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Uslu A, Çekmen N, Torgay A, Haberal M. Perioperative management in pediatric domino liver transplantation for metabolic disorders: A narrative review. Paediatr Anaesth 2024. [PMID: 38980227 DOI: 10.1111/pan.14967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 06/25/2024] [Accepted: 07/01/2024] [Indexed: 07/10/2024]
Abstract
Domino liver transplantation and domino-auxiliary partial orthotopic liver transplantation are emerging techniques that can expand the liver donor pool and provide hope for children with liver disease. The innovative technique of domino liver transplantation has emerged as a pioneering strategy, capitalizing on structurally preserved livers from donors exhibiting single enzymatic defects within a morphologically normal context, effectively broadening the donor pool. Concurrently, the increasingly prevalent domino-auxiliary partial orthotopic liver transplantation method assumes a critical role in bolstering available donor resources. These advanced transplantation methods present a unique opportunity for pediatric patients who, despite having structurally and functionally intact livers and lacking early signs of portal hypertension or extrahepatic involvement, do not attain priority on conventional transplant lists. Utilizing optimal clinical conditions enhances posttransplant outcomes, benefiting patients who would otherwise endure extended waiting periods for traditional transplantation. The perioperative management of children undergoing these procedures is complex and requires careful consideration of some factors, including clinical and metabolic conditions of the specific metabolic disorder, and the need for tailored perioperative management planning. Furthermore, the prudent consideration of de novo disease development in the recipient assumes paramount significance when selecting suitable donors for domino liver transplantation, as it profoundly influences prognosis, mortality, and morbidity. This narrative review of domino liver transplantation will discuss the pathophysiology, clinical evaluation, perioperative management, and prognostic expectations, focusing on perioperative anesthetic considerations for children undergoing domino liver transplantation.
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Affiliation(s)
- Ahmed Uslu
- Department of Surgical Sciences, Anesthesiology and Intensive Care Medicine, Başkent University, Ankara, Türkiye
| | - Nedim Çekmen
- Department of Surgical Sciences, Anesthesiology and Intensive Care Medicine, Başkent University, Ankara, Türkiye
| | - Adnan Torgay
- Department of Surgical Sciences, Anesthesiology and Intensive Care Medicine, Başkent University, Ankara, Türkiye
| | - Mehmet Haberal
- Department of Surgical Sciences, Organ and Tissue Transplantation Center, Başkent University, Ankara, Türkiye
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Smith MA, Feinglass NG. Perioperative implications of amyloidosis and amyloid cardiomyopathy: A review for anesthesiologists. J Clin Anesth 2024; 92:111271. [PMID: 37820520 DOI: 10.1016/j.jclinane.2023.111271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/17/2023] [Accepted: 09/22/2023] [Indexed: 10/13/2023]
Abstract
It is well recognized that amyloid protein can infiltrate many regions of the body. This can include the peripheral nerves, the liver, kidney, spleen, the gastrointestinal tract, and most importantly the myocardium. The amyloid proteins that cause cardiomyopathy may come from genetically altered liver genes (transthyretin amyloid, ATTR) or from the bone marrow with malignant plasma cells (light chain amyloid, AL) generating the aberrant protein. These two types of amyloidosis cause significant damaging effects on both the myocardial cells as well as the conduction system of the heart. The resultant changes can produce dyspnea and exercise intolerance which is thought to be secondary to diastolic dysfunction and reduced stroke volume. This subclinical decompensation poses a significant problem for members of a care team as it often goes unrecognized. In the operating room patients are exposed to dramatic hemodynamic changes and may have difficult airways, autonomic dysfunction, and conduction abnormalities. Although the topic of amyloidosis is well described in cardiology literature, it is underdiagnosed. The purpose of this review is to describe some of the pathophysiology behind the principle proteins that cause cardiac amyloidosis and to comprehensively describe perioperative considerations for anesthesia providers.
