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J Pediatr. 2015 Jun;166(6):1455-61.e1. doi: 10.1016/j.jpeds.2015.01.051. Epub 2015 Mar 11.

Treatment of methylmalonic acidemia by liver or combined liver-kidney transplantation.

Author information

Division of Medical Genetics, Department of Pediatrics, Stanford University, Stanford, CA. Electronic address:
Division of Abdominal Transplantation, Department of Surgery, Stanford University, Stanford, CA.
Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, CA.
Department of Pathology, Stanford University, Stanford, CA.
Lucile Packard Children's Hospital at Stanford, Stanford, CA.
Division of Medical Genetics, Department of Pediatrics, Stanford University, Stanford, CA; Prenatal Diagnostics, Department of Obstetrics and Gynecology, University of California, San Francisco, San Francisco, CA.
Division of Medical Genetics, Department of Pediatrics, Stanford University, Stanford, CA.



To assess biochemical, surgical, and long-term outcomes of liver (LT) or liver-kidney transplantation (LKT) for severe, early-onset methylmalonic acidemia/acid (MMA).


A retrospective chart review (December 1997 to May 2012) of patients with MMA who underwent LT or LKT at Lucile Packard Children's Hospital at Stanford.


Fourteen patients underwent LT (n = 6) or LKT (n = 8) at mean age 8.2 years (range 0.8-20.7). Eleven (79%) were diagnosed during the neonatal period, including 6 by newborn screening. All underwent deceased donor transplantation; 12 (86%) received a whole liver graft. Postoperative survival was 100%. At a mean follow-up of 3.25 ± 4.2 years, patient survival was 100%, liver allograft survival 93%, and kidney allograft survival 100%. One patient underwent liver re-transplantation because of hepatic artery thrombosis. After transplantation, there were no episodes of hyperammonemia, acidosis, or metabolic decompensation. The mean serum MMA at the time of transplantation was 1648 ± 1492 μmol/L (normal <0.3, range 99-4420). By 3 days, post-transplantation levels fell on average by 87% (mean 210 ± 154 μmol/L), and at 4 months, they were 83% below pre-transplantation levels (mean 305 ± 108 μmol/L). Developmental delay was present in 12 patients (86%) before transplantation. All patients maintained neurodevelopmental abilities or exhibited improvements in motor skills, learning abilities, and social functioning.


LT or LKT for MMA eradicates episodes of hyperammonemia, results in excellent long-term survival, and suggests stabilization of neurocognitive development. Long-term follow-up is underway to evaluate whether patients who undergo early LT need kidney transplantation later in life.

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