Liver Transplantation and Combined Liver-Heart Transplantation in Patients with Familial Amyloid Polyneuropathy: A Single-Center Experience

Transcription

1 LIVER TRANSPLANTATION 16: , 2010 ORIGINAL ARTICLE Liver Transplantation and Combined Liver-Heart Transplantation in Patients with Familial Amyloid Polyneuropathy: A Single-Center Experience Ana-Paula Barreiros, 1 Felix Post, 2 Maria Hoppe-Lotichius, 3 Reinhold P. Linke, 5 Christian F. Vahl, 4 Hans-Joachim Schäfers, 6 Peter R. Galle, 1 and Gerd Otto 3 Departments of 1 Internal Medicine I, 2 Internal Medicine II, 3 Transplantation Surgery, and 4 Cardiothoracic and Vascular Surgery, Johannes Gutenberg University, Mainz, Germany; 5 Reference Center of Amyloid Diseases amymed-1zb, Martinsried, Germany; and 6 Department of Cardiothoracic and Vascular Surgery, University Clinic of Saarland, Homburg/Saar, Germany Liver transplantation (LT) is the only curative option for patients with familial amyloid polyneuropathy (FAP) at present. Twenty patients with FAP underwent LT between May 1998 and June Transthyretin mutations included predominantly the Val30Met mutation but also 10 other mutations. Seven patients received a pacemaker prior to LT, and because of impairment of mechanical cardiac function, 4 combined heart-liver transplants were performed, 1 simultaneously and 3 sequentially. The first patient, who underwent simultaneous transplantation, died. Seven patients died after LT, with 5 dying within the first year after transplantation. The causes of death were cardiac complications (4 patients), infections (2 patients), and malnutrition (1 patient). One-year survival was 75.0%, and 5-year survival was 64.2%. Gly47Glu and Leu12- Pro mutations showed an aggressive clinical manifestation: 2 patients with the Gly47Glu mutation, the youngest patients of all the non-val30met patients, suffered from severe cardiac symptoms leading to death despite LT. Two siblings with the Leu12Pro mutation, who presented only with grand mal seizures, died after LT because of sepsis. In conclusion, the clinical course in patients with FAP is very variable. Cardiac symptoms occurred predominantly in patients with non-val30met mutations and prompted combined heart-liver transplantation in 4 patients. Although early LT in Val30Met is indicated in order to halt the typical symptoms of polyneuropathy, additional complications occurring predominantly with other mutations may prevail and lead to life-threatening complications or a fatal outcome. Combined heart-liver transplantation should be considered in patients with restrictive cardiomyopathy. Liver Transpl 16: , VC 2010 AASLD. Received July 17, 2009; accepted November 11, Familial amyloid polyneuropathy (FAP; also known as familiar amyloidosis and hereditary amyloidosis) is an inherited autosomal-dominant disease due to mutations of the transthyretin (TTR) gene coding for the corresponding protein, which consists of 127 amino acids. The gene is located on chromosome 18q. Other mutant precursor proteins produced in the liver, such as serum amyloid A protein, apolipoprotein I, apolipoprotein II, lysozyme, and fibrinogen Aa-chain may be of etiological importance as well. 1 Amyloidogenic mutations of the TTR gene may lead to decreased stability of the corresponding protein and subsequently to extracellular deposition of amyloid in several tissues. The Val30Met mutation, also known as the Portuguese variant, is the most prevalent cause of FAP in heterozygotes. The onset of symptoms is usually between 20 and 35 years of age, but late-onset families are also known. Abbreviations: ATTR, amyloidosis transthyretin; AV, atrioventricular; CMP, cardiomyopathy; CMV, cytomegalovirus; FAP, familial amyloid polyneuropathy; GMS, grand mal seizure; HLT, combined heart-liver transplantation; HTX, heart transplantation; LT, liver transplantation; LVEF, left ventricular ejection fraction; NE, not elevated; PM, pacemaker; SA, sinoatrial; TTR, transthyretin; Tx, transplantation; VZV, varicella zoster virus. Address reprint requests to Ana-Paula Barreiros, M.D., Department of Internal Medicine I, Johannes Gutenberg University, Langenbeckstrasse 1, Mainz, Germany. Telephone: þ ; FAX: þ ; barreiro@mail.uni-mainz.de DOI /lt Published online in Wiley InterScience ( VC 2010 American Association for the Study of Liver Diseases.