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Affiliation(s)
- Michael A Smith
- Mayo Clinic Dept. Anesthesiology and Perioperative Medicine, Critical Care Medicine, Mayo Graduate School of Medicine, USA.
| | - Neil G Feinglass
- Mayo Clinic Dept. Anesthesiology and Perioperative Medicine, Mayo Graduate School of Medicine, USA
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3
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Severe heart disease in an unusual case of familial amyloid polyneuropathy type I. Rev Port Cardiol 2013; 32:729-33. [PMID: 23993291 DOI: 10.1016/j.repc.2013.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2012] [Accepted: 02/03/2013] [Indexed: 11/24/2022] Open
Abstract
Familial amyloid polyneuropathy type I (FAP type I) is a rare hereditary systemic amyloidosis caused by the Val30Met mutation in the transthyretin (TTR) gene. The clinical onset and spectrum are variable and depend on phenotypic heterogeneity. Cardiac complications (dysrhythmias and conduction disturbances, cardiomyopathy and dysautonomia) indicate a poor prognosis, even after liver transplantation. We report an atypical case of FAP type I, highlighting the severe cardiac involvement and its complications. Early diagnosis of amyloid heart disease is increasingly important in the context of several clinical trials of promising new and experimental drugs.
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Oliveira Santos M, Brito D. Severe heart disease in an unusual case of familial amyloid polyneuropathy type I. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2013. [DOI: 10.1016/j.repce.2013.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Mookadam F, Jiamsripong P, Raslan SF, Panse PM, Tajik AJ. Constrictive pericarditis and restrictive cardiomyopathy in the modern era. Future Cardiol 2011; 7:471-83. [DOI: 10.2217/fca.11.18] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
The differentiation between constrictive pericarditis and restrictive cardiomyopathy can be clinically challenging. Pericardial constriction results from scarring and consequent loss of pericardial elasticity leading to impaired ventricular filling. Restrictive cardiomyopathy is characterized by a nondilated rigid ventricle, severe diastolic dysfunction and restrictive filling producing hemodynamic changes, similar to those in constrictive pericarditis. While constrictive pericarditis is usually curable by surgical treatment, restrictive cardiomyopathy requires medical therapy and in appropriate patients, the definitive treatment is cardiac transplantation. Sufficient differences exist between the two conditions to allow noninvasive differentiation, but no single diagnostic tool can be relied upon to make this distinction. Newer echocardiographic techniques such as speckle-track imaging, velocity vector imaging, as well as cardiac computed tomography and cardiac MRI can help differentiate constriction from restriction with high sensitivity and specificity. Outcomes are better with early diagnosis of constriction in particular and early surgical resection.
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Affiliation(s)
- Farouk Mookadam
- Division of Cardiovascular Diseases, Mayo Clinic, 13400 E. Shea Blvd, Scottsdale, AZ 85259, USA
| | - Panupong Jiamsripong
- Division of Cardiovascular Diseases, Mayo Clinic, 13400 E. Shea Blvd, Scottsdale, AZ 85259, USA
| | - Serageldin F Raslan
- Division of Cardiovascular Diseases, Mayo Clinic, 13400 E. Shea Blvd, Scottsdale, AZ 85259, USA
| | | | - A Jamil Tajik
- Division of Cardiovascular Diseases, Mayo Clinic, 13400 E. Shea Blvd, Scottsdale, AZ 85259, USA
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Sieber FE, Barnett SR. Preventing postoperative complications in the elderly. Anesthesiol Clin 2011; 29:83-97. [PMID: 21295754 DOI: 10.1016/j.anclin.2010.11.011] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Postoperative complications are directly related to poor surgical outcomes in the elderly. This review outlines evidence based quality initiatives focused on decreasing neurologic, cardiac, and pulmonary complications in the elderly surgical patient. Important anesthesia quality initiatives for prevention of delirium, the most common neurologic complication in elderly surgical patients, are outlined. There are few age-specific quality measures aimed at prevention of cardiac and pulmonary complications. However, some recommendations for adults can be applied to the geriatric surgical population. In the future, process measures may provide a more global assessment of quality in the elderly surgical population.
