Prospective versus clinical diagnosis and therapy of acute neonatal hyperammonaemia in two sisters with carbamyl phosphate synthetase deficiency

Extracorporeal Ammonia Clearance for Hyperammonemia in Critically Ill Patients: A Scoping Review

INTRODUCTION

Hyperammonemia is a life-threatening condition. However, clearance of ammonia via extracorporeal treatment has not been systematically evaluated.

METHODS

We searched EMBASE and MEDLINE databases. We included all publications reporting ammonia clearance by extracorporeal treatment in adult and pediatric patients with clearance estimated by direct dialysate ammonia measurement or calculated by formula. Two reviewers screened and extracted data independently.

RESULTS

We found 1,770 articles with 312 appropriate for assessment and 28 studies meeting eligibility criteria. Most of the studies were case reports. Hyperammonemia was typically secondary to inborn errors of metabolisms in children and to liver failure in adult patients. Ammonia clearance was most commonly reported during continuous renal replacement therapy (CRRT) and appeared to vary markedly from <5 mL/min/m2 to >250 mL/min/m2. When measured during intermittent hemodialysis (IHD), clearance was highest and correlated with blood flow rate (R2 = 0.853; p < 0.001). When measured during CRRT, ammonia clearance could be substantial and correlated with effluent flow rate (EFR; R2 = 0.584; p < 0.001). Neither correlated with ammonia reduction. Peritoneal dialysis (PD) achieved minimal clearance, and other extracorporeal techniques were rarely studied.

CONCLUSIONS

Extracorporeal ammonia clearance varies widely with sometimes implausible values. Treatment modality, blood flow, and EFR, however, appear to affect such clearance with IHD achieving the highest values, PD achieving minimal values, and CRRT achieving substantial values especially at high EFRs. The role of other techniques remains unclear. These findings can help inform practice and future studies.

Pharmacokinetic data reduce uncertainty in the acceptable daily intake for benzoic acid and its salts

The current acceptable daily intake (ADI) for benzoic acid and its salts as food additives is 0-5 mg/kg body weight. This accounts for a total uncertainty factor (UF) of 100, which includes a default factor of 10 for interspecies differences. Based on pharmacokinetic data in rodents and humans, we derived a chemical-specific adjustment factor (CSAF) of 2 for the pharmacokinetic component of the interspecies UF. Additional analyses indicate that this CSAF is conservative and interspecies differences between rats and humans are likely closer to unity. Human clinical studies indicate that the pharmacokinetics of benzoic acid and its salts are similar in children and adults, and that there is a lack of adverse events in humans at doses comparable to the no observed adverse effect level (NOAEL) in rodents; this suggests that the pharmacokinetic UF for intraspecies variability, as well as the pharmacodynamic components of the UFs, may also be reduced, although we did not calculate to what degree. In conclusion, the total UF can be reduced to 50 (2 for interspecies differences in pharmacokinetics, 2.5 for interspecies differences in pharmacodynamics, and 10 for intraspecies variability), which would increase the ADI to 0-10 mg/kg body weight.

Quantitative RT-PCR comparison of the urea and nitric oxide cycle gene transcripts in adult human tissues

The urea cycle and nitric oxide cycle play significant roles in complex biochemical and physiologic reactions. These cycles have distinct biochemical goals including the clearance of waste nitrogen; the production of the intermediates ornithine, citrulline, and arginine for the urea cycle; and the production of nitric oxide for the nitric oxide pathway. Despite their disparate functions, the two pathways share two enzymes, argininosuccinic acid synthase and argininosuccinic acid lyase, and a transporter, citrin. Studying the gene expression of these enzymes is paramount in understanding these complex biochemical pathways. Here, we examine the expression of genes involved in the urea cycle and the nitric oxide cycle in a panel of eleven different tissue samples obtained from individual adults without known inborn errors of metabolism. In this study, the pattern of co-expressed enzymes provides a global view of the metabolic activity of the urea and nitric oxide cycles in human tissues. Our results show that these transcripts are differentially expressed in different tissues. Using the co-expression profiles, we discovered that the combination of expression of enzyme transcripts as detected in our study, might serve to fulfill specific physiologic function(s) including urea production/nitrogen removal, arginine/citrulline production, nitric oxide production, and ornithine production. Our study reveals the importance of studying not only the expression profile of an enzyme of interest, but also studying the expression profiles of the other enzymes involved in a particular pathway so as to better understand the context of expression. The tissue patterns we observed highlight the variety of important functions of these enzymes and provides insight into the many clinical observations that result from their disruption. These results have implications for the management of urea cycle patients and raise considerations for the care of those patients receiving liver transplants. Finally, this work reaffirms the concept that the co-expression of a few genes can significantly impact complex biochemical and physiologic processes.

One liver for four children: first clinical series of liver cell transplantation for severe neonatal urea cycle defects

BACKGROUND

Urea cycle disorders (UCD) have a poor prognosis despite dietary and pharmacologic therapy, especially if the onset of the disease is within the neonatal period. They are promising target diseases for liver cell transplantation (LCT), which may be a less invasive alternative or supplementation to orthotopic liver transplantation.

