Published online October 30, 2006
PEDIATRICS Vol. 118 No. 6 December 2006, pp. e1896-e1899 (doi:10.1542/peds.2006-0833)

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EXPERIENCE & REASON

Sequential Liver and Bone Marrow Transplantation for Treatment of Erythropoietic Protoporphyria

Elizabeth B. Rand, MD^a, Nancy Bunin, MD^b, William Cochran, MD^c, Eduardo Ruchelli, MD^d, Kim M. Olthoff, MD^e and Joseph R. Bloomer, MD^f

^a Divisions of Gastroenterology
^b Oncology, Department of Pediatrics
^e Division of Transplantation, Department of Surgery
^d Department of Pathology, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
^c Division of Gastroenterology, Department of Pediatrics, Geisinger Medical Center, Danville, Pennsylvania
^f Division of Gastroenterology, Department of Medicine, University of Alabama, Tuscaloosa, Alabama

ABSTRACT

Erythropoietic protoporphyria is a disorder of heme synthesis in which deficient ferrochelatase activity leads to excess production and biliary excretion of protoporphyrin. The main clinical features, photosensitivity and hepatobiliary disease that may progress to liver failure, are caused by the toxicity of protoporphyrin. Liver transplantation has been used to treat liver failure in erythropoietic protoporphyria, but excess production of protoporphyrin by the bone marrow continues causing recurrence of liver disease in the majority of patients. This is the first report of successful sequential liver and bone marrow transplantation in a patient with liver failure as a result of erythropoietic protoporphyria. This combination corrected the severe phenotype, resolving the severe photosensitivity and halting erythropoietic protoporphyria associated liver graft injury. Splenectomy seemed to facilitate the successful bone marrow transplant.

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Key Words: liver transplantation • bone marrow transplantation • porphyria

Abbreviations: EPP, erythropoietic protoporphyria • FECH, ferrochelatase • OLT, orthotopic liver transplantation • ERCP, endoscopic retrograde cholangiopancreatography • HSC, hematopoietic stem cells

Erythropoietic protoporphyria (EPP) is a disorder of heme synthesis in which deficiency of the mitochondrial enzyme ferrochelatase (FECH) results in overproduction and accumulation of protoporphyrin.¹ Approximately 85% of heme synthesis takes place in the erythroid precursors of the bone marrow. The remainder takes place mainly in the liver, where heme is integral to cytochrome P-450 and other hepatic hemoproteins. The defining clinical characteristic of EPP is photosensitivity caused by the photoactive protoporphyrin in skin. Hepatic involvement is less common but is also mediated by protoporphyrin,^1,2 a poorly water-soluble compound excreted exclusively in bile. Excess protoporphyrin seems to cause direct hepatocellular and biliary damage,^3,4 yet hepatic uptake of protoporphyrin continues despite impaired secretion into bile. This ultimately results in high concentrations of protoporphyrin within hepatocytes, producing crystalline deposits and additional cell injury. Altered bile composition in a mouse model of EPP has been proposed as a mechanism of biliary fibrosis.⁵ A molecular study of gene expression in hepatic explants from individuals with EPP demonstrated altered expression of bile salt/organic anion transporters, further suggesting that cholestasis is important in the pathogenesis of liver disease caused by EPP.¹

Management of photosensitivity in EPP includes protection from sunlight and oral ß-carotene therapy.⁶ Affected individuals who develop superimposed acute and/or chronic liver failure characterized by coagulopathy and cholestasis (in addition to the intermittent symptoms of porphyria decompensation) have been managed by hematin infusions with or without plasmapheresis.^7–9 Hemin acts to reduce protoporphyrin production via feedback inhibition of -aminolevulinic acid synthase, the enzyme catalyzing the first committed step in erythroid heme synthesis (the major site of production) and the rate-limiting step in hepatic synthesis. In addition to direct feedback inhibition, hematin is thought to decrease both the synthesis and intracellular movement of aminolevulinic acid synthase. Although useful for acute skin and painful EPP crises by reducing protoporphyrin levels and symptoms, this intravenous therapy is difficult for long-term management and does not seem to prevent ultimate liver failure.

