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Sakamoto S, Kasahara M, Mazariegos GV. The role of pediatric living donor liver transplantation for inherited metabolic disorders. Pediatr Transplant 2024; 28:e14764. [PMID: 38659232 DOI: 10.1111/petr.14764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/27/2024] [Accepted: 04/08/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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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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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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McKiernan PJ, Ganoza A, Squires JE, Squires RH, Vockley J, Mazariegos G, Soltys K, Sun Q, Sindhi R. Evolving Trends in Liver Transplant for Metabolic Liver Disease in the United States. Liver Transpl 2019; 25:911-921. [PMID: 30753750 DOI: 10.1002/lt.25433] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 02/02/2019] [Indexed: 02/07/2023]
Abstract
Indications for liver transplantation (LT) in metabolic disease are evolving. We reviewed the US experience with primary LT for metabolic disease in the Scientific Registry for Transplant Recipients (October 1987 to June 2017) to determine the following: temporal changes in indications, longterm outcomes, and factors predicting survival. Patients were grouped by the presence of structural liver disease (SLD) and whether the defect was confined to the liver. There were 5996 patients who underwent LT for metabolic disease, 2354 (39.3%) being children. LT for metabolic disease increased in children but not in adults. Children experienced a 6-fold increase in LT for metabolic disease without SLD. Indications for LT remained stable in adults. Living donor liver transplantation increased between era 1 and era 3 from 5.6% to 7.6% in children and 0% to 4.5% in adults. Patient and graft survival improved with time. The latest 5-year patient survival rates were 94.5% and 81.5% in children and adults, respectively. Outcomes were worse in adults and in those with extrahepatic disease (P < 0.01), whereas SLD did not affect outcomes. Survival improved with younger age at LT until age <2 years. On multivariate analysis, diagnostic category, inpatient status, age at LT, and transplant era significantly predicted outcomes in all ages with male sex predicting survival in childhood only. Children without structural disease were less likely to die awaiting LT and had improved post-LT survival compared with children with chronic liver disease. In conclusion, LT for metabolic disease is increasingly used for phenotypic correction in children; extrahepatic manifestations significantly impact survival at all ages; where indicated, transplantation should not be unnecessarily delayed; and the development of new allocation models may be required.
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Affiliation(s)
- Patrick J McKiernan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA.,Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Armando Ganoza
- Hillman Center for Pediatric Transplantation, University of Pittsburgh, Pittsburgh, PA
| | - James E Squires
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA.,Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Robert H Squires
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA.,Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Jerry Vockley
- Division of Medical Genetics, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA
| | - George Mazariegos
- Hillman Center for Pediatric Transplantation, University of Pittsburgh, Pittsburgh, PA
| | - Kyle Soltys
- Hillman Center for Pediatric Transplantation, University of Pittsburgh, Pittsburgh, PA
| | - Qing Sun
- Hillman Center for Pediatric Transplantation, University of Pittsburgh, Pittsburgh, PA
| | - Rakesh Sindhi
- Hillman Center for Pediatric Transplantation, University of Pittsburgh, Pittsburgh, PA
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Abi-Wardé MT, Roda C, Arnoux JB, Servais A, Habarou F, Brassier A, Pontoizeau C, Barbier V, Bayart M, Leboeuf V, Chadefaux-Vekemans B, Dubois S, Assoun M, Belloche C, Alili JM, Husson MC, Lesage F, Dupic L, Theuil B, Ottolenghi C, de Lonlay P. Long-term metabolic follow-up and clinical outcome of 35 patients with maple syrup urine disease. J Inherit Metab Dis 2017; 40:783-792. [PMID: 28905140 DOI: 10.1007/s10545-017-0083-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 08/16/2017] [Accepted: 08/18/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Maple syrup urine disease (MSUD) is a rare disease that requires a protein-restricted diet for successful management. Little is known, however, about the psychosocial outcome of MSUD patients. This study investigates the relationship between metabolic and clinical parameters and psychosocial outcomes in a cohort of patients with neonatal-onset MSUD. METHODS Data on academic achievement, psychological care, family involvement, and biochemical parameters were collected from the medical records of neonatal MSUD patients treated at Necker Hospital (Paris) between 1964 and 2013. RESULTS Thirty-five MSUD patients with a mean age of 16.3 (2.1-49.0) years participated. Metabolic decompensations (plasma leucine >380 μmol/L) were more frequent during the first year of life and after 15 years, mainly due to infection and dietary noncompliance, respectively. Leucine levels increased significantly in adulthood: 61.5% of adults were independent and achieved adequate social and professional integration; 56% needed occasional or sustained psychological or psychiatric care (8/19, with externalizing, mood, emotional, and anxiety disorders being the most common). Patients needing psychiatric care were significantly older [mean and standard deviation (SD) 22.6 (7.7) years] than patients needing only psychological follow-up [mean (SD) 14.3 (8.9) years]. Patients with psychological follow-up experienced the highest lifetime number of decompensations; 45% of families had difficulty coping with the chronic disease. Parental involvement was negatively associated with the number of lifetime decompensations. CONCLUSION Adults had increased levels of plasma leucine, consistent with greater chronic toxicity. Psychological care was associated with age and number of decompensations. In addition, parental involvement appeared to be crucial in the management of MSUD patients.
