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Inicio Cirugía Española (English Edition) Liver transplantation for intermittent acute porphyria resistant to medical trea...
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Vol. 99. Issue 9.
Pages 695-697 (November 2021)
Vol. 99. Issue 9.
Pages 695-697 (November 2021)
Scientific letter
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Liver transplantation for intermittent acute porphyria resistant to medical treatment
Trasplante hepático por porfiria aguda intermitente resistente a tratamiento médico
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Cándido Alcázar Lópeza,b, Gonzalo P. Rodríguez Laiza,b,
Corresponding author
rodriguez_gon@gva.es

Corresponding author.
, Rosario Sánchez Martínezb,c, Sonia Pascual Bartolomeb,d, José Manuel Ramiaa,b
a Unidad de Cirugía Hepatobiliopancreática y Trasplante Hepático, Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Alicante, Alicante, Spain
b Instituto de Investigación Sanitaria y Biomédica de Alicante – ISABIAL –, Alicante, Spain
c Unidad de Enfermedades Raras, Servicio de Medicina Interna, Hospital General Universitario de Alicante, Alicante, Spain
d Sección de Hepatología, Servicio de Aparato Digestivo, Hospital General Universitario de Alicante, Alicante, Spain
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Table 1. Cases published of AIP treated with liver transplantation.
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Acute intermittent porphyria (AIP) is a rare metabolic disease. Patients are usually either asymptomatic or able to control their symptoms by avoiding triggers and administering intravenous hemin during neurovisceral crises1,2. A small number of patients have attacks that are resistant to treatment, resulting in a very poor quality of life1,2. In 2004, the first liver transplantation used as treatment for AIP was published2. We have conducted a systematic review of the literature in PubMed using the search terms “liver transplantation and acute intermittent porphyria”, which identified 41 articles; 9 of these studies included a total of 17 patients who underwent transplantation for AIP (Table 1)1. We present a patient affected by AIP who did not respond to conventional treatment and was therefore treated with liver transplantation (LT).

Table 1.

Cases published of AIP treated with liver transplantation.

Author/year  Age  Sex  Time of symptoms (yrs)  Symptoms  Indication OLT  Type of transplant  Immediate post-OLT complications  Biochemical Normalization  Post-OLT porphyria attacks  Follow-up (months)  Retrasplantation  Death 
Wahlin et al./20101124  Female  NE  Abdominal pain, Neuropathy, Kidney failure  Medically uncontrollable AIP symptoms  OLT + kidney transplant  No  Yes  No  16  No  No 
  55  Female  10  Neuropathy, kidney failure  Medically uncontrollable AIP symptoms  OLT + kidney transplant  Biliary leak  Yes  No  11  No  No 
              Rejected kidney           
Dowman et al., 2012610*  31  9/10  NS  Abdominal pain, Labile HTN and Neuropathy  Medically uncontrollable AIP symptoms  OLT  4 HAT  Yes (10/10)  No (10/10)  23.4  1/10 due to HAT (13 days post-OLT)  2/10 (98 days and 26 months post-OLT) 
    Female          1 Biliary leak           
Frei et al., 2012458  Female  35  Renal insufficiency and hypertension  Liver failure  OLT  No  Yes  No  12  No  No 
          Hemin overdose               
Yasuda et al., 20153  36  Female  11  Neuropathy  Medically uncontrollable AIP symptoms  OLT  No  Yes  No  24  No  No 
Malinzak et al., 2018130  Female  14  Abdominal pain, Neuropathy  Medically uncontrollable AIP symptoms  SPLIT  Kidney failure  Yes  No  15  No  No 
            Right liver  Collection           
Spiritos et al., 20191016  Female  NE  Abdominal pain  Medically uncontrollable AIP symptoms  SPLIT  No  Yes  No  12  No  No 
            Right liver             
Al Samkari et al., 20199  59  Female  18  Abdominal pain  Medically uncontrollable AIP symptoms  Living donor  NS  4 years post-LT, the door had unknown AIP  4 years post-LT, the door had unknown AIP  48  No  No 
H. G. Alicante42  Female  8.5  Abdominal pain  Medically uncontrollable AIP symptoms  OLT  No  Yes  No  15  No  No 
        CNS symptoms                 
Total Series18  35  Female  16  Pain abdominal (15:/18:84%)  AIP symptoms(17)  15 OLT 2 SPLIT, 1 Living donor  6/18 (33%)  No 17/18 (94.5%)  No 17/18 (94.5%)  21.5  1/18 (5.5%)  2/18 (11%) 
    17/18      Hepatic failure (1)               

NS: not specified; HTN: hypertension; HAT: hepatic artery thrombosis; OLT: orthotopic liver transplant.

