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Doshi HP, Vachharajani HH, Tchan MC, Nasreddine MA, Billmore KE. Metabolic crisis in maple syrup urine disease: an unusual complication of a rare disease: a case report. Anaesth Intensive Care 2024; 52:64-68. [PMID: 37994838 DOI: 10.1177/0310057x231183981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
A 19-year-old woman with known maple syrup urine disease presented to hospital with metabolic crisis in the setting of influenza type A infection and intractable vomiting, rapidly progressing to acute cerebral oedema manifesting as refractory seizures and decreased level of consciousness needing emergency intubation and mechanical ventilation, continuous veno-venous haemodiafiltration and thiopentone coma. A computed tomography scan and magnetic resonance imaging of the brain demonstrated classic signs of cerebral oedema secondary to a metabolic crisis from the metabolic disorder. Her management posed multiple challenges to all teams involved due to lack of familiarity and experience in managing this clinical scenario in the adult intensive care setting.
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Affiliation(s)
- Hemang P Doshi
- Department of Intensive Care Services, Westmead Hospital, Sydney, Australia
| | | | - Michael C Tchan
- Department of Genetic Medicine, Westmead Hospital, Sydney, Australia
| | | | - Kate E Billmore
- Department of Genetic Medicine, Westmead Hospital, Sydney, Australia
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2
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Carou-Senra P, Rodríguez-Pombo L, Monteagudo-Vilavedra E, Awad A, Alvarez-Lorenzo C, Basit AW, Goyanes A, Couce ML. 3D Printing of Dietary Products for the Management of Inborn Errors of Intermediary Metabolism in Pediatric Populations. Nutrients 2023; 16:61. [PMID: 38201891 PMCID: PMC10780524 DOI: 10.3390/nu16010061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
The incidence of Inborn Error of Intermediary Metabolism (IEiM) diseases may be low, yet collectively, they impact approximately 6-10% of the global population, primarily affecting children. Precise treatment doses and strict adherence to prescribed diet and pharmacological treatment regimens are imperative to avert metabolic disturbances in patients. However, the existing dietary and pharmacological products suffer from poor palatability, posing challenges to patient adherence. Furthermore, frequent dose adjustments contingent on age and drug blood levels further complicate treatment. Semi-solid extrusion (SSE) 3D printing technology is currently under assessment as a pioneering method for crafting customized chewable dosage forms, surmounting the primary limitations prevalent in present therapies. This method offers a spectrum of advantages, including the flexibility to tailor patient-specific doses, excipients, and organoleptic properties. These elements are pivotal in ensuring the treatment's efficacy, safety, and adherence. This comprehensive review presents the current landscape of available dietary products, diagnostic methods, therapeutic monitoring, and the latest advancements in SSE technology. It highlights the rationale underpinning their adoption while addressing regulatory aspects imperative for their seamless integration into clinical practice.
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Affiliation(s)
- Paola Carou-Senra
- Departamento de Farmacología, Farmacia y Tecnología Farmacéutica, I+D Farma (GI-1645), Facultad de Farmacia, Materials Institute (iMATUS) and Health Research Institute of Santiago de Compostela (IDIS), Universidade de Santiago de Compostela, 15782 Santiago de Compostela, Spain; (P.C.-S.); (L.R.-P.); (C.A.-L.)
| | - Lucía Rodríguez-Pombo
- Departamento de Farmacología, Farmacia y Tecnología Farmacéutica, I+D Farma (GI-1645), Facultad de Farmacia, Materials Institute (iMATUS) and Health Research Institute of Santiago de Compostela (IDIS), Universidade de Santiago de Compostela, 15782 Santiago de Compostela, Spain; (P.C.-S.); (L.R.-P.); (C.A.-L.)
| | - Einés Monteagudo-Vilavedra
- Servicio de Neonatología, Unidad de Diagnóstico y Tratamiento de Enfermedades Metabólicas Congénitas, Health Research Institute of Santiago de Compostela (IDIS), Hospital Clínico Universitario de Santiago de Compostela, Universidad de Santiago de Compostela, RICORS, CIBERER, MetabERN, 15706 Santiago de Compostela, Spain;
| | - Atheer Awad
- Department of Clinical, Pharmaceutical and Biological Sciences, University of Hertfordshire, College Lane, Hatfield AL10 9AB, UK;
| | - Carmen Alvarez-Lorenzo
- Departamento de Farmacología, Farmacia y Tecnología Farmacéutica, I+D Farma (GI-1645), Facultad de Farmacia, Materials Institute (iMATUS) and Health Research Institute of Santiago de Compostela (IDIS), Universidade de Santiago de Compostela, 15782 Santiago de Compostela, Spain; (P.C.-S.); (L.R.-P.); (C.A.-L.)
