1
|
Choudhary D, Lekshmon K, Singh C, Subramani VN, Singh Y, Mitra S, Sekar A, Malik M, Bhagat N, Shiva Kumar S, Taneja S, Gupta V, Ramachandran R, Singh S, Nada R, Kenwar D, Duseja AK, Yadav T, Malhotra P, Sharma A. Simultaneous Liver and Kidney Transplantation in a Patient With Telomere Biology Disorder: A Case Study. J Clin Exp Hepatol 2024; 14:101355. [PMID: 38389866 PMCID: PMC10879790 DOI: 10.1016/j.jceh.2024.101355] [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: 11/29/2023] [Accepted: 01/27/2024] [Indexed: 02/24/2024] Open
Abstract
Organ transplantation is the primary therapy for organ failure caused by telomere biology disorder (TBD). We describe the first documented case of simultaneous liver and kidney transplantation (SLKTx) for TBD, although the diagnosis of TBD was reached only three months following SLKTx. The patient was born prematurely, displayed growth retardation, and developed chronic kidney and liver diseases. His pre-SLKTx autoimmune, metabolic, and viral assessments were negative, and persistent pancytopenia (bone marrow cellularity 70-80%) was attributed to renal disease-associated bone marrow changes. Following SLKTx, he was discharged with stable graft function on tacrolimus and prednisolone. Although mycophenolate mofetil was discontinued on the second postoperative day, his pancytopenia persisted. Despite extensive evaluations, including drug, immune, nutritional, and viral assessments, all results were negative. A bone marrow biopsy conducted three months post-transplant revealed significant hypocellularity (40-50%). Whole genome sequencing revealed a likely pathogenic variant of the TINF2 gene. The patient was subsequently treated with danazol. At the nine-month follow-up post-SLKTx, he exhibited stable graft function and improved cell counts while maintaining triple-drug immunosuppression. Given the lack of uniform diagnostic criteria for TBD, healthcare providers must be vigilant with patients presenting with multi-organ failure and persistent cytopenias. Effective pre-transplant screening for TBD can lead to timely diagnoses, better management, and improved post-transplant outcomes.
Collapse
Affiliation(s)
- Devprakash Choudhary
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| | - K.S. Lekshmon
- Department of Haematology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| | - Charanpreet Singh
- Department of Haematology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| | - Vanji N. Subramani
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| | - Yogendra Singh
- Department of Hepatology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| | - Suvradeep Mitra
- Department of Pathology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| | - Aravind Sekar
- Department of Pathology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| | - Manaswinee Malik
- Department of Haematology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| | - Naveen Bhagat
- Department of Hepatology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| | - S.P. Shiva Kumar
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| | - Sunil Taneja
- Department of Hepatology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| | - Vikas Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| | - Raja Ramachandran
- Department of Nephrology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| | - Sarbpreet Singh
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| | - Ritambhra Nada
- Department of Pathology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| | - Deepesh Kenwar
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| | - Ajay K. Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| | - T.D. Yadav
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| | - Pankaj Malhotra
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| | - Ashish Sharma
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India
| |
Collapse
|
2
|
Vittal A, Niewisch MR, Bhala S, Kudaravalli P, Rahman F, Hercun J, Kleiner DE, Savage SA, Koh C, Heller T, Giri N. Progression of liver disease and portal hypertension in dyskeratosis congenita and related telomere biology disorders. Hepatology 2023; 78:1777-1787. [PMID: 37184208 PMCID: PMC10733788 DOI: 10.1097/hep.0000000000000461] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/28/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND AND AIMS Dyskeratosis congenita (DC) and related telomere biology disorders (TBD) are characterized by very short telomeres and multisystem organ involvement including liver disease. Our study aimed to characterize baseline hepatic abnormalities in patients with DC/TBD and determine risk factors associated with liver disease progression. APPROACH AND RESULTS A retrospective review was performed on a cohort of 58 patients (39 males) with DC/TBD who were prospectively evaluated at a single institute from 2002 to 2019. The median age at initial assessment was 18 (1.4-67.6) years, and median follow-up duration was 6 (1.4-8.2) years. Patients with autosomal or X-linked recessive inheritance and those with heterozygous TINF2 DC were significantly younger, predominantly male, and more likely to have DC-associated mucocutaneous triad features and severe bone marrow failure compared with autosomal dominant-non- TINF2 DC/TBD patients. Liver abnormality (defined at baseline assessment by laboratory and/or radiological findings) was present in 72.4% of patients with predominantly cholestatic pattern of liver enzyme elevation. Clinically significant liver disease and portal hypertension developed in 17.2% of patients during the 6-year follow-up; this progression was mainly seen in patients with recessive or TINF2 -associated DC. Significant risk factors associated with progression included the presence of pulmonary or vascular disease. CONCLUSIONS Our experience shows a high prevalence of cholestatic pattern of liver abnormality with progression to portal hypertension in patients with DC/TBD. Presence of pulmonary and/or vascular disease in patients with recessive or TINF2 DC was an important predictor of liver disease progression, suggesting the need for increased vigilance and monitoring for complications in these patients.