*

This publication includes cases by Soonowalla et al. and Dar et al.

The patients is a 42-year-old woman who began experiencing symptoms of severe abdominal pain, dark urine and hyponatremia in 2011. Hoesch test was positive, with elevated urinary porphobilinogen (PBG) (54.4 mg/24 h) and 5-aminolevulinic acid (ALA) (172 μmol/24 h) levels. The genetic study revealed mutations 669–698 of 30 in the gene encoding for the PBG-deaminase enzyme. With a diagnosis of AIP, treatment was initiated with intravenous hemin when the patient had crises, which initially achieved clinical improvement.

The patient continued to have increasingly frequent attacks triggered by stress or menstruation, which required monthly prophylactic hemin. We tried genetic therapies (included in the DIGNA-2011 study with the rAAV2/5-PBGD genetic vector) and prophylactic oophorectomy, but these were not effective. The patient’s condition became more complicated, leading to osteoporosis, weekly neurovisceral crises that were difficult to control with hemin and analgesia, CNS symptoms (visual hallucinations, agitation, delirium) and a progressive increase in opiate use, leading to secondary addiction. The decision was made to add her to the LT waiting list. In March 2019, she received an organ from a brain-dead donor (donor risk index: 2.5). Induction was begun with basiliximab, mycophenolate mofetil and corticosteroids. Tacrolimus was introduced on the 4th day post-transplantation. Urine porphyrins became negative on day 2 after transplantation. The ICU stay was 10 h, and the patient was discharged from hospital on the 6th day. In the explant, a large amount of iron was observed in the hepatocytes, a consequence of treatment with hemin (Fig. 1). After 15 months of follow-up, PBG and ALA levels ​​are normal, and the patient has presented no exacerbations, nor has she required analgesic treatment.

Fig. 1.

Liver biopsy: large quantity of iron accumulated in the hepatocytes as a result of treatment with hemin (Perl’s Prussian blue). The color of the figure can only be seen in the electronic version of the article.

(0.12MB).

AIP is the most common acute porphyria and belongs to the group of hepatic porphyrias1–5. It is an autosomal dominant transmission disease caused by partial porphobilinogen deaminase deficiency, which causes an accumulation of ALA and PBG1–5; it is more frequent in women1.

Some 90% of patients are asymptomatic2. Symptomatic patients present neurovisceral abdominal pain crises, without skin photosensitivity, triggered by factors that increase the demand of the heme group (stress, drugs, alcohol, eating, hormonal changes, etc)1,2,4,6. Other symptoms that can accompany crises include: vomiting, constipation, urinary retention, tachycardia, blood pressure alterations, motor neuropathy and convulsions1–3. The diagnosis is based on increased urinary levels of ALA and PBG5.

Treatment involves avoiding triggers of the attacks (by suppressing ovulation), analgesia, hydration, and a diet rich in carbohydrates, while intravenous hemin is administered during attacks1,2,4,6. 90% of patients with porphyria progress satisfactorily with these measures, but a small group of patients continue to present frequent crises1,2. In addition, chronic treatment with hemin causes several complications, such as liver fibrosis due to iron storage and/or progressive resistance to treatment1,2,6–8. Recurrent symptoms and multiple hospital admissions cause these patients to have a poor quality of life and a lower life expectancy1,2.