METHODS

Cryopreserved hepatocytes were isolated under good manufacturing practice conditions. Four children with severe neonatal UCD (age 1 day-3 years) received multiple intraportal infusions of cryopreserved hepatocytes from that same donor, a 9-day old neonate. Portal vein access was achieved surgically in two children, whereas the umbilical vein was suitable for interventional catheter placement in two neonates. Cell applications were carefully monitored by means of Doppler ultrasound and portal vein pressure.

RESULTS

LCT was feasible in all children. No signs of portal vein thrombosis or extrahepatic shunting were observed. All children showed metabolic stabilization during observation periods of 4 to 13 months. One child with prenatally diagnosed ornithine transcarbamylase deficiency died after 4 months from a fatal metabolic decompensation.

CONCLUSIONS

Given the poor prognosis of UCD with conservative therapy, LCT caused considerable beneficial effects. Periods of hyperammonemia and clinically relevant crises could be reduced during an observation period of up to 13 months. Though cell therapy is not a permanent therapeutic option, bridging to liver transplantation may be substantially improved.

Current strategies for the management of neonatal urea cycle disorders

The treatment of newborns with urea cycle disorders has evolved over the years into a complex multidisciplinary effort. The complexity derives from the number of issues that must be addressed simultaneously. At the Urea Cycle Disorders Consensus Meeting held in Washington, D.C., a panel of physicians and other professionals with extensive experience in this field was assembled to bring some systematization to this task. This manuscript is a condensation of the collective opinion and experience of that group. The outcome of untreated or poorly treated patients with urea cycle disorders is universally bad. Although a favorable outcome is not always feasible, even with the best therapy, the methods outlined here should help treat such a patient by drawing on the experience of others who have treated patients with urea cycle disorders. This article does not purport to be the final word in treating children with these disorders. However, by establishing some common ground, new methods can be tried and compared with existing ones. In a future that holds the prospect of gene therapy "cures" for these diseases, striving for the best possible outcome in the critical newborn period is a worthy goal.

Continuous arteriovenous hemodiafiltration in the acute treatment of hyperammonaemia due to ornithine transcarbamylase deficiency

BACKGROUND

Acute hyperammonemia caused by urea cycle disorder is a medical emergency for which immediate managements should be taken to minimize permanent brain damage. Among different enzyme defects, ornithine transcarbamylase deficiency (OTC) is one of the most common enzyme defect in urea cycle disorders. We utilized continuous renal replacement therapy techniques in the acute treatment of hyperammonemia due to ornithine transcarbamylase deficiency.

PATIENTS AND METHODS

Three male neonates with elevated serum ammonia levels were shown, based on urine organic acid analysis and serum amino acid studies, to have OTC deficiency. Administration of sodium benzoate and sodium phenylacetate for activating alternative nitrogen waste pathway were used associated with protein restriction. Other modalities, including blood exchange transfusion, peritoneal dialysis, continuous renal replacement therapy were utilized in an attempt to lower serum ammonia concentration.

RESULTS

We report the successful use of continuous arteriovenous hemofiltration (CAVH), continuous arteriovenous hemodialysis (CAVHD), continuous arteriovenous hemodiafiltration (CAVHDF) in the acute management of hyperammonemia due to OTC deficiency. We also compared the ammonia clearance between peritoneal dialysis, exchange transfusion, CAVH, CAVHD and CAVHDF. It demonstrated the evidence that CAVHDF provides the best ammonia clearance.

CONCLUSION

Continuous renal replacement therapy including CAVH, CAVHD, and CAVHDF may be the alternative techniques for acute management of hyperammonemia in inborn error of metabolism when dialysis machine is not available. Our data suggests CAVHDF provides the best ammonia clearance.

Chronic moderate hyperammonemia impairs active and passive avoidance behavior and conditional discrimination learning in rats

The cerebral dysfunction associated with hepatic encephalopathy is generally considered to have hyperammonemia as one of its main causes. Hyperammonemia impairs the neuronal glutamate-nitric oxide-cyclic GMP pathway and the induction of NMDA receptor-dependent long-term potentiation in the hippocampus. We studied the performance of pre/neonatally and postnatally exposed rats to hyperammonemia on active avoidance, passive avoidance, and conditional discrimination tasks. Pre/neonatal hyperammonemia slowed learning of active avoidance behaviors and impaired memory for the passive avoidance task while postnatal hyperammonemia impaired learning on the conditional discrimination task. Hyperammonemia thus may produce cognitive disturbances that relate to the effects of ammonia on the neuronal glutamate-nitric oxide-cyclic GMP pathway.

Effective hemodialysis and hemofiltration driven by an extracorporeal membrane oxygenation pump in infants with hyperammonemia

Two infants with urea cycle disorders had life-threatening hyperammonemia within the first 5 days of life. Both patients were small for dates, poorly oxygenated, and hemodynamically unstable. We employed a combination of extracorporeal oxygenation and hemodialysis to provide high-flow filtration in a controlled system to rapidly detoxify both patients.