| | - Abdul W. Basit
- Department of Pharmaceutics, UCL School of Pharmacy, University College London, 29-39 Brunswick Square, London WC1N 1AX, UK;
- FABRX Ltd., Henwood House, Henwood, Ashford, Kent TN24 8DH, UK
- FABRX Artificial Intelligence, 27543 O Saviñao, Spain
| | - Alvaro Goyanes
- Departamento de Farmacología, Farmacia y Tecnología Farmacéutica, I+D Farma (GI-1645), Facultad de Farmacia, Materials Institute (iMATUS) and Health Research Institute of Santiago de Compostela (IDIS), Universidade de Santiago de Compostela, 15782 Santiago de Compostela, Spain; (P.C.-S.); (L.R.-P.); (C.A.-L.)
- Department of Pharmaceutics, UCL School of Pharmacy, University College London, 29-39 Brunswick Square, London WC1N 1AX, UK;
- FABRX Ltd., Henwood House, Henwood, Ashford, Kent TN24 8DH, UK
- FABRX Artificial Intelligence, 27543 O Saviñao, Spain
| | - María L. Couce
- Servicio de Neonatología, Unidad de Diagnóstico y Tratamiento de Enfermedades Metabólicas Congénitas, Health Research Institute of Santiago de Compostela (IDIS), Hospital Clínico Universitario de Santiago de Compostela, Universidad de Santiago de Compostela, RICORS, CIBERER, MetabERN, 15706 Santiago de Compostela, Spain;
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Köstekci YE, Kendirli T, Gün E, Uçmak H, Demirtaş F, Havan M, Köse E, Okulu E, Eminoğlu FT, Erdeve Ö, Atasay B, Arsan S. Evaluation of the efficacy and associated complications of regional citrate anticoagulation in neonates: experience from a fourth level neonatal intensive care unit. Eur J Pediatr 2023; 182:4897-4908. [PMID: 37597047 DOI: 10.1007/s00431-023-05162-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 08/21/2023]
Abstract
Continuous kidney replacement therapy (CKRT) use has increased in recent years, but anticoagulation is a challenge for neonates. Regional citrate anticoagulation (RCA) is rarely preferred in neonates because of citrate accumulation (CA) and metabolic complications. We aimed to demonstrate the efficacy and safety of RCA in neonates. We retrospectively analyzed the medical records of 11 neonates treated with RCA-CKRT between 2018 and 2023. The initial dose of RCA was 2.1-3 mmol/l, and then, its dose was increased according to the level of ionized calcium (iCa+2) in the circuit and patients. The total/iCa+2 ratio after-treatment > 2.5 was indicated as CA. We evaluated to citrate dose, CA, circuit lifespan, and dialysis effectivity. The median gestational age was 39 (36.4-41.5) weeks, the median body weight (BW) was 3200 (2400-4000) grams, and the mean postnatal age was 4 (2-24) days. The most common indication for CKRT was hyperammonemia (73%). All neonates had metabolic acidosis and hypocalcemia during CKRT. Other common metabolic complications were hypophosphatemia (90%), hypokalemia (81%), and hypomagnesemia (63%). High dialysate rates with a median of 5765 ml/h/1.73 m2 allowed for a rapid decrease in ammonia levels to normal. Four patients (36.3%) had CA, and seven (63.7%) did not (non-citrate accumulation, NCA). Mean BW, median postnatal age, biochemical parameters, coagulation tests, and ammonia levels were similar between the CA and NCA groups. Low pH, low HCO3, high lactate, and SNAPPE-II scores could be associated with a higher T/iCa ratio. CONCLUSION RCA was an efficient and safe anticoagulation for neonates requiring CKRT. Metabolic complications may occur, but they could be managed with adequate supplementation. WHAT IS KNOWN • Continuous kidney replacement therapy (CKRT) has become popular in recent years due to its successful treatment of fluid overload, electrolyte imbalance, metabolic acidosis, multi-organ failure, and hyperleucinemia/hyperammonemia associated with inborn errors of metabolism. • The need for anticoagulation is the major difficulty in neonatal CKRT. In adult and pediatric patients, regional citrate anticoagulation has been shown to be effective. WHAT IS NEW • RCA is an effective and safe anticoagulation method for neonates who require CKRT. • Electrolyte imbalances and metabolic acidosis could be managed with adequate supplementation and appropriate treatment parameters such as citrate dose, blood flow rate, and dialysate flow rate.