2 TRANSPLANTATION IN PATIENTS WITH FAP 315 TABLE 1. Demographic Data, Symptoms, and Additional Therapeutic Approaches Before Liver Transplantation Number of patients 20 Age [median (range)] 46.8 years ( years) Gender (female/male) 8/12 Duration of symptoms 35 months before transplantation (10-63 months) [median (range)] Follow-up [median (range)] 44.7 months ( months) Number of patients with 4 combined heart-liver transplantation Number of patients with 7 a pacemaker TTR amyloid is predominantly produced in the liver, with approximately 5% being synthesized in the retina and choroid plexus. 2 Treatment with plasmapheresis or immunoadsorption has been tried in order to reduce the serum load and possibly reduce amyloid deposition. Hemodialysis may be required in some patients with progressive kidney failure. Liver transplantation (LT) has been widely accepted as the ultimate curative treatment of this disease in order to prevent a fatal outcome and ameliorate disabling symptoms 3 and quality of life. 4 Cardiac involvement is of major concern in patients awaiting LT because cardiac insufficiency and cardiac autonomic dysfunction leading to rhythmic disturbances are often the main causes of death in patients with FAP. According to the Familial Amyloidotic Polyneuropathy World Transplant Registry, 5 the preoperative or perioperative insertion of pacemakers to prevent fatal cardiac arrhythmias 6 and combined heart-liver transplantation have been reported. However, there are only sparse data concerning the benefit of prophylactic pacemaker implantation before LT and a few case reports on combined heart-liver transplantation. 7 In order to further elucidate the problems of LT in patients with FAP, we report on 20 patients treated at our institution. It was the purpose of this retrospective study to compare complications in the short term and the long term after surgery in patients with a Val30Met mutation and non-val30met mutations. Particular emphasis was given to cardiac and rhythmic complications requiring additional therapeutic approaches before LT, such as combined heart-liver transplantation and pacemaker implantation. PATIENTS AND METHODS Patients Twenty consecutive patients with FAP who underwent transplantation between May 1998 and June 2007 at the Transplantation Center of Johannes Gutenberg University (Mainz, Germany) were included in this retrospective study. Demographic data, follow-up data, and additional approaches are listed in Table 1. Patients presented with highly variable symptoms, which are listed in Table 2. Neurological and cardiac symptoms were predominantly detectable, but gastrointestinal symptoms and renal insufficiency were also found. Decisions to implant a pacemaker were based on symptoms and findings during the clinical workup according to internationally accepted guidelines. 8 Diagnosis and Classification of Amyloid and Amyloidosis Amyloidosis was diagnosed on the basis of rectal tissue biopsy samples and serum samples. The biopsy samples were formalin-fixed and paraffin-embedded. Amyloid was diagnosed in 4- to 6-lm-thick tissue sections by the specific pinkish coloration in bright light and the pathognomonic green birefringence in polarized light after modified staining with Congo red according to Puchtler et al. 9 Typing of the amyloid class was performed immunohistochemically with a panel of anti-amyloid antibodies that have been documented to be reliable. 10 A strong reaction to the anti amyloidosis TTR antibody was taken as proof of the presence of TTR-derived amyloid, whereas six other hereditary and sporadic amyloids were excluded by much weaker and more inconsistent reactions of specificity. Positive and negative antigen and antibody controls were in line with the assumption of specificity. Genetic Analysis Amyloidogenic variants/mutations were identified according to published procedures. 11,12 Surgery The technique of heart-liver transplantation has been described elsewhere. 13 In 3 patients, heart transplantation was performed with the standard technique: the recipient heart was removed at the midatrial level, with the caval and pulmonary veins left in place. The pulmonary artery and aorta were transected above the respective valves. The donor heart was sutured onto the patient s right and left atria and onto the great vessels. LT was performed without venovenous bypass in the orthotopic position. The retrohepatic portion of the inferior caval vein was removed along with the amyloid liver in order to use the excised organ as a domino graft. Apart from 2 instances with severe steatosis, this goal was achieved in 18 cases. The donor graft was implanted in the orthotopic position. After completion of the suprahepatic and infrahepatic anastomoses, the portal vein was reconstructed, and the graft was recirculated. Thereafter, the anastomosis of the hepatic artery was established.

3 316 BARREIROS ET AL. TABLE 2. Results of Gene Analyses, Age at Onset of Disease, and Symptoms with a Focus on Neurological and Cardiac Symptoms Age at Onset Motoric/ Polyneuropathy Loss of Mutation (years) Sensoric Autonomic Weight Impairment Conductory Restrictive 1. Val30Met 32.8 X X X X 2. Val30Met 34.7 X X X X X X 3. Val30Met 58.9 X X 4. Val30Met 36.0 X X X 5. Val30Met 33.0 X X X 6. Val30Met 64.5 X X X X 7. Val30Met 63.3 X 8. Phe33Leu 47.1 X X X X X 9. Leu12Pro 27.7 GMS X 10. Leu12Pro 36.6 GMS X 11. Gly47Glu 31.6 X X X X 12. Gly47Glu 35.0 X X X X X 13. Asp18Gly 48.8 X X X 14. Glu89Lys 43.2 X X 15. Glu89Lys 46.1 X 16. Ala97Gly 58.4 X 17. Ile107Val 65.4 X 18. Val20IIe 56.9 X X 19. Thr49Ala 37.5 X 20. Leu58His 55.8 X Renal Cardiac Function End-to-end bile duct reconstruction was performed in all patients. One patient had a living donation of the right lobe. In 1 patient (the very first patient) treated with combined heart-liver transplantation, the en bloc technique was used. The liver remained attached to the heart by the caval vein and had to be cooled with icewater towels for 1 hour while heart surgery was performed. At the end of cardiac transplantation, the infrahepatic portion of the caval vein and the portal vein of the liver graft were sutured. The heart and liver were simultaneously recirculated. Thereafter, the hepatic artery and the bile duct were reconstructed. Immunosuppressive Therapy Initial immunosuppressive therapy was performed with tacrolimus in 13 cases and with