Neonatal seizures: a clinician's overview

Seizures are the most frequent neurological event in newborns (NBs), provoked often by noxae not apt to cause them in later life. This is because receptor families of excitatory amino acids (EAA) are overexpressed at this stage of brain ontogenesis, which is also why most neonatal seizures rapidly abate, even when neurological deficits persist. The brain's immaturities dictate distinct seizure phenotypes. A classification proposed in the late 1960s has been criticized, and a new one has been advocated, based on correlations between EEGs and behaviors, leading to a classification of seizures into 'epileptic' and 'non-epileptic'. The taxonomic pitfalls of these classifications are discussed, and the notion advanced that many seizures fail to fulfil the criteria to label them as epileptic. While etiological factors have changed in time, the striking dichotomy in outcome has persisted. Many etiologies, often multifactorial, are unique in NBs, and they are discussed with reference to diagnosis and therapies. Four syndromes of NB seizures, accepted into the International Classification of the Epilepsies, are critically analyzed, some appearing to rest on fragile grounds. Controversies persist whether seizures per se are injurious to the immature brain. Clinical studies suggest that neither duration in days or length of seizure phenotypes correlates with outcomes, the most valid prognostic indices being offered by etiologies and by patterns of EEG polygraphy. However, because most seizures are symptomatic, it may be difficult to distinguish morbidity due to underlying pathology from that possibly added by seizures. Animal experiments suggested that they are injurious. The theory of energy failure, postulated to cause a cascade of events leading to inhibitions of DNA, proteins, lipids and disrupted neuronal proliferation, synaptogenesis, myelination, has largely been disproved. Brains of immature animals have been shown to have the oxidative machinery needed to fulfill energy demands, even during status convulsivus. They are also capable of using anaerobic metabolism and require less ATP when aerobic energy production ceases. Recent explanations for the injurious consequences of hypoxic ischemia and of prolonged convulsions postulate that neuronal damage occurs from excessive release of EAA which, by binding to their ligand-gated ionic receptors, cause a large influx of Ca2+, resulting in cell death. Because of the overabundance of EAA receptors in early ontogenesis, the excitotoxic hypothesis would appear attractive, but some observations militate against it. Among these is the dissociation found between the focal neurotoxicities induced by EAA injected into the brain and their absence following the concomitant convulsions. The latter are not blocked by pretreatment with EAA antagonists, while these prevent injuries caused by the injected EAA. There is no convincing evidence that excessive release of EAA occurs during NBs' seizures. Even if it does occur, it has been shown that immature neurons have a better capacity to self-protect from increased Ca2+ influx, and also that direct application of glutamate to immature neurons leads to significantly lower Ca2+ influx. These data raise doubts about the postulated excitotoxicity caused by NBs' seizures, being consistent with the fact that no one, so far, has observed neuronal damage from drug-induced convulsive states in NBs. Lack of overt neuronal injuries does not preclude that long-term subtle changes might be induced by noxae apt to provoke transient ictal events. Thus models developed in our laboratories demonstrate that long-term epileptogenicity results following postnatal O2 deprivation without evidence of neuronal injuries or of long-term behavioral or electrophysiological alteration. However, both age at which hypoxia occurs and specific proconvulsant methods used strictly determine whether increased epileptogenicity will occur.

Inborn errors of urea synthesis

Inborn errors of urea synthesis can present in the newborn period as a catastrophic illness or later in childhood or adulthood with an indolent course punctuated by hyperammonemic episodes. Because symptoms mimic other neuropsychiatric disorders, it is common for there to be a delay in diagnosis, often with dire consequences. Diagnosis relies on the combination of clinical suspicion and the measurement of ammonium, lactate, and amino acids in plasma and organic acids and orotic acid in urine. Treatment involves nitrogen restriction combined with the stimulation of alternate pathways of waste nitrogen excretion. More recently liver transplantation has been performed as enzyme replacement therapy. The outcome is poor in children who survive prolonged neonatal hyperammonemic coma, with most manifesting developmental disabilities. The etiology of neuronal injury in this disorder is unclear but may involve some combination of ammonia/amino acid accumulation, neurotransmitter alterations, and excitotoxic injury. Gene therapy holds the promise of improved treatment in the future.

The biochemistry and toxicology of benzoic acid metabolism and its relationship to the elimination of waste nitrogen

Detoxification of sodium benzoate by elimination as a conjugate with glycine, a nonessential amino acid, provides a pathway for the disposal of waste nitrogen. Since 1979, sodium benzoate has been widely used in the therapeutic regimen to combat ammonia toxicity in patients born with genetic defects in the urea cycle. Although the clinical use of benzoate is associated with improved outcome, the search for biochemical evidence in support of the rationale for benzoate therapy has produced conflicting results. This review begins with an historical account leading to elucidation of the biochemistry of benzoate detoxification and early work indicating the potential utility of the pathway for elimination of waste nitrogen. An introduction to contemporary efforts at employing benzoate to treat hyperammonemia is followed by a detailed review of studies on benzoate metabolism and resultant toxic interactions with other major metabolic pathways. With this background, the several metabolic routes by which benzoate is thought to promote the disposal of waste nitrogen are then examined, followed by a consideration of alternative mechanisms by which benzoate might combat ammonia toxicity.