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Affiliation(s)
- Yasemin Ezgi Köstekci
- Division of Neonatology, Department of Pediatrics, Ankara University Faculty of Medicine, 06590, Mamak, Ankara, Turkey.
| | - Tanıl Kendirli
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Emrah Gün
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Hacer Uçmak
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ferhan Demirtaş
- Division of Neonatology, Department of Pediatrics, Ankara University Faculty of Medicine, 06590, Mamak, Ankara, Turkey
| | - Merve Havan
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Engin Köse
- Division of Pediatric Metabolism, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Emel Okulu
- Division of Neonatology, Department of Pediatrics, Ankara University Faculty of Medicine, 06590, Mamak, Ankara, Turkey
| | - Fatma Tuba Eminoğlu
- Division of Pediatric Metabolism, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ömer Erdeve
- Division of Neonatology, Department of Pediatrics, Ankara University Faculty of Medicine, 06590, Mamak, Ankara, Turkey
| | - Begüm Atasay
- Division of Neonatology, Department of Pediatrics, Ankara University Faculty of Medicine, 06590, Mamak, Ankara, Turkey
| | - Saadet Arsan
- Division of Neonatology, Department of Pediatrics, Ankara University Faculty of Medicine, 06590, Mamak, Ankara, Turkey
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Gün E, Gurbanov A, Nakip ÖS, Yöntem A, Aslan AD, Botan E, Kahveci F, Özcan S, Azapağası E, Emeksiz S, Yazıcı MU, Kesici S, Horoz ÖÖ, Erdeve Ö, Bayrakçı B, Yıldızdaş RD, Kendirli T. Clinical characteristics and outcomes of continuous renal replacement therapy performed on younger children weighing up to 10 kg. Turk J Med Sci 2023; 53:791-802. [PMID: 37476891 PMCID: PMC10388067 DOI: 10.55730/1300-0144.5642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/14/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND This study aimed to investigate the clinical features, modality, complications, and effecting factors on the survival of children weighing up to 10 kg who received continuous renal replacement therapy (CRRT). METHODS This study was a retrospective observational study conducted in five pediatric intensive care units in tertiary hospitals in Turkey between January 2015 and December 2019. RESULTS One hundred and forty-one children who underwent CRRT were enrolled in the study. The median age was 6 (range, 2-12)months, and 74 (52.5%) were male. The median weight of the patients was 6 (range, 4-8.35) kg and 52 (36.9%) weighed less than 5 kg. The most common indication for CRRT was fluid overload in 75 (53.2%) patients, and sepsis together with multiorgan failure in 62 (44%). The overall mortality was 48.2%. DISCUSSION Despite its complexity, CRRT in children weighing less than 10 kg is a beneficial, lifesaving extracorporeal treatment modality.
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Affiliation(s)
- Emrah Gün
- Department of Pediatric Intensive Care, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Anar Gurbanov
- Department of Pediatric Intensive Care, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Özlem Saritaş Nakip
- Department of Pediatric Intensive Care, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ahmet Yöntem
- Department of Pediatric Intensive Care, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Ayşen Durak Aslan
- Department of Pediatric, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Edin Botan
- Department of Pediatric Intensive Care, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Fevzi Kahveci
- Department of Pediatric Intensive Care, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Serhan Özcan
- Department of Pediatric Intensive Care, Faculty of Medicine, Ankara City Hospital, Ankara, Turkey
| | - Ebru Azapağası
- Department of Pediatric Intensive Care, Faculty of Medicine, Dr. Sami Ulus Gynecology Obstetrics and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Serhat Emeksiz
- Department of Pediatric Intensive Care, Faculty of Medicine, Ankara City Hospital, Ankara, Turkey
| | - Mutlu Uysal Yazıcı
- Department of Pediatric Intensive Care, Faculty of Medicine, Dr. Sami Ulus Gynecology Obstetrics and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Selman Kesici
- Department of Pediatric Intensive Care, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Özden Özgür Horoz
- Department of Pediatric Intensive Care, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Ömer Erdeve
- Department of Neonatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Benan Bayrakçı
- Department of Pediatric Intensive Care, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Rıza Dinçer Yıldızdaş
- Department of Pediatric Intensive Care, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Tanil Kendirli
- Department of Pediatric Intensive Care, Faculty of Medicine, Ankara University, Ankara, Turkey
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Redant S, Warrillow S, Honoré PM. Ammonia and nutritional therapy in the critically ill: when to worry, when to test and how to treat? Curr Opin Clin Nutr Metab Care 2023; 26:160-166. [PMID: 36892962 DOI: 10.1097/mco.0000000000000899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
PURPOSE OF REVIEW Hyperammonaemia is almost always develops in patients with severe liver failure and this remains the commonest cause of elevated ammonia concentrations in the ICU. Nonhepatic hyperammonaemia in ICU presents diagnostic and management challenges for treating clinicians. Nutritional and metabolic factors play an important role in the cause and management of these complex disorders. RECENT FINDINGS Nonhepatic hyperammonaemia causes such as drugs, infection and inborn errors of metabolism may be unfamiliar to clinicians and risk being overlooked. Although cirrhotic patients may tolerate marked elevations in ammonia, other causes of acute severe hyperammonaemia may result in fatal cerebral oedema. Any coma of unclear cause should prompt urgent measurement of ammonia and severe elevations warrant immediate protective measures as well as treatments such as renal replacement therapy to avoid life-threatening neurological injury. SUMMARY The current review explores important clinical considerations, the approach to testing and key treatment principles that may prevent progressive neurological damage and improve outcomes for patients with hyperammonaemia, especially from nonhepatic causes.