cyclosporine A in the remaining 7 patients. In addition, the patients received steroids during the first 3 to 6 months after transplantation. Mycophenolate mofetil was given to 5 patients. Acute rejection of the transplanted liver was successfully treated in 9 patients with a high-dose steroid bolus for 3 days. Although the same immunosuppressive agents were given to patients who underwent LT or heart-liver transplantation, the target levels of calcineurin inhibitors differed. After LT, tacrolimus was given with targeted levels of 7 to 10 ng/ml for 4 weeks and 3 to 8 ng/ml thereafter; cyclosporine was given with targeted levels of 100 to 150 ng/ml for 4 weeks and 80 to 100 ng/ml thereafter. The respective levels in heart-liver transplantation patients were tacrolimus target levels of 12 to 15 ng/ml for 4 weeks and then 10 to 12 ng/ml and cyclosporine target levels of 150 to 220 ng/ml for 4 weeks and 120 to 150 ng/ml thereafter. Statistics Patients were stratified according to putative factors influencing survival: gender, cardiac comorbidity, preoperative symptoms, form of mutation, episodes of acute rejection, pacemaker implantation, cold ischemia time, duration of surgery, amount of packed red blood cells, intensive care unit stay, and total stay in the hospital after transplantation. Survival was calculated with Kaplan-Meier estimates. For the comparison of categorical data of particular events in the stratified groups, Fisher s exact test was used. All statistical calculations were performed with SPSS for Windows (SPSS, Inc.). RESULTS Preoperative Symptoms and Workup In Table 2, the mutations of the 20 patients, their age at onset of the disease, and their leading symptoms are shown. Eleven different mutations were identified (Fig. 1). The Val30Met mutation was detected in 7 patients. Prior to LT, 18 of the 20 patients (90%) suffered from typical sensory and motoric peripheral neuropathy and gastrointestinal symptoms (diarrhea, nausea,

4 TRANSPLANTATION IN PATIENTS WITH FAP 317 TABLE 3. Cardiac Symptoms: Restrictive Impairment Versus Rhythmic Impairment in Patients with the Portuguese Mutation Versus Other Mutations Mutation No Cardiac Symptoms Arrhythmia Restrictive CMP Pacemaker HLT Portuguese 1 6 1* 6 0 Others 7 1 y 6 z 1 4 *One patient suffered from arrhythmia and restrictive CMP. y One patient suffered from arrhythmia and restrictive CMP and underwent HLT. z Three patients underwent HLT. first patient), the indication for combined heart-liver transplantation was based on massive polytopic ventricular heart rhythm disturbances occurring during the first attempt to perform LT. An overview of heart-related problems in our cohort is shown in Table 4. Figure 1. Transthyretin variants in liver transplant patients at Johannes Gutenberg University (Mainz, Germany). vomitus, and filling). The particular clinical manifestations listed in Table 2 were found in 14 patients. In 2 patients, symptoms were restricted to grand mal seizures. These symptoms had been persisting for 12 and 57 months, respectively, before transplantation. In both patients, who were siblings, no typical Portuguese variant was detectable, but the Leu12Pro mutation was present. Important cardiac symptoms leading to heart transplantation in 4 cases were encountered exclusively in patients with mutations other than the Portuguese variant (Table 3). In Tables 3 and 4, cardiac symptoms are listed with explicit differentiation between restrictive or mechanical disturbances and problems of conduction in patients with the Val30Met mutation and other mutations. Notably, patients with the Portuguese variant suffered predominantly from arrhythmic cardiac disorders, whereas patients with non-portuguese TTR mutations suffered mainly from restrictive/mechanical cardiac problems such as a concentric thickened left ventricular wall and presented with severe heart failure due to diastolic dysfunction. Combined heart-liver transplantation was performed in 1 patient with a simultaneous approach and in the remaining 3 patients with a sequential approach. One FAP patient of the 4 combined transplantation patients died (1/4, 25%) because of FAP-related malnutrition. Indications for heart transplantation preceding LT are given in Table 5. Three patients suffered from restrictive cardiomyopathy with significant heart failure and from pulmonary hypertension with mean pulmonary pressure values >40 mm Hg. In 1 patient (the Surgery and Perioperative Course In the first patient finally treated with combined heart-liver transplantation, life-threatening polytopic ventricular heart rhythm disturbances occurred after the caval vein was clamped. This was accompanied by a distinctive decline of the systolic blood pressure (<70 mm Hg). The decision to perform combined heart-liver transplantation was made. This approach was accomplished 4 weeks after the first surgery. After the simultaneous recirculation of both grafts, the patient had to be kept on extracorporeal hemocirculation because of cardiac instability for the next 2 hours. This problematic approach led to an increase in serum aminotransferases up to 7000 U/L, which dropped to normal within a few days. The bilirubin level never exceeded 6 mg/dl. The patient died 10 months after combined heart-liver transplantation from malnutrition due to intestinal malabsorption caused by amyloid deposition. In the other 3 patients, heart transplantation was performed 3 to 8 months prior to LT, and the surgical approach of hepatic transplantation was uneventful. As for LT, the median cold ischemia time was 667 minutes (range ¼ minutes), the median time of surgery was 315 minutes (range ¼ minutes), a median of 6 U of packed red blood cells (range ¼ 0-28 U) was used, the median intensive care unit stay after transplantation was 4 days (range ¼ 1-99 days), and the median total stay in the hospital was 30 days (range ¼ days). Reoperations had to be performed in 4 patients for biliary leakage, stenosis of the caval vein, postoperative arterial bleeding, and wound rupture. No patient had to undergo retransplantation. All postoperative complications are given in Table 6. In our study, postoperative complications after LT were comparable to complications described in the literature, with the most frequent complications being infections (36.5%), which were followed by renal insufficiency (14.8%) and acute rejection (11.1%).

