Liver transplantation as rescue treatment in a patient with primary AL kappa amyloidosis

Although involvement of the liver is common in systemic amyloidosis, clinic al manifestations of hepatic dysfunction and liver biochemical abnormalitie s are often absent or only mild. Here we report on a patient with primary a myloidosis and rapid development of liver failure, who was successfully tre ated by liver transplantation. The patient is a 61-year-old Swedish man who was admitted to the local hospital for spontaneous rupture of the spleen. Before admission, he had suffered from diffuse upper abdominal discomfort, diminished appetite, and had lost 15 kg in 6 months. Shortly after splenect omy, he developed cholestatic liver failure with moderate hepatomegaly, jau ndice, ascites and hyponatremia. Over a period of 3 weeks his liver failure progressed, renal function deteriorated rapidly, and he developed encephal opathy. Liver transplantation was performed on the 35th day after splenic r upture. Histological examination revealed extensive deposits of amyloid in the spleen and liver. N-terminal amino acid sequence analysis of the amyloi d protein, purified from the patient's native liver, revealed an AL protein of kappa I-type origin. The postoperative course was uncomplicated, apart from one episode of sepsis and one course of treatment for acute rejection. He was discharged from hospital with normal liver function and good kidney function. One year after surgery, he was in good condition, with normal li ver function. However, a liver biopsy taken at the same time showed de novo amyloid deposits in the grafted liver. We conclude that fiver transplantat ion may be indicated as a life-saving procedure in rapidly progressing hepa tic amyloidosis with cholestatic jaundice, although the underlying disease has not changed.