Collapse
Affiliation(s)
- Anusha Vittal
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Marena R. Niewisch
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Sonia Bhala
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Pujitha Kudaravalli
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Farial Rahman
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Julian Hercun
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - David E. Kleiner
- Laboratory of Pathology, National Cancer Institute, Bethesda, Maryland, USA
| | - Sharon A. Savage
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Christopher Koh
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Theo Heller
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Neelam Giri
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| |
Collapse
|
3
|
Pasantes DG, Pérez AG, Orozco JG, Polo JIR, Seoane RÁ, González JA, Gutiérrez MG. Use of the Extracorporeal Membrane Oxygenation System for Severe Cardiocirculatory Dysfunction During Combined Liver-Lung Transplant: A Case Report. Transplant Proc 2022; 54:2556-2558. [PMID: 36319492 DOI: 10.1016/j.transproceed.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/02/2022] [Accepted: 09/02/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Dora Gómez Pasantes
- Department of General Surgery, Liver Transplantation Unit, University Hospital Complex A Coruña, A Coruña, Spain.
| | - Alejandro García Pérez
- Department of Thoracic Surgery, Lung Transplantation Unit, University Hospital Complex A Coruña, A Coruña, Spain
| | - Julián García Orozco
- Department of General Surgery, Liver Transplantation Unit, University Hospital Complex A Coruña, A Coruña, Spain
| | - José Ignacio Rivas Polo
- Department of General Surgery, Liver Transplantation Unit, University Hospital Complex A Coruña, A Coruña, Spain
| | - Rosa Álvarez Seoane
- Department of General Surgery, Liver Transplantation Unit, University Hospital Complex A Coruña, A Coruña, Spain
| | | | - Manuel Gómez Gutiérrez
- Department of General Surgery, Liver Transplantation Unit, University Hospital Complex A Coruña, A Coruña, Spain
| |
Collapse
|
4
|
Wu WK, Grogan WM, Ziogas IA, Patel YJ, Bacchetta M, Alexopoulos SP. Extracorporeal membrane oxygenation in patients with hepatopulmonary syndrome undergoing liver transplantation: A systematic review of the literature. Transplant Rev (Orlando) 2022; 36:100693. [DOI: 10.1016/j.trre.2022.100693] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/31/2022] [Accepted: 04/03/2022] [Indexed: 02/07/2023]
|
5
|
Niewisch MR, Giri N, McReynolds LJ, Alsaggaf R, Bhala S, Alter BP, Savage SA. Disease progression and clinical outcomes in telomere biology disorders. Blood 2022; 139:1807-1819. [PMID: 34852175 PMCID: PMC8952184 DOI: 10.1182/blood.2021013523] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/11/2021] [Indexed: 11/20/2022] Open
Abstract
Dyskeratosis congenita related telomere biology disorders (DC/TBDs) are characterized by very short telomeres caused by germline pathogenic variants in telomere biology genes. Clinical presentations can affect all organs, and inheritance patterns include autosomal dominant (AD), autosomal recessive (AR), X-linked (XLR), or de novo. This study examined the associations between mode of inheritance with phenotypes and long-term clinical outcomes. Two hundred thirty-one individuals with DC/TBDs (144 male, 86.6% known genotype, median age at diagnosis 19.4 years [range 0 to 71.6]), enrolled in the National Cancer Institute's Inherited Bone Marrow Failure Syndrome Study, underwent detailed clinical assessments and longitudinal follow-up (median follow-up 5.2 years [range 0 to 36.7]). Patients were grouped by inheritance pattern, considering AD-nonTINF2, AR/XLR, and TINF2 variants separately. Severe bone marrow failure (BMF), severe liver disease, and gastrointestinal telangiectasias were more prevalent in AR/XLR or TINF2 disease, whereas pulmonary fibrosis developed predominantly in adults with AD