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Affiliation(s)
- Frederick E Sieber
- Department of Anesthesiology, Johns Hopkins Bayview Medical Center, Johns Hopkins Medical Institutions, 4940 Eastern Avenue, A588, Baltimore, MD 21224, USA.
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Bukata SV, Digiovanni BF, Friedman SM, Hoyen H, Kates A, Kates SL, Mears SC, Mendelson DA, Serna FH, Sieber FE, Tyler WK. A guide to improving the care of patients with fragility fractures. Geriatr Orthop Surg Rehabil 2011; 2:5-37. [PMID: 23569668 PMCID: PMC3597301 DOI: 10.1177/2151458510397504] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Susan V Bukata
- Corresponding Author: Associate Professor, Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, NY
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Kristen AV, Dengler TJ, Hegenbart U, Schonland SO, Goldschmidt H, Sack FU, Voss F, Becker R, Katus HA, Bauer A. Prophylactic implantation of cardioverter-defibrillator in patients with severe cardiac amyloidosis and high risk for sudden cardiac death. Heart Rhythm 2007; 5:235-40. [PMID: 18242546 DOI: 10.1016/j.hrthm.2007.10.016] [Citation(s) in RCA: 171] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Accepted: 10/06/2007] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cardiac light-chain amyloidosis carries a high risk for death predominantly from progressive cardiomyopathy or sudden death (SCD). Independent risk factors for SCD are syncope and complex nonsustained ventricular arrhythmias. OBJECTIVE The purpose of this study was to test whether prophylactic placement of an implantable cardioverter-defibrillator (ICD) reduces SCD in patients with cardiac amyloidosis. METHODS Nineteen patients with histologically proven cardiac amyloidosis and a history of syncope and/or ventricular extra beats (Lown grade IVa or higher) received an ICD. RESULTS During a mean follow-up of 811 +/- 151 days, two patients with sustained ventricular tachyarrhythmias were successfully treated by the ICD. Two patients underwent heart transplantation, and seven patients died due to electromechanical dissociation (n = 6) or glioblastoma (n = 1). Nonsurvivors more often showed progression of left ventricular wall thickness, low-voltage pattern, ventricular arrhythmias (Lown grade IVa or higher), and higher N-terminal pro-brain natriuretic peptide levels than did survivors. Bradycardias requiring ventricular pacing (VVI 40/min <1%, DDD 60/min 6% +/- 1%) occurred only rarely. CONCLUSION Patients with cardiac amyloidosis predominantly die as a result of electromechanical dissociation and other diagnoses not amenable to ICD therapy. Selected patients with cardiac amyloidosis may benefit from ICD placement. Better predictors of arrhythmia-associated SCD and randomized trials are required to elucidate the impact of ICD placement in high-risk patients with cardiac amyloidosis.
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Affiliation(s)
- Arnt V Kristen
- Department of Cardiology, Angiology, and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany.