Orthotopic liver transplantation (OLT) is an effective treatment of liver failure caused by EPP, but it does not ameliorate the underlying protoporphyrin overproduction in the native bone marrow, thus leaving the recipient at risk for recurrent disease. EPP recurrence after OLT has been reported from several centers.^10–12 A retrospective analysis of 20 individuals who underwent OLT for liver disease resulting from EPP revealed that 11 of 17 who survived >2 months after transplant had biopsy-proven recurrent disease that occurred as early as 8 months after transplantation.¹² Of the 11 patients with recurrence, 4 died without retransplantation, 2 died with complications of retransplantation (1 related to attempted bone marrow transplantation), and 1 underwent successful retransplantation. Because of the likelihood of recurrent hepatic liver disease caused by EPP after OLT, subsequent bone marrow transplantation has been proposed as a possible curative treatment after liver transplantation.¹² Here we describe successful sequential liver and bone marrow transplantation in a teenager who developed liver failure as a result of EPP.

CASE REPORT

The patient is a white boy who was diagnosed with EPP at 2 years of age when he was evaluated for severe photosensitivity caused by limited sun exposure. Liver biopsy at 12 years of age showed scattered dark-brown pigment deposits without fibrosis. His erythrocyte protoporphyrin level was 2683 µg/dL (reference: <100). At 14.7 years of age, he developed jaundice, coagulopathy, and severe abdominal pain and required hospitalization. MRI showed hepatosplenomegaly (spleen: 21 cm), and hypersplenism was reflected in thrombocytopenia and leukopenia. He underwent plasmapheresis and intravenous hematin infusion for treatment of coagulopathy and porphyria crisis and was transferred to Children's Hospital of Philadelphia for additional evaluation and management. Percutaneous liver biopsy demonstrated marked pigment deposition and cirrhosis. He was placed on the United Network of Organ Sharing waiting list and maintained on plasmapheresis and hematin infusion while awaiting liver transplantation. Twelve days after admission, a whole ABO identical graft was allocated, and he underwent OLT. The operating room lights were filtered with Madico film (Madico ISO, CLS200X; Madico, Inc, Woburn, MA) to prevent a photosensitivity reaction. The hepatic explant was massively enlarged (weight: >3 kg) and was black in color, with histology remarkable for cirrhosis and extensive protoporphyrin pigment deposition (Fig 1). The graft functioned promptly with normalization of clotting parameters and bilirubin levels. Ten days after transplant he developed evidence of cholestasis with elevated bilirubin and gamma glutamyl transpeptidase. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated biliary sludging associated with a biliary stricture that was successfully treated with endoscopic balloon dilation, sphincterotomy, and biliary stent placement. Because of recurrent episodes of biliary stent obstruction with viscous bile (clinically characterized by rising bilirubin and gamma-glutamyl transferase and pruritus), he underwent repeated (every 4–6 weeks) ERCP for stent replacement.

View larger version (143K): [in this window] [in a new window]   FIGURE 1 A, Hepatectomy specimen with diffuse dark discoloration and micronodular cirrhosis. B, The microscopic changes are characterized by focal deposition of dark-brown pigment in hepatocytes, Kupffer cells, canaliculi, and connective tissue. Bile, which has a paler green-yellow color, can also be seen in some canaliculi and bile ducts. C, Electron micrograph showing an aggregate of curved hair-like crystals within a dilated canaliculus.