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Affiliation(s)
- Marie-Thérèse Abi-Wardé
- Reference Center of Inherited Metabolic Diseases, Hospital Necker Enfants Malades, APHP, Institute Imagine, University Paris Descartes, Paris, France
| | - Célina Roda
- Reference Center of Inherited Metabolic Diseases, Hospital Necker Enfants Malades, APHP, Institute Imagine, University Paris Descartes, Paris, France
| | - Jean-Baptiste Arnoux
- Reference Center of Inherited Metabolic Diseases, Hospital Necker Enfants Malades, APHP, Institute Imagine, University Paris Descartes, Paris, France
| | - Aude Servais
- Reference Center of Inherited Metabolic Diseases, Hospital Necker Enfants Malades, APHP, Institute Imagine, University Paris Descartes, Paris, France
- Department of Nephrology-Transplantation, Hospital Necker Enfants Malades, APHP, University Paris Descartes, Paris, France
| | - Florence Habarou
- Reference Center of Inherited Metabolic Diseases, Hospital Necker Enfants Malades, APHP, Institute Imagine, University Paris Descartes, Paris, France
- Metabolic Biochemistry, Hospital Necker Enfants Malades, APHP, University Paris Descartes, Paris, France
| | - Anais Brassier
- Reference Center of Inherited Metabolic Diseases, Hospital Necker Enfants Malades, APHP, Institute Imagine, University Paris Descartes, Paris, France
| | - Clément Pontoizeau
- Metabolic Biochemistry, Hospital Necker Enfants Malades, APHP, University Paris Descartes, Paris, France
| | - Valérie Barbier
- Reference Center of Inherited Metabolic Diseases, Hospital Necker Enfants Malades, APHP, Institute Imagine, University Paris Descartes, Paris, France
| | - Manuella Bayart
- Reference Center of Inherited Metabolic Diseases, Hospital Necker Enfants Malades, APHP, Institute Imagine, University Paris Descartes, Paris, France
| | - Virginie Leboeuf
- Reference Center of Inherited Metabolic Diseases, Hospital Necker Enfants Malades, APHP, Institute Imagine, University Paris Descartes, Paris, France
| | - Bernadette Chadefaux-Vekemans
- Reference Center of Inherited Metabolic Diseases, Hospital Necker Enfants Malades, APHP, Institute Imagine, University Paris Descartes, Paris, France
- Metabolic Biochemistry, Hospital Necker Enfants Malades, APHP, University Paris Descartes, Paris, France
| | - Sandrine Dubois
- Reference Center of Inherited Metabolic Diseases, Hospital Necker Enfants Malades, APHP, Institute Imagine, University Paris Descartes, Paris, France
| | - Murielle Assoun
- Reference Center of Inherited Metabolic Diseases, Hospital Necker Enfants Malades, APHP, Institute Imagine, University Paris Descartes, Paris, France
| | - Claire Belloche
- Reference Center of Inherited Metabolic Diseases, Hospital Necker Enfants Malades, APHP, Institute Imagine, University Paris Descartes, Paris, France
| | - Jean-Meidi Alili
- Pharmaceutical Establishment of APHP, AGEPS, APHP, Paris, France
| | | | - Fabrice Lesage
- Reference Center of Inherited Metabolic Diseases, Hospital Necker Enfants Malades, APHP, Institute Imagine, University Paris Descartes, Paris, France
- Intensive Care Unit, Hospital Necker Enfants Malades, APHP, University Paris Descartes, Paris, France
| | - Laurent Dupic
- Reference Center of Inherited Metabolic Diseases, Hospital Necker Enfants Malades, APHP, Institute Imagine, University Paris Descartes, Paris, France
- Intensive Care Unit, Hospital Necker Enfants Malades, APHP, University Paris Descartes, Paris, France
| | - Benoit Theuil
- Department of Child and Adolescent Psychiatry, Hospital Bichat Claude Bernard, APHP, University Denis Diderot Paris 7, Paris, France
| | - Chris Ottolenghi
- Reference Center of Inherited Metabolic Diseases, Hospital Necker Enfants Malades, APHP, Institute Imagine, University Paris Descartes, Paris, France
- Metabolic Biochemistry, Hospital Necker Enfants Malades, APHP, University Paris Descartes, Paris, France
| | - Pascale de Lonlay
- Reference Center of Inherited Metabolic Diseases, Hospital Necker Enfants Malades, APHP, Institute Imagine, University Paris Descartes, Paris, France.