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Lauro A, Diago Usò T, Masetti M, Di Benedetto F, Cautero N, De Ruvo N, Dazzi A, Quintini C, Begliomini B, Siniscalchi A, Ramacciato G, Risaliti A, Miller CM, Pinna AD. Liver Transplantation for Familial Amyloid Polyneuropathy Non-VAL30MET Variants: Are Cardiac Complications Influenced by Prophylactic Pacing and Immunosuppressive Weaning? Transplant Proc 2005; 37:2214-20. [PMID: 15964382 DOI: 10.1016/j.transproceed.2005.03.065] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2005] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cardiac complications represent a cause of morbidity and mortality after liver transplantation among patients with familial amyloid polyneuropathy (FAP), especially for the non-VAL30MET variant types. METHODS We retrospectively evaluated 11 recipients from a nonendemic area including 90.9% affected by FAP variants. Preoperative cardiovascular symptoms were present in 81% of patients. An intraoperative pacemaker was placed prophylactically in 90.9% of all recipients. Since tacrolimus has been reported in the international literature to display cardiac toxicity, we evaluated the influence of intraoperative prophylactic pacing and rapid postoperative weaning from tacrolimus, mainly allowed by thymoglobulin on the occurrence of posttransplantation cardiac complications. RESULTS One patient received a combined heart-liver transplant, another, living donor liver transplantation. We did not observe any significant intraoperative cardiac complications. Postoperatively, the pacemaker was removed from all patients but 1. Five patients received tacrolimus and steroids; a subsequent, second group of 6 patients (54.5%) was treated with thymoglobulin followed by tacrolimus. At discharge the mean tacrolimus level was 10.6 ng/mL, whereas after 1 month it was 7.5 ng/mL. We observed a case of acute cellular rejection before discharge, which was successfully treated with intravenous steroids and OKT3. After a mean follow-up of 17.4 months (range, 1-31), 2 patients had died (18.1%): 1 due to sepsis and another, to MI. Two recipients experienced cardiac complications (18.1%), namely, the patient who died due to an myocardial infarction and a second one with a tachyarrhythmia, which was treated successfully with beta-blockers and amiodarone. CONCLUSION Prophylactic pacing and rapid weaning from immunosuppression are still associated with a significant rate of postoperative cardiac complications.
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Affiliation(s)
- A Lauro
- UO Chirurgia dei Trapianti di Fegato e Multiorgano, PAD 25-Policlinico S. Orsola-Malpighi, Universitá di Bologna, Via Massarenti 9, 40138 Bologna, Italy.
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Neelakanta G, Mahajan A, Antin C. Systemic vasodilation is a predominant cause of hypotension in a patient with familial amyloid polyneuropathy during liver transplantation. J Clin Anesth 2005; 17:202-4. [PMID: 15896588 DOI: 10.1016/j.jclinane.2004.03.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2003] [Accepted: 03/08/2004] [Indexed: 11/23/2022]
Abstract
A patient with familial amyloid polyneuropathy underwent a living, nonrelated orthotopic liver transplant and developed hypotension after induction of anesthesia. Causes of hypotension in patients with familial amyloid polyneuropathy are discussed. Transesophageal echocardiographic monitoring was invaluable in differentiating various causes of hypotension and in diagnosing peripheral vasodilation as the predominant cause of hypotension.
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Affiliation(s)
- Gundappa Neelakanta
- Department of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA.
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Nowak G, Suhr OB, Wikström L, Wilczek H, Ericzon BG. The long-term impact of liver transplantation on kidney function in familial amyloidotic polyneuropathy patients. Transpl Int 2005; 18:111-5. [PMID: 15612992 DOI: 10.1111/j.1432-2277.2004.00015.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The aim of the study is to evaluate the long-term kidney function after liver transplantation (LTx) in familial amyloidotic polyneuropathy (FAP) Portuguese type patients and compare the findings with patients transplanted for chronic liver disease of other origin. We analysed the medical records of 32 FAP patients who underwent transplantation between 1990 and 1999 with a follow-up of more than 1 year after LTx. The control group consisted of 61 patients who had undergone LTx for chronic liver disease. Kidney function was measured by the glomerular filtration rate (GFR), serum creatinine and urea. There were no differences between the groups in creatinine and urea levels during the follow-up. However, during the first year after transplantation, the increase in creatinine and urea was significantly higher in the control group (P < 0.01). The decline in GFR after transplantation was also more pronounced in the controls (P < 0.01). Initially after LTx, kidney function deteriorated in both FAP and control patients, but the deterioration was more pronounced in the controls. The decline of the FAP patients' kidney function after LTx was not more pronounced than that observed in control patients, although many FAP patients' kidney function was impaired before the procedure, suggesting that LTx may halt the progression of kidney damage caused by amyloid deposition.
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Affiliation(s)
- Grzegorz Nowak
- Department of Transplantation Surgery, Karolinska Institute, Huddinge University Hospital, Stockholm, Sweden.
