
- Department of Paediatrics, National University Hospital, National University Health Systems, Singapore; Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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