The pathogenesis of the attacks is unknown, although it is believed that they occur due to the hepatic production of porphyrin precursors as a result of the underlying metabolic deficiency2,6. Therefore, LT is the only curative treatment since the deficient enzyme is replaced1,2,4. The most widely accepted indications for LT in AIP are crises that do not respond to treatment with hemin, poor quality of life, progressive neurological disease, or liver failure due to hemin overdose1,4,5. The results obtained with LT in AIP are difficult to interpret due to the small number of published cases (Table 1)1,6,9–11. There is only one series of 10 transplant patients with AIP belonging to the British registry, in which the indication for LT was poor quality of life, either due to recurrent abdominal crises and/or neurological symptoms. The median follow-up was 23.4 months, with two deaths 98 days and 26 months after surgery. A much higher rate than usual of arterial thrombosis was observed (4 cases)6, and one of these 4 patients required retransplantation. The authors were not able to find an etiological explanation for the correlation between AIP and the high rate of thrombosis, but this may make it advisable to administer antithrombotic prophylaxis. PBG and ALA levels ​​always normalized within 72 h post-LT, with no recurrence of abdominal crises, although neurological deficits were not recovered. 70% of the explants presented hemosiderosis, as in our case6.

There are no reported cases of AIP recurrence after cadaveric LT. One recurrence has been published in a recipient who received a living donor transplant from a brother who had asymptomatic AIP9. In our case, all available treatments were tried, with no improvement, and the patient was resistant to treatment with hemin. We decided to perform LT as a last option, with excellent clinical results. As in most benign diseases susceptible to LT, determining the optimal time for transplantation is always difficult, but one should never wait for the onset of severe neurological symptoms due to the high risk of their not improving after LT6.

References
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E.B. Malinzak, N.W. Knudsen, A.D. Udani, D. Vikraman, D.L. Sudan, T.E. Miller.
Perioperative challenges in liver transplantation for a patient with acute intermittent porphyria.
J Cardiothorac Vasc Anesth., 32 (2018), pp. 2716-2720
[2]
Z.F. Soonawalla, T. Orug, M.N. Badminton, G.H. Elder, J.M. Rhodes, S.R. Bramhall, et al.
Liver transplantation as a cure for acute intermittent porphyria.
Lancet., 363 (2004), pp. 705-706
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Liver transplantation for acute intermittent porphyria: biochemical and pathologic studies of the explanted liver.
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Liver transplantation because of acute liver failure due to heme arginate overdose in a patient with acute intermittent porphyria.
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[6]
J.K. Dowman, B.K. Gunson, D.F. Mirza, S.R. Bramhall, M.N. Badminton, P.N. Newsome, on behalf of the UK Liver Selection and Allocation Working Party.
Liver transplantation for acute intermittent porphyria is complicated by a high rate of hepatic artery thrombosis.
Liver Transplant., 18 (2012), pp. 195-200
[7]
C. Schmitt, H. Lenglet, A. Yu, C. Delaby, A. Benecke, T. Lefebre, et al.
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J Intern Med., 284 (2018), pp. 78-91
[8]
M. Balwani, E. Sardh, P. Ventura, P. Aguilera Peiró, D.C. Rees, U. Stölzel, et al.
Phase 3 trial of RNAi therapeutic givosiran for acute intermittent porphyria.
N Engl J Med., 382 (2020), pp. 2289-2301
[9]
H. Al-Samkari, A.A. Patel, T.D. Schiano, D.J. Kuter.
Recurrence of acute intermittent porphyria after liver transplantation.
Ann Intern Med., 170 (2019), pp. 904-905
[10]
Z. Spiritos, S. Salvador, D. Mosquera, J. Wilder.
Acute intermittent porphyria: current perspectives and case presentation.
Ther Clin Risk Manag., 15 (2019), pp. 1443-1451
[11]
S. Wahlin, P. Harper, E. Sardh, C. Andersson, D.E. Andersson, B.G. Ericzon.
Combined liver and kidney transplantation in acute intermittent porphyria.
Transpl Int., 23 (2010), pp. e18-21

Please cite this article as: Alcázar López C, Rodríguez Laiz GP, Sánchez Martínez R, Pascual Bartolome S, Ramia JM. Trasplante hepático por porfiria aguda intermitente resistente a tratamiento médico. Cir Esp. 2021;99:697–699.

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