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Delahaye N, Le Guludec D, Dinanian S, Delforge J, Slama MS, Sarda L, Dollé F, Mzabi H, Samuel D, Adams D, Syrota A, Merlet P. Myocardial muscarinic receptor upregulation and normal response to isoproterenol in denervated hearts by familial amyloid polyneuropathy. Circulation 2001; 104:2911-6. [PMID: 11739305 DOI: 10.1161/hc4901.100380] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with familial amyloid polyneuropathy, a rare hereditary form of amyloidosis, have progressive autonomic neuropathy. The disease usually does not induce heart failure but is associated with sudden death, conduction disturbances, and an increased risk of complications during anesthesia. Although cardiac sympathetic denervation has been clearly demonstrated, the postsynaptic status of the cardiac autonomic nervous system remains unelucidated. METHODS AND RESULTS Twenty-one patients were studied (age, 39+/-11 years; normal coronary arteries; left ventricular ejection fraction 68+/-9%). To evaluate the density and affinity constants of myocardial muscarinic receptors, PET with (11)C-MQNB (methylquinuclidinyl benzilate), a specific hydrophilic antagonist, was used. Cardiac beta-receptor functional efficiency was studied by the heart rate (HR) response to intravenous infusion of isoproterenol (5 minutes after 2 mg of atropine, 5, 10, and 15 ng/kg per minute during 5 minutes per step). The mean muscarinic receptor density was higher in patients than in control subjects (B'(max), 35.5+/-8.9 versus 26.1+/-6.7 pmol/mL, P=0.003), without change in receptor affinity. The increase in HR after injection of atropine as well as of MQNB was lower in patients compared with control subjects despite a similar basal HR (DeltaHR after atropine, 11+/-21% versus 62+/-17%; P<0.001), consistent with parasympathetic denervation. Incremental infusion of isoproterenol induced a similar increase in HR in patients and control subjects. CONCLUSIONS Cardiac autonomic denervation in familial amyloid polyneuropathy results in an upregulation of myocardial muscarinic receptors but without change in cardiac beta-receptor responsiveness to catecholamines.
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Affiliation(s)
- N Delahaye
- Service de Médecine Nucléaire, Hôpital Bichat, AP-HP, Paris, France.
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Viana JS, Bento C, Vieira H, Neves S, Seco C, Perdigoto R, Craveiro AL, Furtado L. Requirements of circulatory support during liver transplantation: are patients with familial amyloidosis different from other patients? Transplant Proc 2000; 32:2652-3. [PMID: 11134745 DOI: 10.1016/s0041-1345(00)01825-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- J S Viana
- Department of Transplantation and Department of Anaesthesiology, University Hospitals of Coimbra, Coimbra, Portugal.
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Lång K, Wikström L, Danielsson A, Tashima K, Suhr OB. Outcome of gastrointestinal complications after liver transplantation for familial amyloidotic polyneuropathy. Scand J Gastroenterol 2000; 35:985-9. [PMID: 11063162 DOI: 10.1080/003655200750023084] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Gastrointestinal disturbances are important prognostic factors for mortality and morbidity after liver transplantation for familial amyloidotic polyneuropathy (FAP). However, the impact of liver transplantation on malabsorption and bacterial small-bowel contamination has not been evaluated. METHODS Twenty-three FAP patients were available for the study. They were examined for gastrointestinal disturbances as a part of the evaluation for liver transplantation for FAP. Bile acid malabsorption was diagnosed with the [75Se]-homocholic acid taurate (SeHCAT) test; fat malabsorption by measuring faecal fat excretion; and bacterial small-bowel contamination with the hydrogen breath test (HBT). RESULTS No significant improvement of malabsorption test results were noted from the pre-transplant evaluation 8 months (range, 2-20 months) before transplantation to the post-transplant evaluation performed a median of 20 months (range, 9-62 months) after the procedure. The SeHCAT test result became abnormal in two patients and normal in one, and changes in the test correlated with the time the patients were waiting for transplantation. Faecal fat excretion after transplantation correlated with duration of the disease and with fat excretion before transplantation. A significantly increased fat excretion was noted at the post-transplant evaluation. A change in HBT result was noted in only one patient, in whom the test result became normal; pre-transplant values correlated with those obtained after transplantation. CONCLUSION For most FAP patients no improvement in gastrointestinal function was found after transplantation. The finding underlines the importance of an early transplantation before the patients have developed gastrointestinal dysfunction.