5 318 BARREIROS ET AL. TABLE 4. Detailed Cardiac Symptoms: Restrictive Disturbances Versus Rhythmic Disturbances According to the Mutation Total Number of Portuguese Mutation Symptoms Patients (Val30Met) Other Mutations Restrictive/mechanical disturbances Impaired systolic function (LVEF < 50%) (Glu89Lys and Val20Ile) Restrictive cardiomyopathy (Glu89Lys, Asp18Glu, and Val20Ile) Thickened left ventricular wall [Glu89Lys, Phe33Leu, Asp18Glu, Gly47Glu, Leu12Pro (2), and Val20Ile] Rhythmic disturbances Bradycardia AV block (Glu89Lys) Sinus bradycardia 1 1 SA block 1 1 Tachycardia Supraventricular tachycardia (Thr49Ala) Ventricular tachycardia (all nonsustained) [Gly47Glu (2), Phe33Leu, Val20Ile, and Thr49Ala] Other Left bundle branch block (incomplete) 2 2 Left bundle branch block (complete) 1 1 (Glu89Lys) Right bundle branch block (incomplete) 1 1 (Ile107Val) Miscellaneous Cardiac amyloid (Glu89Leu, Phe33Leu, Gly47Glu, and Val20Ile) Sudden death (Phe33Leu and Gly47Glu) Pacemaker (N/Leu12Pro) HTX and LT (Gly47Glu, Asp18Glu, Glu89Lys, and Phe33Leu) TABLE 5. Indications for Heart Transplantation in Non-Val30Met Patients (n 5 13) with Restrictive Cardiac Impairment Versus Patients with Non-Val30Met Mutations Without an Indication for Combined Transplantation Thickened Left Impaired Left Heart Pulmonary Ejection Mutation HLT Age (years) Myocardium Function Pressure (mm Hg) Fraction (%) 1. Phe33Leu X 47.1 X 47 30* 2. Leu12Pro 27.7 X NE Leu 12 Pro 36.6 X NE Gly47Glu 31.6 NE Normal 5. Gly47Glu 35.0 NE Normal 6. Asp18Gly X 48.8 X X Glu89Lys X 43.2 X X Glu89Lys 46.1 NE Normal 9. Ala97Gly 58.4 NE Normal 10. Ile107Val 65.4 NE Normal 11. Val20Ile X 56.9 X X Thr49Ala 37.5 NE Normal 13. Leu58His 55.8 NE Normal NOTE: Patients who underwent combined transplantation are designated in bold type. The normal ejection fraction was defined as >50%. *In addition to restrictive cardiomyopathy, there was severe arrhythmia during attempted liver transplantation.

6 TRANSPLANTATION IN PATIENTS WITH FAP 319 Postoperative aspartate aminotransferase peaked at a median level of 1931 IU/L (range ¼ IU/L), alanine aminotransferase peaked at a median level of 1216 IU/L (range ¼ IU/L), glutamate dehydrogenase peaked at a median level of IU/L (range ¼ IU/L), and bilirubin peaked at a level of 2.58 mg/dl (range ¼ IU/L). TABLE 6. Postoperative Complications Number of Complication Patients Infections 23 (36.5%) CMV infection 6 (26.1%) VZV infection 3 (13%) Intracerebral abscesses 1 (4.3%) caused by Nocardia Pneumonia 52 (1.1%) Mycoplasma pneumonia 1 (4.3%) CMV 3 (13%) Renal insufficiency 9 (14.8%) Intermittent renal hemodialysis 4 (44%) Acute rejection 7 (11.1%) Death 7 (11.1%) Convulsion 5 (7.9%) Hemorrhage 5 (7.9) Psychiatric complication 4 (6.3%) Wound rupture 2 (3.1%) Argyll-Robertson syndrome 1 (1.6%) NOTE: One patient could suffer from more than 1 complication (n ¼ 63). Morbidity, Mortality, and Long-Term Outcome Overall, 7 patients died after LT (7/20, 35%), and they all died from FAP-related complications. The causes of death were cardiac complications in 4 patients (4/7, 57%), infectious complications after cerebral seizures in 2 patients (2/7, 29%), and malnutrition due to severe intestinal malnutrition in 1 patient (1/7, 14%; see Table 7). One-year survival was 75.0%, and 5-year survival was 64.2% (Kaplan-Meier; Fig. 2). Women had a better outcome than men. One-year survival in women was 100%. In contrast to this, it was only 58.3% in men. Five-year survival in women was 85.7% versus 50.0% in men. Despite the small number of patients, the difference was very close to reaching significance (P ¼ 0.073; Fig. 3). The 4 patients with fatal cardiac complications died within the first year after transplantation (4/7, 57%) 2, 4, 9, and 11 months after surgery (Fig. 4). Two of these patients had a Val30Met mutation, and the others had a Gly47Glu mutation. It is worth mentioning that both patients with the Portuguese mutation died at the age of 68 years; the others were 37 and 34 years old and thus significantly younger. The implantation of prophylactic pacemakers, organ rejection after LT, and the different types of mutations had no influence on survival (Figs. 4 and 5). We generally observed that patients with distinctive and severe complications of FAP before LT had a worse outcome. In particular, patients with advanced cachexia as a sign of gastrointestinal deposition of amyloid had a bad outcome. We cannot report on the significance of cardiac amyloidosis because all patients with apparent cardiac complications underwent combined heart-liver transplantation. In contrast to the first liver-heart TABLE 7. Course and Outcome for 7 Patients with the Val30Met Mutation and 13 Patients with Other Mutations Mutation Age at Onset (years) Clinical Course Cause of Death 1. Val30Met 32.8 Uneventful 2. Val30Met 34.7 Uneventful 3. Val30Met 58.9 Uneventful 4. Val30Met 36.0 Uneventful 5. Val30Met 33.0 Uneventful 6. Val30Met 64.5 Died after 13 months Cardiac arrest despite PM 7. Val30Met 63.3 Died after 1 month Cardiac insufficiency 8. Phe33Leu 47.1 Died after 10 months: HLT Malnutrition 9. Leu12Pro 27.7 Died after 36 months Grand mal seizure and sepsis 10. Leu 12 Pro 36.6 Died after 6 months Grand mal seizure and sepsis 11. Gly47Glu 31.6 Died after 6 months: PM Cardiac arrest 12. Gly47Glu 35.0 Died after 7 months Cardiac arrest 13. Asp18Gly 48.8 Uneventful: HLT 14. Glu89Lys 43.2 Complicated: HLT 15. Glu89Lys 46.1 Uneventful 16. Ala97Gly 58.4 Uneventful 17. Ile107Val 65.4 Uneventful 18. Val20Ile 56.9 Complicated: HLT 19. Thr49Ala 37.5 Uneventful 20. Leu58His 55.8 Uneventful