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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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Celik N, Squires RH, Vockley J, Sindhi R, Mazariegos G. Liver transplantation for maple syrup urine disease: A global domino effect. Pediatr Transplant 2016; 20:350-1. [PMID: 27038300 DOI: 10.1111/petr.12697] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Neslihan Celik
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Robert H Squires
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Jerry Vockley
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Rakesh Sindhi
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - George Mazariegos
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.
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Feier F, Schwartz IVD, Benkert AR, Seda Neto J, Miura I, Chapchap P, da Fonseca EA, Vieira S, Zanotelli ML, Pinto e Vairo F, Camelo JS, Margutti AVB, Mazariegos GV, Puffenberger EG, Strauss KA. Living related versus deceased donor liver transplantation for maple syrup urine disease. Mol Genet Metab 2016; 117:336-43. [PMID: 26786177 DOI: 10.1016/j.ymgme.2016.01.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 01/10/2016] [Accepted: 01/10/2016] [Indexed: 01/04/2023]
Abstract
Maple syrup urine disease (MSUD) is an inherited disorder of branched chain ketoacid (BCKA) oxidation associated with episodic and chronic brain disease. Transplantation of liver from an unrelated deceased donor restores 9-13% whole-body BCKA oxidation capacity and stabilizes MSUD. Recent reports document encouraging short-term outcomes for MSUD patients who received a liver segment from mutation heterozygous living related donors (LRDT). To investigate effects of living related versus deceased unrelated grafts, we studied four Brazilian MSUD patients treated with LRDT who were followed for a mean 19 ± 12 postoperative months, and compared metabolic and clinical outcomes to 37 classical MSUD patients treated with deceased donor transplant. Patient and graft survival for LRDT were 100%. Three of 4 MSUD livers were successfully domino transplanted into non-MSUD subjects. Following LRDT, all subjects resumed a protein-unrestricted diet as mean plasma leucine decreased from 224 ± 306 μM to 143 ± 44 μM and allo-isoleucine decreased 91%. We observed no episodes of hyperleucinemia during 80 aggregate postoperative patient-months. Mean plasma leucine:isoleucine:valine concentration ratios were ~2:1:4 after deceased donor transplant compared to ~1:1:1.5 following LRDT, resulting in differences of predicted cerebral amino acid uptake. Mutant heterozygous liver segments effectively maintain steady-state BCAA and BCKA homeostasis on an unrestricted diet and during most catabolic states, but might have different metabolic effects than grafts from unrelated deceased donors. Neither living related nor deceased donor transplant affords complete protection from metabolic intoxication, but both strategies represent viable alternatives to nutritional management.
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Affiliation(s)
- Flavia Feier
- Hospital Sirio Libanes, São Paulo, Brazil; Hospital Santa Casa de Misericórdia, Porto Alegre, Brazil
| | - Ida Vanessa D Schwartz
- Medical Genetics Service, Hospital de Clinicas de Porto Alegre, Brazil; Genetics Department, Universidade Federal do Rio Grande do Sul, Brazil
| | | | | | | | | | | | - Sandra Vieira
- Pediatrics Department, Universidade Federal do Rio Grande do Sul, Brazil; Pediatrics Liver Transplantation Program, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Maria Lúcia Zanotelli
- Pediatrics Liver Transplantation Program, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | | | - Jose Simon Camelo
- Pediatrics Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | | | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, Children's Hospital of UPMC, Pittsburgh, PA, USA
| | - Erik G Puffenberger
- Clinic for Special Children, Strasburg, PA, USA; Franklin & Marshall College, Lancaster, PA, USA
| | - Kevin A Strauss
- Clinic for Special Children, Strasburg, PA, USA; Franklin & Marshall College, Lancaster, PA, USA; Lancaster General Hospital, Lancaster, PA, USA.
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