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Affiliation(s)
- K Lång
- Dept. of Medicine, Piteå Hospital, Sweden
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Suhr OB, Ando Y, Ohlsson PI, Olofsson A, Andersson K, Lundgren E, Ando M, Holmgren G. Investigation into thiol conjugation of transthyretin in hereditary transthyretin amyloidosis. Eur J Clin Invest 1998; 28:687-92. [PMID: 9767365 DOI: 10.1046/j.1365-2362.1998.00345.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND For all forms of amyloidosis, the amyloid-generating mechanism is unknown. Familial amyloidotic polyneuropathy type I is caused by a variant transthyretin (TTR Met-30). As electrospray ionization mass spectrometry (ESI-MS) discloses both thiol-conjugated and -unconjugated forms of wild-type and variant TTR, we wanted to investigate the relationship between TTR conjugation and clinically overt amyloid disease. METHODS Plasma from 35 individuals (12 symptomatic TTR Met-30 carriers, nine asymptomatic and 14 healthy control subjects) were analysed using ESI-MS. RESULTS The total TTR concentration was significantly lower in symptomatic TTR Met-30 carriers than in control subjects. An increased percentage of conjugated TTR Met-30 was found in symptomatic carriers compared with asymptomatic, whereas the percentage conjugated wild-type TTR was similar for control subjects, asymptomatic and symptomatic TTR Met-30 carriers. CONCLUSION The finding of a decreased ratio of unconjugated to conjugated TTR Met-30 in plasma samples from symptomatic TTR Met-30 carriers indicates that thiol conjugation of TTR could be involved in amyloid formation.
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Affiliation(s)
- O B Suhr
- Department of Medicine, Umeå University Hospital, Sweden.
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Stangou AJ, Hawkins PN, Heaton ND, Rela M, Monaghan M, Nihoyannopoulos P, O'Grady J, Pepys MB, Williams R. Progressive cardiac amyloidosis following liver transplantation for familial amyloid polyneuropathy: implications for amyloid fibrillogenesis. Transplantation 1998; 66:229-33. [PMID: 9701270 DOI: 10.1097/00007890-199807270-00016] [Citation(s) in RCA: 140] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Circulating transthyretin (TTR) is derived from the liver, and orthotopic liver transplantation (OLT) is widely performed for variant TTR-associated familial amyloid polyneuropathy (FAP). The effect of OLT on FAP-related cardiac amyloid is of particular interest because wild-type TTR can itself be deposited as senile cardiac amyloid. METHODS Serial echocardiography was performed in 20 FAP patients, 14 of whom underwent OLT, and 10 other liver transplant patients. Follow-up included serum amyloid P component scintigraphy and measurement of plasma TTR before and after OLT. RESULTS Cardiac amyloidosis progressed rapidly in three FAP patients (TTR Pro52 and Thr84 mutations) after OLT, even though the deposits elsewhere had stabilized or regressed. Results of echocardiography improved in three transplant patients with TTR Met30 and remained normal in seven other patients. Plasma TTR levels were altered substantially after OLT, but they did not reflect the cardiac findings. CONCLUSIONS Although amyloid deposition in FAP is generally inhibited after OLT, cardiac amyloidosis can be exacerbated, probably due to enhanced deposition of wild-type TTR on a template of amyloid derived from variant TTR. The phenomenon may be mutation-dependent. These findings suggest that amyloid formation de novo and its subsequent accumulation can be promoted by different factors, which may be organ-specific.