 
Because recurrent liver disease resulting from EPP seemed inevitable, a bone marrow transplant was planned. Previous FECH analysis had shown the patient to have a splicing mutation (IVS7-1gc) in 1 allele that caused exon-8 skipping, along with a polymorphism (IVS3-48c) in the nonmutant allele that caused low expression. His HLA-matched 18-year-old sister had only the polymorphism and no signs or symptoms of EPP, because the presence of the polymorphism by itself does not cause a significant alteration in protoporphyrin metabolism.¹³ Six months post-OLT he underwent a bone marrow transplant from his sister after conditioning with total-body irradiation and cyclophosphamide, but he remained pancytopenic. He received a peripheral stem cell boost after additional immunosuppression with Campath but again failed to engraft as documented by chimerism studies with variable nucleotide tandem repeats. He was maintained with subcutaneous granulocyte-stimulating factor and transfusions of red blood cells and platelets. Three months later his splenomegaly increased, and he developed fever and nasopharyngeal adenopathy and had an associated rise in serum Epstein-Barr virus polymerase chain reaction. He received 4 doses of rituximab with resolution of nasopharyngeal adenopathy, but his splenomegaly persisted. Splenectomy was performed 11 months post-OLT in hopes of improving his chances for engraftment with a planned second peripheral stem cell transplant. The explanted spleen was 25 cm at its longest dimension and weighed 1.5 kg. He had prompt normalization of his cell lines. Thirteen months post-OLT he received a second peripheral stem cell transplant from his sister after conditioning with busulfan, fludarabine, cytoxan, and thymoglobulin. He had prompt engraftment documented by variable nucleotide tandem repeats. His erythrocyte protoporphyrin level became normal (80 µg/dL), his photosensitivity disappeared, and there was no additional evidence of hepatobiliary injury. Final ERCP was performed 2 months after engraftment with removal of the patent biliary stent; he has remained without evidence of biliary obstruction for 10 months. He has complete hematopoietic chimerism.

DISCUSSION

EPP is a disorder of heme synthesis, which has been estimated to have a frequency of 1 in 75000 to 200000.¹⁴ Although the bone marrow is the major site of production of heme, the clinical features of this disorder manifest in the skin and liver. Liver transplantation is effective therapy for the liver failure that can occur in this disorder, but persistence of the metabolic defect in native bone marrow leads to recurrence of liver injury caused by EPP in the graft in most cases. An optimal therapy for EPP would correct the defect in heme synthesis and eliminate the photosensitivity before the development of significant liver injury. Bone marrow transplantation performed for the treatment of leukemia in a woman with EPP converted her genotype and phenotype to that of her donor brother.¹⁵ Preemptive bone marrow transplantation could be considered in individuals with severe photosensitivity and/or progressive hepatic pigment deposition but would only be an option for those patients with appropriate donors. A preselective gene-therapy technique that achieved long-term cure of EPP in a mouse model was described by Pawliuk et al¹⁶ in 1999 and suggests a potential future option. The authors performed retrovirus-mediated gene transfer of the human FECH complementary DNA into hematopoietic stem cells (HSCs) from male EPP mice and were able to select successfully transduced cells on the basis of coexpressed green fluorescent protein. The HSCs were then administered to myeloablated female EPP mice, allowing rigorous identification of cell lineage and resulting in normalization of serologic abnormalities and cure of photosensitivity. It is possible to envision future adaptation of this technique for human subjects, allowing genetic modification of autologous HSCs for bone marrow transplantation.

This report shows that bone marrow transplantation after liver transplantation for EPP can correct the biochemical abnormality in EPP, eliminating photosensitivity and recurrence of EPP injury in the liver graft. The marked splenomegaly noted at the time of transplant and later at splenectomy likely contributed to the failure of the first bone marrow transplant. We conclude that sequential liver and bone marrow transplantation can correct irreversible liver failure and then prevent hepatic recurrence from underlying disease.

ACKNOWLEDGMENTS

This study was supported in part by National Institutes of Health research grant DK26466 (Dr Bloomer) and the Fred and Suzanne Biesecker Liver Center (Drs Rand and Olthoff).

FOOTNOTES

Accepted Jun 20, 2006.

Address correspondence to Elizabeth B. Rand, MD, Department of Pediatrics, Children's Hospital of Philadelphia, Liver Transplant Program, 324 S 34th St, Philadelphia, PA 19104. E-mail: rand{at}email.chop.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.

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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics

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This Article Abstract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Rand, E. B. Articles by Bloomer, J. R. Search for Related Content PubMed PubMed Citation Articles by Rand, E. B. Articles by Bloomer, J. R. Related Collections Blood Social Bookmarking                         What's this?