disease. After adjusting for age at DC/TBD diagnosis, we observed the highest cancer risk in AR/XLR individuals. At last follow-up, 42% of patients were deceased with a median overall survival (OS) of 52.8 years (95% confidence interval [CI] 45.5-57.6), and the hematopoietic cell or solid organ transplant-free median survival was 45.3 years (95% CI 37.4-52.1). Significantly better OS was present in AD vs AR/XLR/TINF2 disease (P < .01), while patients with AR/XLR and TINF2 disease had similar survival probabilities. This long-term study of the clinical manifestations of DC/TBDs creates a foundation for incorporating the mode of inheritance into evidence-based clinical care guidelines and risk stratification in patients with DC/TBDs. This trial was registered at www.clinicaltrials.gov as #NCT00027274.
Collapse
Affiliation(s)
- Marena R Niewisch
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Neelam Giri
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Lisa J McReynolds
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Rotana Alsaggaf
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Sonia Bhala
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Blanche P Alter
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Sharon A Savage
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| |
Collapse
|
6
|
Huang J, Yoeli D, Sundaram SS, Carpenter T, Annam A, Pahlavan S, Wachs M, Adams MA. Extracorporeal membrane oxygenation as rescue therapy in a pediatric liver transplant recipient with very severe hepatopulmonary syndrome. Pediatr Transplant 2022; 26:e14185. [PMID: 34741368 DOI: 10.1111/petr.14185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/22/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND In children with cirrhosis, the prevalence of HPS ranges from 3% to 20%, resulting in impaired gas exchange due to alterations in pulmonary microvasculature. LT is the gold-standard cure for cirrhosis complicated by HPS and should ideally be performed prior to the development of severe HPS due to increased risk for post-transplant hypoxia, right heart failure, and outflow obstruction. METHODS We present a case of a 13-year-old man, who underwent pediatric LT for severe HPS complicated by postoperative respiratory collapse, requiring a 92-day course of veno-venous ECMO. RESULTS Post-transplant, despite BiPAP, inhaled nitric oxide and isoproterenol infusion, he remained hypoxic postoperatively and acutely decompensated on postoperative day 25, requiring veno-venous ECMO. After 84 days on ECMO, a persistent large splenorenal shunt was identified that was embolized by interventional radiology, and 8 days after shunt embolization and ASD closure, he was successfully weaned off ECMO. CONCLUSIONS This case describes the longest known duration of ECMO in a pediatric LT recipient and a unique improvement in hypoxemia following a portosystemic shunt closure. ECMO presents a heroic rescue measure for pediatric LT recipients with HPS that develops acute respiratory failure postoperatively refractory to alternative measures.
Collapse
Affiliation(s)
- Joy Huang
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Dor Yoeli
- Division of Transplant Surgery, Colorado Center for Transplantation Care, Research and Education, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Shikha S Sundaram
- Section of Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Todd Carpenter
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Aparna Annam
- Division of Pediatric Radiology, Department of Radiology, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Sheila Pahlavan
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael Wachs
- Colorado Center for Transplantation Care, Research and Education, Division of Transplant Surgery, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Megan A Adams
- Colorado Center for Transplantation Care, Research and Education, Division of Transplant Surgery, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| |
Collapse
|