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Affiliation(s)
- A J Stangou
- Institute of Hepatology, University College Hospital, London, England
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Jonsèn E, Athlin E, Suhr O. Familial amyloidotic patients' experience of the disease and of liver transplantation. J Adv Nurs 1998; 27:52-8. [PMID: 9515608 DOI: 10.1046/j.1365-2648.1998.00503.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Liver transplantation is a new treatment for familial amyloidotic polyneuropathy (FAP). No qualitative study examining these patients' experiences of the disease and the treatment has been published. The purpose of this study was to explore and describe the experience of the disease and the liver transplantation from the FAP patient's perspective. In-depth interviews with 11 liver transplant FAP patients were performed. The process of the FAP disease and a liver transplantation was found to involve the following categories: going downhill, defence and denial, a chance of surviving, the decision -- no choice, waiting powerless and uncertain, the first few steps after surgery, freed from the death sentence, still disabled, mastering up strength to recover, and the need for support and help.
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Affiliation(s)
- E Jonsèn
- Department of Medicine, Umeå University Hospital, Sweden
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Viana JS, Neves S, Vieira H, Bento C, Perdigoto R, Furtado AL. Serum potassium concentrations after suxamethonium in patients with familial amyloid polyneuropathy type I. Acta Anaesthesiol Scand 1997; 41:750-3. [PMID: 9241337 DOI: 10.1111/j.1399-6576.1997.tb04778.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Suxamethonium produces an abnormal increase in serum potassium in some neurological diseases and some authors have suggested that it is safer not to use this drug in patients with familial amyloid polyneuropathy (FAP). However, there are no data previously reported to support this hypothesis. The aim of this study was to evaluate the magnitude of the potassium increase produced by suxamethonium in FAP type I. METHOD Twenty-one FAP Met 30 patients anaesthetised for liver transplantation were studied. Age was 34.9 +/- 6.9 years (mean +/- SD), time elapsed from first symptom 5.5 +/- 3.2 years and weight was 14 +/- 9% below ideal body weight. Anaesthesia was induced with thiopentone and low-dose fentanyl. Samples for blood gas and 5 min after 1 mg/kg of suxamethonium was given for tracheal intubation. RESULTS Before induction serum potassium levels were 3.8 +/- 0.4 mmol/L. One minute after suxamethonium, values were 3.8 +/- 0.4 mmol/L and 5 min after 4.3 +/- 0.5 mmol/L. The maximal increase observed was 1.6 mmol/L (from 3.4 mmol/L to 5.0 mmol/L). CONCLUSION The average increase in plasma potassium concentrations observed in FAP patients after suxamethonium was similar to the increase observed in a normal population by others. Our study can exclude the hypothesis that an anomalous increase in potassium would be a typical and frequent response to suxamethonium in FAP met 30 patients. However, we cannot exclude that a dangerous rise in serum potassium may exist in a certain percentage of FAP patients.
