Successful domino liver transplantation in maple syrup urine disease using a related living donor

Abstract

Maple syrup urine disease (MSUD) is an autosomal recessive disease associated with high levels of branched-chain amino acids. Children with MSUD can present severe neurological damage, but liver transplantation (LT) allows the patient to resume a normal diet and avoid further neurological damage. The use of living related donors has been controversial because parents are obligatory heterozygotes. We report a case of a 2-year-old child with MSUD who underwent a living donor LT. The donor was the patient's mother, and his liver was then used as a domino graft. The postoperative course was uneventful in all three subjects. DNA analysis performed after the transplantation (sequencing of the coding regions of BCKDHA, BCKDHB, and DBT genes) showed that the MSUD patient was heterozygous for a pathogenic mutation in the BCKDHB gene. This mutation was not found in his mother, who is an obligatory carrier for MSUD according to the family history and, as expected, presented both normal clinical phenotype and levels of branched-chain amino acids. In conclusion, our data suggest that the use of a related donor in LT for MSUD was effective, and the liver of the MSUD patient was successfully used in domino transplantation. Routine donor genotyping may not be feasible, because the test is not widely available, and, most importantly, the disease is associated with both the presence of allelic and locus heterogeneity. Further studies with this population of patients are required to expand the use of related donors in MSUD.

Figure 1. A, Pre- and post-transplantation branched-chain amino acid (BCAA) levels of the recipient with maple syrup urine disease. B, Molar relationship between BCAAs (log₁₀). LT: liver transplantation.

Figure 2. DNA sequencing of Patient 1. A, Analysis of exon 5 of the BCKDHB gene: base C (blue) was exchanged by T (red) - R168C. B, Analysis of exon 9 of the DBT gene: base A (green) was exchanged by G (black) - G384S.