7 320 BARREIROS ET AL. Figure 2. Overall survival in transplant patients (n 5 20). Figure 4. Cardiac amyloidosis patients with a cardiac pacemaker (n 5 7) versus patients without a cardiac pacemaker (n 5 9) before liver Tx and patients who underwent combined heart-liver Tx (n 5 4; P ). Figure 3. Cumulative survival: male patients (n 5 12) versus female patients (n 5 8; P ). transplant in the series, the other 3 patients underwent LT 3 to 8 months after heart transplantation. These 4 patients showed no cardiac deposits of amyloid in protocol myocardial biopsies performed yearly after heart transplantation. After LT, neurological symptoms remained stable or improved slightly in 13 patients. Only 1 patient had progressive neurological symptoms of the lower limbs. Other reasons for polyneuropathy, such as diabetes or calcineurin toxicity, were excluded. Nevertheless, immunosuppression was switched from tacrolimus to mammalian target of rapamycin inhibitor. A summary of the clinical course and outcomes of our cohort with 7 patients with the Val30Met mutation and 13 patients with other mutations is given in Table 7. Figure 5. Survival of patients with the Portuguese ATTR Val30Met variant (n 5 7) and patients with non-portuguese variants (n 5 13; P ). DISCUSSION Presently, more than 100 different TTR mutations are known 14 with various rates in different geographic areas. The most important clusters have been identified in Portugal and Sweden. Clusters from other

8 TRANSPLANTATION IN PATIENTS WITH FAP 321 countries such as Japan, Germany, and the United States have been smaller with respect to the number of affected families. 15 Despite similar genetic aberrations, the correlation with clinical symptoms fails, and this suggests complex pathomechanisms. 11,16 Several forms of TTR-mutations in one patient appear to interfere with one another. That has been shown for the Thr119Met mutation on the second TTR allele, which protects Val30Met carriers from disease. 17 Some authors have suggested that nutrition in combination with the genetic background may be one of the major reasons for the different outcomes and courses of the disease. 18 The initial symptom of the Portuguese variant of the Val30Met mutation is usually peripheral polyneuropathy, which is frequently followed by autonomic nervous signs. Patients suffering from FAP often report cardiovascular symptoms including arrhythmia and orthostatic dysfunction, proteinuria pointing to kidney involvement, and gastrointestinal and erectile dysfunction. In Portugal, the first symptoms of the disease occur around 30 years of age, whereas in Sweden, the identical mutation leads to symptoms occurring as late as the fifth decade of life. Without therapy, FAP takes a lethal course within 5 to 15 years after the initial symptoms. 19 Because of the varying clinical symptoms, the diagnosis of FAP is difficult. 20 A family history is one of the most important sources of information. Genetic and immunohistochemical analyses of involved organs are crucial for validating the diagnosis. Genetic counseling is of major importance because other family members may be affected by the genetic defect as well. Although it is rare, FAP is a major medical challenge. Because of a lack of alternative forms of treatment, LT currently represents the only effective therapy for these patients. Our experience comprises 20 patients treated with LT and heart-liver transplantation. With respect to the underlying genetic mutations leading to FAP, our cohort was highly variable in comparison with previous studies and, in particular, with the only published study from Germany. 21 The Val30Met mutation was encountered in 7 patients, and 10 additional mutations were found in the remaining 13 patients. All patients had different clinical manifestations. A mild course with the Portuguese mutation was characterized by mild polyneuropathy, neurological symptoms in both feet, and autonomic nervous symptoms. Patients with an aggressive course presented with arrhythmias, cystic bladder atony, diarrhea, and cachexia. As described previously, 22 cardiac comorbidity is of major clinical concern. Cardiac autonomic dysfunction with cardiac arrhythmia is known with pathological heart rate variability and intermittent atrial arrhythmia, as described before. 