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Affiliation(s)
- J S Viana
- Department of Anaesthesiology, University Hospitals of Coimbra, Portugal
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Affiliation(s)
- S S Kushwaha
- Cardiovascular Institute, Mount Sinai Medical Center, New York, NY 10029, USA
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Tallgren M, Hockerstedt K, Isoniemi H, Orko R, Lindgren L. Intraoperative Death in Cardiac Amyloidosis with Increased QT Dispersion in the Electrocardiogram. Anesth Analg 1995. [DOI: 10.1213/00000539-199506000-00028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Tallgren M, Höckerstedt K, Isoniemi H, Orko R, Lindgren L. Intraoperative death in cardiac amyloidosis with increased QT dispersion in the electrocardiogram. Anesth Analg 1995; 80:1233-5. [PMID: 7762857 DOI: 10.1097/00000539-199506000-00028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- M Tallgren
- Department of Anaesthesia, Helsinki University Central Hospital, Finland
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Suhr O, Danielsson A, Holmgren G, Steen L. Malnutrition and gastrointestinal dysfunction as prognostic factors for survival in familial amyloidotic polyneuropathy. J Intern Med 1994; 235:479-85. [PMID: 8182405 DOI: 10.1111/j.1365-2796.1994.tb01106.x] [Citation(s) in RCA: 152] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To describe the evolution of nutritional and neurological complications in a Swedish population of patients with familial amyloidotic polyneuropathy, and to identify prognostic factors and useful tests for monitoring the progress of the disease. DESIGN Prospective and retrospective study of patients with familial amyloidotic polyneuropathy. SETTING Tertiary referral centre. SUBJECTS Twenty-seven patients with familial amyloidotic polyneuropathy, and a symptomatic onset before the age of 50. MAIN OUTCOME MEASURES Age at onset, duration of disease before death, serum albumin, body mass index (BMI), duration and grade of peripheral neuropathy and gastrointestinal disturbances. Faecal fat, xylose test and 75selenohomocholic acid-taurine (SeHCAT) test were used for assessment of malabsorption. RESULTS Thirteen patients died during the study period after a disease duration of between 9 and 18 years (mean 13). A short time interval between the onset of neurological and of gastrointestinal symptoms had greater impact on survival than age at onset in this selected group of patients (r = 0.65; P = 0.017). Malnutrition was evaluated by multiplying the [body weight (kg)/height2 (m)] with the serum albumin to compensate for oedema. This modified body mass index (mBMI) was significantly correlated to the number of years before death (r = 0.89; P < 0.0005) and to the duration of gastrointestinal symptoms (r = -0.66; P < 0.0005), but not to duration of disease (r = -0.2; P = 0.20). Polyneuropathy was graded according to functional capacity from I to IV (PND score) and was correlated to the number of years before death and mBMI, but not to serum albumin. The SeHCAT test for bile acid malabsorption was significantly correlated to the duration of gastrointestinal symptoms and to mBMI (r = -0.67; P = 0.0003 and r = -0.62; P = 0.003, respectively). CONCLUSION The investigation disclosed that a short time interval between the onset of neurological and of gastrointestinal symptoms is associated with a decreased survival time. The mBMI was closely related to time before death, duration of gastrointestinal disturbances, malabsorption and functional capacity. The mBMI appears to be well suited to monitoring disease progress and gives prognostic information.
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Affiliation(s)
- O Suhr
- Section of Gastroenterology, University Hospital, Sweden
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Hirabayashi Y, Yokosuka S, Miyashita K, Shimizu R. Anesthetic management for a patient with amyloidosis. J Anesth 1992; 6:218-21. [PMID: 15278569 DOI: 10.1007/s0054020060218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/1991] [Accepted: 09/11/1991] [Indexed: 10/26/2022]
Affiliation(s)
- Y Hirabayashi
- Department of Anesthesiology, Jichi Medical School, Tochigi, Japan
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Affiliation(s)
- D R Jacobson
- Medical Service, New York Veterans Affairs Medical Center, New York
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Affiliation(s)
- R A Kyle
- Mayo Medical School, Rochester, Minnesota
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Castro Tavares J, Maciel L. Anaesthetic management of a patient with familial amyloid polyneuropathy of the Portuguese type. Can J Anaesth 1989; 36:209-11. [PMID: 2539910 DOI: 10.1007/bf03011446] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Although familial amyloid polyneuropathy of the Portuguese type (FAP-PT) was first described in 1952, there is little in the medical literature detailing the anaesthetic management of such patients. FAP-PT is a disease with multiple clinical manifestations which include disturbances of sensibility, progressive paresis starting in the lower extremities, autonomic dysfunction, cardiac conduction disturbances, gastro-intestinal disorders, nephrotic syndrome, sexual and sphincter disorders, extreme emotionalism and apprehension. Several intermingling problems have to be considered in the anaesthetic management of each individual case. In our patient a sinus dysrhythmia resolved after isoflurane and this seems to be a good choice for general anaesthesia in patients with FAP-PT, if they are in an early stage of heart involvement.
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