Liver transplantation in transthyretin amyloidosis: Characteristics and management related to kidney disease.
Orthotopic liver transplantation (LT) was implemented as the inaugural disease-modifying therapy for hereditary transthyretin (ATTR) amyloidosis, a systemic amyloidosis mainly affecting the peripheral nervous system and heart. The first approach to pharmacologic therapy was focused on the stabilization of the TTR tetramer; following that new advent LT was assumed as the second step of treatment, for those patients whose neuropathy becomes worse after a course of pharmacologic therapy. The renal disease has been ignored in hereditary ATTR amyloidosis. The low level of proteinuria or slight renal impairment does not suppose such a heavy glomerular and vascular amyloid deposition. Moreover, severity of renal deposits does not consistently parallel that of myelinated nerve fiber loss. These are pitfalls that limit the success of LT and suggest troublesome criteria for pharmacological therapy or LT. An algorithm of evaluation concerning renal disease and treatment options is presented and some bridges-to-decision are exposed. In stage 4 or 5 kidney disease, the approach remains to deliver combined or sequential liver-kidney transplantation in eligible patients. However, in the majority, hemodialysis is the only option even in the presence of a well-functioning liver graft. In this review, we highlight useful information to aid the transplant hepatologist in the clinical practice.
Department of Nephrology, Hospital de Santo António, Centro Hospitalar do Porto, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal; Unidade Corino de Andrade, Hospital de Santo António, Centro Hospitalar do Porto, Rua D. Manuel II, CICAP, 4050-345, Porto, Portugal; Multidisciplinary Unit for Biomedical Research UMIB, Instituto de Ciências Biomédicas, Abel Salazar, University of Porto, Rua Jorge Viterbo Ferreira, 228, Porto 4050-313, Portugal. Electronic address: acrisbraga@gmail.com.
Ana
A
Rocha
Department of Nephrology, Hospital de Santo António, Centro Hospitalar do Porto, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal; Unidade Corino de Andrade, Hospital de Santo António, Centro Hospitalar do Porto, Rua D. Manuel II, CICAP, 4050-345, Porto, Portugal; Multidisciplinary Unit for Biomedical Research UMIB, Instituto de Ciências Biomédicas, Abel Salazar, University of Porto, Rua Jorge Viterbo Ferreira, 228, Porto 4050-313, Portugal.
Luísa
L
Lobato
D028227:Amyloid Neuropathies, Familial / Q000150:complications* / Q000175:diagnosis / Q000235:genetics; D003131:Combined Modality Therapy; D018450:Disease Progression; D005260:Female; D020022:Genetic Predisposition to Disease; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D007677:Kidney Function Tests; D017093:Liver Failure / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D016031:Liver Transplantation / Q000009:adverse effects* / Q000379:methods; D008297:Male; D011174:Portugal; D011379:Prognosis; D051437:Renal Insufficiency / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy*; D012720:Severity of Illness Index