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Affiliation(s)
- Sebastien Redant
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Stephen Warrillow
- Department of Intensive Care, Austin Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Patrick M Honoré
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Depatment of Intensive Care, CHU UCL Godinne Namur, UCL Louvain Medical School, Namur, Belgium
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Sánchez-Pintos P, Meavilla S, López-Ramos MG, García-Cazorla Á, Couce ML. Intravenous branched-chain amino-acid-free solution for the treatment of metabolic decompensation episodes in Spanish pediatric patients with maple syrup urine disease. Front Pediatr 2022; 10:969741. [PMID: 36046474 PMCID: PMC9420908 DOI: 10.3389/fped.2022.969741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 07/27/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Metabolic decompensation episodes (DEs) in Maple Syrup urine disease (MSUD) result in brain accumulation of toxic branched-chain amino acids (BCAAs) and their respective branched-chain α-keto acids that could induce neuroinflammation, disturb brain bioenergetics, and alter glutamate and glutamine synthesis. These episodes require immediate intervention to prevent irreversible neurological damage. Intravenous (IV) administration of BCAA-free solution could represent a powerful alternative for emergency treatment of decompensations. METHODS This pediatric series discusses the management of DEs in MSUD patients with IV BCAA-free solution, as an emergency treatment for DEs or as a prophylactic in cases requiring surgery. Clinical evolution, amino acid profile and adverse effects were evaluated. RESULTS We evaluated the use of BCAA-free solution in 5 DEs in 5 MSUD pediatric patients, all with significantly elevated plasma leucine levels at admission (699-3296 μmol/L) and in 1 episode of risk of DE due to surgery. Leucine normalization was achieved in all cases with resolution or improvement of clinical symptoms following IV BCAA-free solution. The duration of administration ranged from 3-20 days. Administration of IV BCAA-free solution at the beginning of a DE could reverse depletion of the amino acids that compete with BCAAs for the LAT1 transporter, and the observed depletion of alanine, despite IV alanine supplementation. No related adverse events were observed. CONCLUSIONS Administration of standardized IV BCAA-free solution in emergency settings constitutes an important and safe alternative for the treatment of DEs in MSUD, especially in pediatric patients for whom oral or enteral treatment is not viable.
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Affiliation(s)
- Paula Sánchez-Pintos
- Diagnosis and Treatment Unit of Congenital Metabolic Diseases, Department of Paediatrics, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain.,IDIS-Health Research Institute of Santiago de Compostela, Santiago de Compostela, Spain.,CIBERER, Instituto Salud Carlos III, Madrid, Spain.,MetabERN, European Reference Network for Rare Hereditary Metabolic Disorders, Udine, Italy
| | - Silvia Meavilla
- MetabERN, European Reference Network for Rare Hereditary Metabolic Disorders, Udine, Italy.,Metabolic Diseases Unit, Neurology Department, CIBERER and MetabERN, Sant Joan de Déu Hospital, Barcelona, Spain
| | - María Goretti López-Ramos
- MetabERN, European Reference Network for Rare Hereditary Metabolic Disorders, Udine, Italy.,Metabolic Diseases Unit, Neurology Department, CIBERER and MetabERN, Sant Joan de Déu Hospital, Barcelona, Spain
| | - Ángeles García-Cazorla
- MetabERN, European Reference Network for Rare Hereditary Metabolic Disorders, Udine, Italy.,Metabolic Diseases Unit, Neurology Department, CIBERER and MetabERN, Sant Joan de Déu Hospital, Barcelona, Spain
| | - Maria L Couce
- Diagnosis and Treatment Unit of Congenital Metabolic Diseases, Department of Paediatrics, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain.,IDIS-Health Research Institute of Santiago de Compostela, Santiago de Compostela, Spain.,CIBERER, Instituto Salud Carlos III, Madrid, Spain.,MetabERN, European Reference Network for Rare Hereditary Metabolic Disorders, Udine, Italy
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