23,24 However, a detailed characterization of cardiac symptoms has not been published so far. Heart transplantation has been performed along with LT in some centers In the majority, heart-liver transplantation has been performed in patients with Val30Met mutations suffering from rhythmic disturbances. 28 In our experience, restrictive cardiomyopathy, reflected by a thickened left ventricular wall and a high pulmonary pressure, was the indication for heart-liver transplantation. No other approaches to improving the cardiac situation, including cardiac mechanical devices, provide a significant benefit to the patients. This form of cardiac involvement occurred exclusively in patients with non-val30met mutations in our cohort. Rhythmic disturbances prevailed in only 1 of the 4 patients with combined heartliver transplantation. The long-term outcome in patients with combined transplantation appears to be favorable as cardiac deposits of amyloid could not be found in protocol myocardial biopsies performed yearly after heart transplantation, and hints of recurrent cardiomyopathy were totally absent in echocardiography. Combined heart-liver transplantation was performed in 1 patient with a simultaneous approach and in the remaining 3 patients (3/4, 75%) with a sequential approach. The only patient to undergo simultaneous transplantation died after LT because of FAP-associated malnutrition. The other 3 heart-liver transplantation patients had an uneventful postoperative course. We first used the simultaneous approach in At this time, experience with combined heart-liver transplantation was very sparse as the first combined transplant in FAP patients was reported in 1995 by Rela et al. 29 In this patient, we encountered a critical situation as the just transplanted heart was very susceptible to arrhythmia and depression of the blood pressure for about 30 minutes when the graft was recirculated. Because of this experience, we decided to perform the next combined transplants sequentially to avoid hemodynamic instability. In the mean time, experience has shown that the interval between heart transplantation and LT may be as short as a few hours to reach satisfactory cardiac stability. 30 Thus, we would now also advocate early LT as soon as a few hours after heart transplantation. Similarly, in patients with only LT, progressive cardiac involvement was not detectable by biopsy or echocardiography. In 1 patient after LT, progressive polyneuropathy of the lower extremities had to be attributed to amyloid accumulation as other reasons for aggravating polyneuropathy such as diabetes and calcineurin inhibitor toxicity were excluded. In all other patients, symptoms remained stable or improved. In contrast to the clear symptoms of cardiac impairment leading to the decision for heart transplantation, the indication for the implantation of pacemakers was somewhat arbitrary in most instances. 31,32 According to internationally accepted guidelines, we inserted a pacemaker in every patient with a history of syncope and proven arrhythmia patterns. 8 There were 7 patients in our study who received a pacemaker prior to LT, and 6 of them had a Val30Met mutation. This underlines the fact that cardiac symptoms in patients with Portuguese variants are mostly rhythmic disturbances as reported in the literature. 33 None of these

9 322 BARREIROS ET AL. patients and also none of the patients without pacemaker implantation before LT developed detectable or clinically apparent bradycardia or tachycardia during surgery or in the follow-up. Therefore, the benefit of pacemaker implantation is questionable. 7,33 In addition to this, both bradycardia and tachycardia, as shown in our cohort (Table 4), are encountered in the respective patients. It has to be discussed if the implantation of a defibrillator would make more sense. Studies investigating this approach are lacking. In all, 7 patients died after LT. Among these, 4 patients died because of cardiac complications. Interestingly, only 2 distinct mutations were detected in this small group: Val30Met and Gly47Glu. Remarkably, 2 patients with the non-portuguese mutation died at the ages of 34 and 37 years, and 2 patients with the Portuguese mutation died at the clearly higher age of 68 years. This led us to assume that the Val30Met mutation has a more benign course with respect to fatal cardiac complications and gains significance only with increasing age. The impact of the Gly47Glu mutation deserves attention. Both young patients presented clinically with predominantly neurological symptoms, whereas cardiac involvement appeared to be absent. As both died of cardiac impairment after LT, combined heart-liver transplantation may be generally required in patients with the Gly47- Glu mutation. It would be interesting to see the respective data in the amyloidosis registry because a larger number of patients will be required to make a decision on this important issue. 