Trapianto di fegato in malattie mitocondriali con accumulo di tossici: il caso della MNGIE

Rita Rinaldi, MDUO di NEUROLOGIA, Azienda Ospedaliero-Universitaria di Bologna,

Policlinico S. Orsola-Malpighi, Bologna, Italy

6° Convegno Nazionale sulle Malattie MitocondrialiROMA, 27 – 28 - 29 maggio 2016

Mitochondrial Neuro-Gastro-Intestinal EncephaloMyopathy (MNGIE)

28 years of age 38 years of age

prevalence ~0.15/1,000,000Neurological Sciences, March 2016

(CNS – GUT Neuromuscular system)

TP activity <10%

TP deficiency leads to instability of mitochondrial DNA:

mtDNA multiple deletions (skeletal muscle)

mtDNA depletion (gastrointestinal smooth muscle, skeletal muscle and liver)

mtDNA point mutations (skeletal muscle, lymphocytes, fibroblasts)

mtDNA depletion in liver and COX deficiency

COX/SDH staining

COX+

COX-

1°MNGIE patient in Bologna

We also detected a partial reduction ofmtDNA copy number in our index patient

MNGIE livers (n=3)“NASH like” steatosis

V.M.A F.A. P.N.

TP in healthy liver

healthy liver MNGIE liver

IHC

TP nuclei = blue triangle

TP sinusoidal lining cell = blue arrow

TP cytoplasm = blue circle

VMA, , 25 yrs♂

Consanguineous parents (cousins)

No major remarks in the clinical history

Up to 19 yrs – doing well; however, at the age of 2 yrs, he had an episode of ‘intestinal sub-obstruction’ (apparently treated only with " laxatives ")

From 19 yrs:

•Recurrent arthritis / myalgia•Chronic diarrhea leading to a "diagnosis of IBD" •Partial response to steroid therapy + sulfasalazine

Since May 2014 deterioration of digestive symptoms with episodes of intestinal sub-obstruction; weight loss ( BMI → 13.4 ) → PN

Neurological evaluation• Mild hyporeflexia and imbalance, without ptosis,

ophthalmoparesis or segmental hyposthenia.

• Electromyography showed demyelinating sensory-motor polyneuropathy.

• Brain MRI with spectroscopy revealed moderate-to-severe hyperintensity in the cerebral and cerebellar white matter, along with brain white matter lactate increase.

leukoencephalopathy

Muscle biopsy • COX negative along with rare “ragged-red” fibers

• Ultrastructural mitochondrial abnormalities

• Muscle mtDNA analysis showed slight accumulation of multiple deletions and partial reduction of mtDNA copy number

COX-

Biochemical profiling • Markedly reduced plasma TP activity (4 nmol/h*mg; n.v. >253)

• Increased dThd and dUrd levels (4 μg/mL and 3.7 μg/mL, respectively)

• The TYMP gene sequence revealed a homozygous c.1160-1G>A mutation

1st March 2015 Orthotopic Liver

Transplantation (OLT)

Liver function and blood tests

LOD = Limit of detection (0.12ug/ml)LOQ = Limit of quantification (0.5ug/ml)(Mohamed S et al., 2014)

Plasma dThymidine and dUridine rapidly drop in post-OLT, except for a transient liver function impairment between days 60 and 135

Under the line (0-46 nmol/h*mg) the activity is considered pathologic

As expected, the TP activity in lymphocytes remained extremely impaired, except for an early post-OLT transient and limited increase, possibly due to platelet transfusions

PRE-OLT 90 days post-OLT

180 days post-OLT

300 days post-OLT

Karnofsky (performance status scale)

400 days post-OLT

30 – severely disabled40 – disabled, requires assistance50 – requires assistance and medical care60 – requires occasional assistance

PRE-OLT 90 days post-OLT

180 days post-OLT

300 days post-OLT

SF-36 (quality of life)

400 days post-OLT

PCS=Physical component summaryMCS=Mental component summary

PRE-OLT POST-OLT

EMG

RMN

D

A B

C

COX/SDH COX/SDH

pre-OLT post-OLT

PRE-OLT

POST-OLT

GastroIntestinal tractMasson’s trichrome Orcein

At over 12 months of follow-up:

• Rapid and persistent clearance of plasma nucleosides

• OLT is well tolerated, with no major complications

• No side effects to immunosuppressive therapy

• Persistence of GI disfunction

• No changes of EMG and MRI abnormalities,

•No changes in muscle and gut biopsies

Conclusions

Other two patients are now under

clinical scrutiny as candidate for OLT(both with predominant neurological

phenotype and very mild GI symptoms)

Roberto D’AlessandroDipartimento Scienze Biomediche e Neuromotorie-DIBINEM, IRCCS Istituto di Scienze NeurologicheValerio Carelli, Leonardo Caporali, Manuela Contin, Mariantonietta Capristo, Susan MohamedDipartimento Scienze Biomediche e Neuromotorie-DIBINEM, IRCCS Istituto di Scienze Neurologiche

RF‐2009‐ 1492481 Ita‐MNGIE: An Italian network for MNGIE epidemiology, molecular mechanisms

and enzyme replacement therapy by stem cell transplant

Roberto De Giorgio, Elisa Boschetti, Francesca BiancoDipartimento Scienze Mediche e Chirurgiche-DIMECLoris PironiCenter for Chronic Intestinal Failure, Digestive System DeptRita Rinaldi, Roberto D’AngeloUO NeurologiaAntonia D’ErricoPathology UnitGiovanna Cenacchi, Valentina Papa, Roberta CostaDipartimento Scienze Biomediche e Neuromotorie-DIBINEMRaffaele Lodi, Caterina Tonon, L. L GramegnaUnità di RM Funzionale, DIBINEM

Antonio Daniele Pinna, Maria Cristina MorelliTransplantation and Organ Insufficency Dept, DIMEC