Renal outcome and plasma methylmalonic acid levels after isolated or combined liver or kidney transplantation in patients with methylmalonic acidemia: A multicenter analysis

Background: Methylmalonic acidemia (MMAemia) is characterized by accumulation of methylmalonic acid (MMA) in all body tissues. To minimize disease-related complications, isolated kidney (KTx), liver (LTx) or com-bined liver-kidney transplantation (LKTx) have been suggested. However, the impact of these different trans -plant strategies on outcome are unclear.Methods: In this multicenter retrospective observational study, we compared plasma MMA levels and estimated glomerular filtration rate (eGFR) data of 83 patients. Sixty-eight patients (82%) had a mut0-type MMAemia, one patient had a mut--type MMAemia, and seven (7.3%) had an inherited defect in cobalamin metabolism (cblA-or cblB-type MMAemia). Median observation period was 3.7 years (0-15.1 years).Results: Twenty-six (31%) patients underwent KTx, 24 (29%) LTx and 33 (40%) LKTx. Posttransplant, mean plasma MMA concentration significantly decreased in all three cohorts; but at month 12, plasma MMA in KTx (1372 & PLUSMN; 1101 mu mol/L) was 7.8-fold higher than in LTx (176 & PLUSMN; 103 mu mol/L; P < 0.001) and 6.4-fold higher than in LKTx (215 & PLUSMN; 110 mu mol/L; P < 0.001). Comparable data were observed at month 24. At time of transplan-tation, mean eGFR in KTx was 18.1 & PLUSMN; 24.3 mL/min/1.73 m2, in LTx 99.8 & PLUSMN; 29.9 mL/min/1.73 m2, and in LKTx 31.5 & PLUSMN; 21.2 mL/min/1.73 m2. At month 12 posttransplant, mean eGFR in KTx (62.3 & PLUSMN; 30.3 mL/min/1.73 m2) was 33.4% lower than in LTx (93.5 & PLUSMN; 18.3 mL/min/1.73 m2; P = 0.0053) and 25.4% lower than in LKTx (83.5 & PLUSMN; 26.9 mL/min/1.73 m2; P = 0.0403).Conclusions: In patients with isolated MMAemia, LTx and LKTx lead to markedly lower plasma MMA levels during the first 2 years posttransplant than KTx and are associated with a better preservation of kidney function. LTx should therefore be part of the transplant strategy in MMAemia.(c) 2022 Elsevier Inc. All rights reserved.