34 As another interesting group in our cohort, the siblings with the Leu12Pro mutation need to be discussed. Both presented with grand mal seizures indicating cerebral involvement in leptomeningeal amyloidosis, as reported previously. 35 Further examinations revealed clinically unapparent hypertrophic heart disease. No typical symptoms for FAP could be detected. Both patients died after LT because of sepsis 6 and 36 months after surgery when grand mal seizures led to disabling situations. As the Leu12Pro mutation has been described as a very aggressive TTR mutation, 35 excluding patients with the Leu12Pro mutation from LT may be justified. The timing of LT seems to be of major concern. Yamamoto s group recently showed that the outcome of patients with FAP after LT improves significantly when LT is performed early during the clinical course. 36 In our experience, men presented a more advanced stage of the hereditary disease with more organ systems affected and more FAP-related complications, and men had statistically inferior overall survival in comparison with women. On the other hand, 9 of 12 men suffered from non-val30met mutations, which may also have affected the outcome. Although we could not find a significant difference between the types of mutations in our cohort, there was a clear difference in the clinical course and outcome of the patients with Val30Met mutations and the patients with non-val30met mutations. All other evaluated factors, such as cardiac symptoms, pacemaker implantation, mutation variants, and acute rejection, had no significant influence on survival or outcome within the median observation period of 39 months (range ¼ months) after LT. This underlines the major significance of the clinical situation of the patients prior to LT. Interestingly, we were not able to confirm the influence of a cardiac pacemaker on patient survival in our cohort, which was described earlier by several authors. 7,33 As we pointed out, it has to be focused especially on cardiac involvement, which might lead to life-threatening complications. In summary, our cohort of 20 patients with predominantly non-val30met mutations had inferior survival in comparison with patients who underwent transplantation for other liver diseases. The reasons for the poorer outcome were related to the original amyloidosis (ie, to advanced disease). Cardiac failure was the most frequent reason not only for additional therapeutic approaches but also for death. The clinical course of FAPpatientsbeforeandafterLTishighlyvariableand may depend on the different types of mutations of the TTR gene, the age at onset of FAP, the nutritional status of the patients, and the age at the time of LT. Our data corroborate the general experience with performing LT early during the course of disease, with the optimal timing as early as the first symptoms occur. ACKNOWLEDGMENTS Genetic counseling and identification of the TTR variants in the plasma fraction and the mutations in the TTR gene were performed by Professor K. Altland and P. Winter (Institute of Human Genetics, Justus Liebig University, Giessen, Germany). REFERENCES 1. Benson DA, Karsch-Mizrachi I, Lipman DJ, Ostell J, Wheeler DL. GenBank: update. Nucleic Acids Res 2004; 32:D23-D Murakami T, Uchino M, Ando M. Genetic abnormalities and pathogenesis of familial amyloidotic polyneuropathy. Pathol Int 1995;45: Suhr OB, Friman S, Ericzon BG. Early liver transplantation improves familial amyloidotic polyneuropathy patients survival. Amyloid 2005;12: Telles-Correia D, Barbosa A, Mega I, Mateus E, Monteiro E. When does quality of life improve after liver transplantation? A longitudinal prospective study. Transplant Proc 2009;41: Ericzon BG, Larsson M, Herlenius G, Wilczek HE. Report from the Familial Amyloidotic Polyneuropathy World Transplant Registry (FAPWTR) and the Domino Liver Transplant Registry (DLTR). Amyloid 2003;10(suppl 1): Monteiro E, Perdigoto R, Furtado AL. Liver transplantation for familial amyloid polyneuropathy. Hepatogastroenterology 1998;45: Eriksson P, Olofsson BO. Pacemaker treatment in familial amyloidosis with polyneuropathy. Pacing Clin Electrophysiol 1984;7: Vardas P, Auricchio A, Blanc J, Daubert J, Drexler H, Ector H, et al. Guidelines for cardiac pacing and cardiac resynchronization therapy. The Task Force for Cardiac Pacing and Cardiac Resynchronization Therapy of the European Society of Cardiology. Developed in collaboration with the European Heart Rhythm Association. Eurospace 2007;9:

10 TRANSPLANTATION IN PATIENTS WITH FAP Linke R. Congo red staining of amyloid. Improvements and practical guide for a more precise diagnosis of amyloid and the different amyloidoses. In: Uversky VN, Fink AL, eds. Protein Misfolding, Aggregation and Conformational Diseases. New York, NY: Springer; 2006: Linke RP, Oos R, Wiegel NM, Nathrath WB. Classification of amyloidosis: misdiagnosing by way of incomplete immunohistochemistry and how to prevent it. Acta Histochem 2006;108: Altland K, Benson MD, Costello CE, Ferlini A, Hazenberg BP, Hund E, et al. Genetic microheterogeneity of human transthyretin detected by IEF. Electrophoresis 2007;28: Jenne DE, Denzel K, Blatzinger P, Winter P, Obermaier B, Linke RP, et al. A new isoleucine substitution of Val- 20 in transthyretin tetramers selectively impairs dimerdimer contacts and causes systemic amyloidosis. Proc Natl Acad Sci U S A 1996;93: WongBW,RahmaniM,RezaiN,McManusBM.Progressin heart transplantation. Cardiovasc Pathol 2005;14: Connors LH, Lim A, Prokaeva T, Roskens VA, Costello CE. Tabulation of human transthyretin (TTR) variants, Amyloid 2003;10: Ii S, Sommer SS. The high frequency of TTR M30 in familial amyloidotic polyneuropathy is not due to a founder effect. Hum Mol Genet 1993;2: Plante-Bordeneuve V, Ferreira A, Lalu T, Zaros C, Lacroix C, Adams D, et al. Diagnostic pitfalls in sporadic transthyretin familial amyloid polyneuropathy (TTR- FAP). Neurology 2007;69: Hammarstrom P, Schneider F, Kelly JW. Trans-suppression of misfolding in an amyloid disease. Science 2001; 293: Altland K. Life style and transthyretin-type amyloidosis: what could be the links? Acta Histochem 2006;108: de Carvalho M, Conceicao I, Bentes C, Luis ML. Longterm quantitative evaluation of liver transplantation in familial amyloid polyneuropathy (Portuguese V30M). Amyloid 2002;9: Rapezzi C, Perugini E, Salvi F, Grigioni F, Riva L, Cooke RM, et al. Phenotypic and genotypic heterogeneity in transthyretin-related cardiac amyloidosis: towards tailoring of therapeutic strategies? Amyloid 2006;13: Singer R, Mehrabi A, Schemmer P, Kashfi A, Hegenbart U, Goldschmidt H, et al. Indications for liver transplantation in patients with amyloidosis: a single-center experience with 11 cases. Transplantation 2005;80(suppl):S156-S Suhr OB, Lindqvist P, Olofsson BO, Waldenstrom A, Backman C. Myocardial hypertrophy and function are related to age at onset in familial amyloidotic polyneuropathy. Amyloid 2006;13: Wiklund U, Hornsten R, Karlsson M, Suhr OB, Jensen SM. Abnormal heart rate variability and subtle atrial arrhythmia in patients with familial amyloidotic polyneuropathy. Ann Noninvasive Electrocardiol 2008;13: Hornsten R, Suhr OB, Jensen SM, Wiklund U. Outcome of heart rate variability and ventricular late potentials after liver transplantation for familial amyloidotic polyneuropathy. Amyloid 2008;15: Barrio IM, Mtnez de Guerenu MA, Real MI, Del Campo I, Perez-Cerda F, Moreno E. Anesthetic management of a combined heart and liver transplantation in an amyloidotic patient: a case report. Transplant Proc 2007;39: Pilato E, Dell Amore A, Botta L, Arpesella G. Combined heart and liver transplantation for familial amyloidotic neuropathy. Eur J Cardiothorac Surg 2007;32: Edwards B, McGregor C, Daly R, Zeldenrust S, Rosen C, Charlton M, et al. Combined organ transplantation for familial amyloidosis. Abstract presented at: 7th International Symposium on Familial Amyloid Polyneuropathy and 1st International Workshop on Hereditary Amyloidosis; 2008; London, United Kingdom. 28. Stangou AJ, Hawkins PN. Liver transplantation in transthyretin-related familial amyloid polyneuropathy. Curr Opin Neurol 2004;17: Rela M, Muiesan P, Heaton ND, Corbally M, Hajj H, Mowat AP, et al. Orthotopic liver transplantation for hepaticbased metabolic disorders. Transpl Int 1995;8: Nardo B, Beltempo P, Bertelli R, Montalti R, Vivarelli M, Cescon M, et al. Combined heart and liver transplantation in four adults with familial amyloidosis: experience of a single center. Transplant Proc 2004;36: Sakashita N, Ando Y, Haraoka K, Terazaki H, Yamashita T, Nakamura M, et al. Severe congestive heart failure with cardiac liver cirrhosis 10 years after orthotopic liver transplantation for familial amyloidotic polyneuropathy. Pathol Int 2006;56: Lauro A, Diago Uso T, Masetti M, Di Benedetto F, Cautero N, De Ruvo N, et al. Liver transplantation for familial amyloid polyneuropathy non-val30met variants: are cardiac complications influenced by prophylactic pacing and immunosuppressive weaning? Transplant Proc 2005;37: Hornsten R, Wiklund U, Olofsson BO, Jensen SM, Suhr OB. Liver transplantation does not prevent the development of life-threatening arrhythmia in familial amyloidotic polyneuropathy, Portuguese-type (ATTR Val30Met) patients. Transplantation 2004;78: Haagsma EB, Hawkins PN, Benson MD, Lachmann HJ, Bybee A, Hazenberg BP. Familial amyloidotic polyneuropathy with severe renal involvement in association with transthyretin Gly47Glu in Dutch, British and American-Finnish families. Amyloid 2004;11: Brett M, Persey MR, Reilly MM, Revesz T, Booth DR, Booth SE, et al. Transthyretin Leu12Pro is associated with systemic, neuropathic and leptomeningeal amyloidosis. Brain 1999;122(pt 2): Yamamoto S, Wilczek HE, Nowak G, Larsson M, Oksanen A, Iwata T, et al. Liver transplantation for familial amyloidotic polyneuropathy (FAP): a single-center experience over 16 years. Am J Transplant 2007;7: