Risk factors for urolithiasis in children on the ketogenic diet

The case for a ketogenic diet in the management of kidney disease

Ketogenic diets have been widely used for weight loss and are increasingly used in the management of type 2 diabetes. Despite evidence that ketones have multiple positive effects on kidney function, common misconceptions about ketogenic diets, such as high protein content and acid load, have prevented their widespread use in individuals with impaired kidney function. Clinical trial evidence focusing on major adverse kidney events is sparse. The aim of this review is to explore the effects of a ketogenic diet, with an emphasis on the pleiotropic actions of ketones, on kidney health. Given the minimal concerns in relation to the potential renoprotective effects of a ketogenic diet, future studies should evaluate the safety and efficacy of ketogenic interventions in kidney disease.

Human milk and breastfeeding during ketogenic diet therapy in infants with epilepsy: Clinical practice guideline

Ketogenic diet therapy (KDT) is a safe and effective treatment for epilepsy and glucose transporter type 1 (GLUT1) deficiency syndrome in infancy. Complete weaning from breastfeeding is not required to implement KDT; however, breastfeeding remains uncommon. Barriers include feasibility concerns and lack of referrals to expert centres. Therefore, practical strategies are needed to help mothers and professionals overcome these barriers and facilitate the inclusion of breastfeeding and human milk during KDT. A multidisciplinary expert panel met online to address clinical concerns, systematically reviewed the literature, and conducted two international surveys to develop an expert consensus of practical recommendations for including human milk and breastfeeding in KDT. The need to educate about the nutritional benefits of human milk and to increase breastfeeding rates is emphasized. Prospective real-world registries could help to collect data on the implementation of breastfeeding and the use of human milk in KDT, while systematically including non-seizure-related outcomes, such as quality of life, and social and emotional well-being, which could improve outcomes for infants and mothers.

Ketogenic diets: A systematic review of current scientific evidence and possible applicability in dogs and cats

Ketogenic diets (KD) have been used in the treatment of epilepsy in humans for around a century and, more recently, they have been implanted for cancer patients, as well as in the treatment of obesity. This type of diet consists of high-fat levels, an adequate amount of protein and restricted carbohydrates, or high medium-chain triglycerides. Recently, the ketogenic diet has gained attention in veterinary medicine and studies were published evaluating the effects of KD in dogs with epilepsy. The objective of this review was to highlight recent studies about the application of KD in dogs and cats, to describe the neurobiochemical mechanisms through which KD improves epilepsy crisis, and their adverse effects. Studies were identified by a systematic review of literature available on PubMed, Embase, and Scopus. All cohort and case-control studies were included, and all articles were exported to Mendeley® citation manager, and duplicates were automatically removed. Seven articles and three conference abstracts conducted with dogs were included in the present study. There is evidence that the consumption of diets with medium-chain triglycerides increases the concentration of circulating ketone bodies and improves epilepsy signs, although these diets have higher carbohydrate and lower fat content when compared to the classic KD.

Intermittent fasting and Alzheimer's disease-Targeting ketone bodies as a potential strategy for brain energy rescue

Alzheimer's disease (AD) lacks effective clinical treatments. As the disease progresses, the cerebral glucose hypometabolism that appears in the preclinical phase of AD gradually worsens, leading to increasingly severe brain energy disorders. This review analyzes the brain energy deficit in AD and its etiology, brain energy rescue strategies based on ketone intervention, the effects and mechanisms of IF, the differences in efficacy between IF and ketogenic diet and the duality of IF. The evidence suggests that brain energy deficits lead to the development and progression of AD pathology. IF, which improves brain energy impairments by promoting ketone metabolism, thus has good therapeutic potential for AD.

Kidney Stones in Epileptic Children Receiving Ketogenic Diet: Frequency and Risk Factors

BACKGROUND

Although it is a valuable option for children with drug-resistant epilepsy, ketogenic diet (KD) therapy is associated with several side effects. The frequency of kidney stones and risk factors for their development in epileptic children receiving KD is unclear. The aim of this study was to determine the frequency and risk factors for the development of renal stones in children receiving KD therapy.

METHODS

A total of 95 patients receiving KD were identified. Of these, seven patients were excluded from the study due to the duration of KD being less than 12 months. The remaining 88 children were enrolled in the study.

RESULTS

Renal stones were detected in 15 patients (17%), of which 12 (73.3%) received potassium citrate treatment. Two (13.3%) patients needed lithotripsy despite receiving potassium citrate treatment, and one of these, who received potassium citrate treatment for 5 months, developed acute vesicourethral reflux and underwent surgery. No patient discontinued KD due to renal stone development. The serum uric acid concentrations and urine calcium/creatinine ratio did not change significantly over the 24-month follow-up period. Age, gender, etiology, age at seizure onset, duration of KD, mobility status, use of topiramate or zonisamide, and the number of antiepileptic drugs used were not significantly different between patients with and without kidney stones.

CONCLUSION

Renal stone appears to be a common adverse effect of KD therapy. Although adequate hydration and potassium citrate treatment are effective in most patients, lithotripsy and surgery may be required in a minority of patients.

Ketogenic therapy in childhood and adolescence: recommendations of the Brazilian experts group

Ketogenic dietary therapies (KDTs) are a safe and effective treatment for pharmacoresistant epilepsy in children. There are four principal types of KDTs: the classic KD, the modified Atkins diet (MAD), the medium-chain triglyceride (MCT) diet, and the low glycemic index diet (LGID). The International Ketogenic Diet Study Group recommends managing KDTs in children with epilepsy. However, there are no guidelines that address the specific needs of the Brazilian population. Thus, the Brazilian Child Neurology Association elaborated on these recommendations with the goal of stimulating and expanding the use of the KD in Brazil.

Breaking the Cycle of Recurrent Calcium Stone Disease

Calcium stones are common and recurrent in nature, yet few therapeutic tools are available for secondary prevention. Personalized approaches for stone prevention have been informed by 24-hour urine testing to guide dietary and medical interventions. However, current evidence is conflicting about whether an approach guided by 24-hour urine testing is more effective than a generic one. The available medications for stone prevention, namely thiazide diuretics, alkali, and allopurinol, are not always prescribed consistently, dosed correctly, or tolerated well by patients. New treatments on the horizon hold the promise of preventing calcium oxalate stones by degrading oxalate in the gut, reprogramming the gut microbiome to reduce oxalate absorption, or knocking down expression of enzymes involved in hepatic oxalate production. New treatments are also needed to target Randall's plaque, the root cause of calcium stone formation.

Dietary weight loss strategies for kidney stone patients

PURPOSE

Overweight has been associated with an increased risk of incident and recurrent kidney stone disease. Weight reduction is the therapeutic consequence to decrease the risk of stone formation. This review examines the effectiveness of different weight loss strategies on weight reduction and cardiometabolic risk profile, with a particular focus on risk factors for urolithiasis.

METHODS

A selective literature search was performed using PubMed and Cochrane library.

RESULTS

Clinical evidence for the potential benefits of dietary weight loss strategies for kidney stone disease is limited. A conventional, energy-restricted diet may significantly induce weight loss and reduce urinary supersaturation of calcium oxalate in overweight individuals with or without a history of stone formation. The current data indicate that an energy-restricted diet with partial meal replacement may additionally decrease the relative supersaturation of uric acid and further improve the cardiometabolic risk profile, and, thus, may be a favourable option for overweight kidney stone patients. Studies on the Mediterranean and DASH diets on the association between weight loss and the risk of urinary stone formation are lacking.

CONCLUSION

An energy-restricted diet with or without meal replacement could be a promising weight loss strategy for overweight kidney stone patients. Further studies are needed to evaluate the impact of different weight loss strategies on urinary risk factors and cardiometabolic risk profile in urolithiasis.

A Review of the Multi-Systemic Complications of a Ketogenic Diet in Children and Infants with Epilepsy

Ketogenic diets (KDs) are highly effective in the treatment of epilepsy. However, numerous complications have been reported. During the initiation phase of the diet, common side effects include vomiting, hypoglycemia, metabolic acidosis and refusal of the diet. While on the diet, the side effects involve the following systems: gastrointestinal, hepatic, cardiovascular, renal, dermatological, hematologic and bone. Many of the common side effects can be tackled easily with careful monitoring including blood counts, liver enzymes, renal function tests, urinalysis, vitamin levels, mineral levels, lipid profiles, and serum carnitine levels. Some rare and serious side effects reported in the literature include pancreatitis, protein-losing enteropathy, prolonged QT interval, cardiomyopathy and changes in the basal ganglia. These serious complications may need more advanced work-up and immediate cessation of the diet. With appropriate monitoring and close follow-up to minimize adverse effects, KDs can be effective for patients with intractable epilepsy.

Association of hypercalciuria with vitamin D supplementation in patients undergoing ketogenic dietary therapy

Background

Ketogenic dietary therapy (KDT) is used as an effective treatment for epilepsy. However, KDT carries the risk of bone health deterioration; therefore, vitamin D supplementation is required. Vitamin D replacement therapy in KDT has not been established because it may be related to hypercalciuria/urolithiasis, which are common adverse effects of KDT. Hence, this study aimed to evaluate the dose-dependent association between vitamin D₃ and hypercalciuria/urolithiasis in patients undergoing KDT and dose optimization for renal complications.

Materials and methods

Overall, 140 patients with intractable childhood epilepsy started 3:1 KDT (lipid to non-lipid ratio) at the Severance Children’s Hospital from January 2016 to December 2019. Regular visits were recommended after KDT initiation. Participants were assessed for height, weight, serum 25-hydroxyvitamin D (25-OH-D₃) level, parathyroid hormone level, and ratio of urinary excretion of calcium and creatinine (Uca/Ucr). Kidney sonography was conducted annually. Patients who already had urolithiasis and were taking hydrochlorothiazide before KDT, failed to maintain KDT for 3 months, did not visit the pediatric endocrine department regularly, did not take prescribed calcium and vitamin D3 properly, or needed hospitalization for > 1°month because of serious medical illness were excluded. Data from patients who started diuretic agents, e.g., hydrochlorothiazide, were excluded from that point because the excretion of calcium in the urine may be altered in these patients.

Result

In total, 49 patients were included in this study. Uca/Ucr ratio significantly decreased with increasing levels of 25-OH-D₃ (p = 0.027). The odds ratio for hypercalciuria was 0.945 (95% confidence interval, 0.912–0.979; p = 0.002) per 1.0 ng/mL increment in 25-OH-D₃ level. Based on findings of receiver operating characteristic curve analysis and Youden’s J statistic, the cut-off 25-OH-D₃ level for preventing hypercalciuria was > 39.1 ng/mL at 6 months. Furthermore, the vitamin D₃ supplementation dose cut-off was > 49.5 IU/kg for hypercalciuria prevention.

Conclusion

An inverse relationship between Uca/Ucr ratio and 25-OH-D₃ level was noted, which means that vitamin D supplementation is helpful for preventing hypercalciuria related to KDT. We suggest that the recommended 25-OH-D₃ level is > 40 ng/mL for hypercalciuria prevention and that KDT for children with epilepsy can be optimized by vitamin D₃ supplementation at 50 IU/kg.

Potentials of ketogenic diet against chronic kidney diseases: pharmacological insights and therapeutic prospects

BACKGROUND

Chronic kidney disease (CKD) is a worldwide public health concern. Nutritional interventions become a primary concern in managing various diseases, including CKD. Ketogenic diets (KD) are a popular diet and an increasingly used diet for weight loss.

MAIN BODY

With the increasing cases of CKD, KD has been proposed as a treatment by many scientists. Several studies have shown that KD can slow down the progression rate of renal abnormalities. Also, this diet is regarded as a safe route for managing CKD. CKD is generally associated with increased inflammation, oxidative stress, fibrosis, autophagy dysfunction, and mitochondrial dysfunction, while all of these can be attenuated by KD. The protective effect of KD is mainly mediated through inhibition of ROS, NF-κB, and p62 signaling.

CONCLUSIONS

It is suggested that KD could be considered a new strategy for managing and treating CKD more carefully. This review explores the potential of KD on CKD and the mechanism involved in KD-mediated kidney protection.

Modified Atkins diet for drug-resistant epilepsy and the risk of urolithiasis

BACKGROUND

Ketogenic diet (KD) is widely used for drug-resistant epilepsy (DRE). The study was designed to evaluate one of the risk factors for development of renal calculi with KD.

METHODS

Twenty patients with DRE on Modified Atkins diet (MAD) were subjected to full history and laboratory investigations, including microscopic urine analysis, urinary calcium after overnight fasting, and calcium/creatinine ratio, as well as pelviabdominal ultrasound. Frequency and severity of seizures assessed by Chalfont severity score were recorded. All assessment measures were repeated after 3 and 6 months of KD therapy.

RESULTS

There were significant reductions in both frequency and severity of seizures, yet 2 patients (10%) developed renal stones after 6 months on KD. Gross hematuria was reported in 1 of those 2 patients (50%), but microscopic hematuria was detected in both patients. The urine calcium and the urine calcium/creatinine ratio were elevated in both patients having renal calculi after 6 months.

CONCLUSIONS

KD increases the risk of renal stones with hypercalciuria among the causes. We recommend initiation of prophylactic measures once KD is commenced by maximizing fluid intake and urine alkalinization with regular urinary studies including calcium/creatinine ratio and renal ultrasound for patients with symptoms.

IMPACT

KD has been increasingly used in epilepsy management and beyond. The potential side effects of such diet should be highlighted while valuing the merits. KD increases the risk of renal stones because of hypercalciuria among other causes. We recommend initiation of prophylactic measures once KD is commenced by maximizing fluid intake and urine alkalinization with estimation of urinary calcium/creatinine ratio and renal ultrasound in patients with relevant symptoms.

The Efficacy of Ketogenic Therapies in the Clinical Management of People with Neurodegenerative Disease: A Systematic Review

Ketone bodies have potential disease-modifying activity that represent a novel therapeutic approach for neurodegenerative diseases (NDD). The aim of this systematic review was to summarize and evaluate the evidence for the application of ketogenic therapies (dietary or exogenous ketogenic agents) for NDD and provide recommendations for future research. Eight databases were electronically searched for articles reporting on controlled trials (≥4 wk duration) that induced ketosis or elevated serum ketone concentrations in people with NDD. Of 4498 records identified, 17 articles met the inclusion criteria with a total of 979 participants including studies on mild cognitive impairment (MCI; n = 6), multiple sclerosis (n = 4), Alzheimer's disease (n = 5), Parkinson's disease (n = 1), and MCI secondary to Parkinson's disease (n = 1). Of 17 studies, 7 were randomized double-blind placebo-controlled trials. Most studies used dietary interventions (n = 9), followed by medium-chain triglycerides (n = 7) and a fasting protocol (n = 1). Generally, trials were 6 wk in duration and assessed cognition as the primary outcome. Studies were heterogeneous in type and severity of NDD, interventions used, and outcomes assessed. Overall, 3/17 studies carried a low risk of bias. Based on available evidence, exogenous ketogenic agents may be more feasible than dietary interventions in NDD from a compliance and adherence perspective; more research is required to confirm this. Recommendations for future research include improving exogenous formulations to reduce adverse effects, exploring interindividual factors affecting response-to-treatment, and establishing a "minimum required dose" for clinically meaningful improvements in disease-specific symptoms, such as cognition or motor function.

Ketogenic Diets and Chronic Disease: Weighing the Benefits Against the Risks

Very-low-carbohydrate ketogenic diets have been long been used to reduce seizure frequency and more recently have been promoted for a variety of health conditions, including obesity, diabetes, and liver disease. Ketogenic diets may provide short-term improvement and aid in symptom management for some chronic diseases. Such diets affect diet quality, typically increasing intake of foods linked to chronic disease risk and decreasing intake of foods found to be protective in epidemiological studies. This review examines the effects of ketogenic diets on common chronic diseases, as well as their impact on diet quality and possible risks associated with their use. Given often-temporary improvements, unfavorable effects on dietary intake, and inadequate data demonstrating long-term safety, for most individuals, the risks of ketogenic diets may outweigh the benefits.

Ketogenic Diet Decreases Alcohol Intake in Adult Male Mice

The classic ketogenic diet is a diet high in fat, low in carbohydrates, and well-adjusted proteins. The reduction in glucose levels induces changes in the body’s metabolism, since the main energy source happens to be ketone bodies. Recent studies have suggested that nutritional interventions may modulate drug addiction. The present work aimed to study the potential effects of a classic ketogenic diet in modulating alcohol consumption and its rewarding effects. Two groups of adult male mice were employed in this study, one exposed to a standard diet (SD, n = 15) and the other to a ketogenic diet (KD, n = 16). When a ketotic state was stable for 7 days, animals were exposed to the oral self-administration paradigm to evaluate the reinforcing and motivating effects of ethanol. Rt-PCR analyses were performed evaluating dopamine, adenosine, CB1, and Oprm gene expression. Our results showed that animals in a ketotic state displayed an overall decrease in ethanol consumption without changes in their motivation to drink. Gene expression analyses point to several alterations in the dopamine, adenosine, and cannabinoid systems. Our results suggest that nutritional interventions may be a useful complementary tool in treating alcohol-use disorders.

Incidence and Characteristics of Kidney Stones in Patients on Ketogenic Diet: A Systematic Review and Meta-Analysis

Very-low-carbohydrate diets or ketogenic diets are frequently used for weight loss in adults and as a therapy for epilepsy in children. The incidence and characteristics of kidney stones in patients on ketogenic diets are not well studied. Methods: A systematic literature search was performed, using MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews from the databases’ inception through April 2020. Observational studies or clinical trials that provide data on the incidence and/or types of kidney stones in patients on ketogenic diets were included. We applied a random-effects model to estimate the incidence of kidney stones. Results: A total of 36 studies with 2795 patients on ketogenic diets were enrolled. The estimated pooled incidence of kidney stones was 5.9% (95% CI, 4.6–7.6%, I2 = 47%) in patients on ketogenic diets at a mean follow-up time of 3.7 +/− 2.9 years. Subgroup analyses demonstrated the estimated pooled incidence of kidney stones of 5.8% (95% CI, 4.4–7.5%, I2 = 49%) in children and 7.9% (95% CI, 2.8–20.1%, I2 = 29%) in adults, respectively. Within reported studies, 48.7% (95% CI, 33.2–64.6%) of kidney stones were uric stones, 36.5% (95% CI, 10.6–73.6%) were calcium-based (CaOx/CaP) stones, and 27.8% (95% CI, 12.1–51.9%) were mixed uric acid and calcium-based stones, respectively. Conclusions: The estimated incidence of kidney stones in patients on ketogenic diets is 5.9%. Its incidence is approximately 5.8% in children and 7.9% in adults. Uric acid stones are the most prevalent kidney stones in patients on ketogenic diets followed by calcium-based stones. These findings may impact the prevention and clinical management of kidney stones in patients on ketogenic diets.

European Guidelines for Obesity Management in Adults with a Very Low-Calorie Ketogenic Diet: A Systematic Review and Meta-Analysis

BACKGROUND

The very low-calorie ketogenic diet (VLCKD) has been recently proposed as an appealing nutritional strategy for obesity management. The VLCKD is characterized by a low carbohydrate content (<50 g/day), 1-1.5 g of protein/kg of ideal body weight, 15-30 g of fat/day, and a daily intake of about 500-800 calories.

OBJECTIVES

The aim of the current document is to suggest a common protocol for VLCKD and to summarize the existing literature on its efficacy in weight management and weight-related comorbidities, as well as the possible side effects.

METHODS

This document has been prepared in adherence with Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Literature searches, study selection, methodology development, and quality appraisal were performed independently by 2 authors and the data were collated by means of a meta-analysis and narrative synthesis.

RESULTS

Of the 645 articles retrieved, 15 studies met the inclusion criteria and were reviewed, revealing 4 main findings. First, the VLCKD was shown to result in a significant weight loss in the short, intermediate, and long terms and improvement in body composition parameters as well as glycemic and lipid profiles. Second, when compared with other weight loss interventions of the same duration, the VLCKD showed a major effect on reduction of body weight, fat mass, waist circumference, total cholesterol and triglyceridemia as well as improved insulin resistance. Third, although the VLCKD also resulted in a significant reduction of glycemia, HbA1c, and LDL cholesterol, these changes were similar to those obtained with other weight loss interventions. Finally, the VLCKD can be considered a safe nutritional approach under a health professional's supervision since the most common side effects are usually clinically mild and easily to manage and recovery is often spontaneous.

CONCLUSIONS

The VLCKD can be recommended as an effective dietary treatment for individuals with obesity after considering potential contra-indications and keeping in mind that any dietary treatment has to be personalized. Prospero Registry: The assessment of the efficacy of VLCKD on body weight, body composition, glycemic and lipid parameters in overweight and obese subjects: a meta-analysis (CRD42020205189).

3-Hydroxybutyrate as a Metabolite and a Signal Molecule Regulating Processes of Living Organisms

3-hydroxybutyrate (3-HB) as a very important metabolite occurs in animals, bacteria and plants. It is well known that in animals, 3-HB is formed as a product of the normal metabolism of fatty acid oxidation and can therefore be used as an energy source in the absence of sufficient blood glucose. In microorganisms, 3-HB mainly serves as a substrate for the synthesis of polyhydroxybutyrate, which is a reserve material. Recent studies show that in plants, 3-HB acts as a regulatory molecule that most likely influences the expression of genes involved in DNA methylation, thereby altering DNA methylation levels. Additionally, in animals, 3-HB is not only an intermediate metabolite, but also an important regulatory molecule that can influence gene expression, lipid metabolism, neuronal function, and overall metabolic rate. Some of these effects are the direct effects of 3-HB itself, while others are indirect effects, regulated by the metabolites into which 3-HB is converted. One of the most important regulatory functions of 3-HB is the inhibition of the activity of histone deacetylases and thus the epigenetic regulation of many genes. Due to the number of functions of this compound, it also shows promising therapeutic properties.

Hypercalcemia in Children Using the Ketogenic Diet: A Multicenter Study

CONTEXT

The ketogenic diet is associated with progressive skeletal demineralization, hypercalciuria, and nephrolithiasis. Acute hypercalcemia has been described as a newly recognized complication of this treatment.

OBJECTIVE

To describe the clinical characteristics of acute hypercalcemia in children on the ketogenic diet through analysis of the presentation, response to treatment, and natural history in a large cohort of patients.

DESIGN

A multicenter case series was performed including children who developed acute hypercalcemia while treated with the ketogenic diet. Information on clinical presentation, treatment, and course of this complication was collated centrally.

RESULTS

There were 14 patients (median (range) age 6.3 (0.9 to 18) years) who developed hypercalcemia 2.1 (range, 0.2-12) years after starting the ketogenic diet. All had low levels of parathyroid hormone and levels of 1,25-dihydroxyvitamin D were low in all except one. Seven (50%) had impaired renal function at presentation. All except the 2 oldest had low alkaline phosphatase levels for age. Once normocalcemia was achieved, hypercalcemia recurred in only 2 of these patients over observation of up to 9.8 years. One patient discontinued the ketogenic diet prior to achieving normocalcemia while 4 more stopped the diet during follow-up after resolution of hypercalcemia.

CONCLUSIONS

Ketotic hypercalcemia can occur years after starting the ketogenic diet, especially in the setting of renal impairment. The mechanism is unknown but appears to be due to reduced osteoblast activity and impaired bone formation. We recommend close attention to optimizing bone health in these children, and screening for the development of ketotic hypercalcemia.

Diet in the Treatment of Epilepsy: What We Know So Far

Epilepsy is a chronic and debilitating neurological disorder, with a worldwide prevalence of 0.5–1% and a lifetime incidence of 1–3%. An estimated 30% of epileptic patients continue to experience seizures throughout life, despite adequate drug therapy or surgery, with a major impact on society and global health. In recent decades, dietary regimens have been used effectively in the treatment of drug-resistant epilepsy, following the path of a non-pharmacological approach. The ketogenic diet and its variants (e.g., the modified Atkins diet) have an established role in contrasting epileptogenesis through the production of a series of cascading events induced by physiological ketosis. Other dietary regimens, such as caloric restriction and a gluten free diet, can also exert beneficial effects on neuroprotection and, therefore, on refractory epilepsy. The purpose of this review was to analyze the evidence from the literature about the possible efficacy of different dietary regimens on epilepsy, focusing on the underlying pathophysiological mechanisms, safety, and tolerability both in pediatric and adult population. We believe that a better knowledge of the cellular and molecular biochemical processes behind the anticonvulsant effects of alimentary therapies may lead to the development of personalized dietary intervention protocols.

Therapeutic Use of the Ketogenic Diet in Refractory Epilepsy: What We Know and What Still Needs to Be Learned

Ketogenic diet (KD) has been used to treat epilepsy for 100 years. It is a high-fat, low-carbohydrate, and sufficient-protein-for-growth diet that mimics the metabolic changes occurring during starvation. Except for classic KD, its modified counterparts, including modified Atkins diet and low-glycemic-index treatment, have gained grounds to increase palatability and adherence. Strong evidence exists that the KD offers protection against seizures in difficult-to-treat epilepsy and possesses long-lasting anti-epileptic activity, improving long-term disease outcome. The KD can also provide symptomatic and disease-modifying activity in a wide range of neurodegenerative diseases. In an era of highly available new anti-seizure medications (ASMs), the challenge of refractory epilepsy has still not been solved. This metabolic therapy is increasingly considered due to unique mechanisms and turns out to be a powerful tool in the hands of a skillful team. Despite decades of extensive research to explain the mechanism of its efficacy, the precise mechanism of action is to date still largely unknown. The key feature of this successful diet is the fact that energy is derived largely from fat but not from carbohydrates. Consequently, fundamental change occurs regarding the method of energy production that causes alterations in numerous biochemical pathways, thus restoring energetic and metabolic homeostasis of the brain. There are barriers during the use of this special and individualized therapy in many clinical settings worldwide. The aim of this review is to revisit the current state of the art of therapeutic application of KD in refractory epilepsy.

Efficacy and Safety of a Ketogenic Diet in Children and Adolescents with Refractory Epilepsy-A Review

Epilepsy in the pediatric and adolescent populations is a devastating condition where individuals are prone to recurrent epileptic seizures or changes in behavior or movement that is the direct result of a primary change in the electrical activity in the brain. Although many children with epilepsy will have seizures controlled with antiseizure medications (ASMs), a large percentage of patients are refractory to drug therapy and may consider initiating a ketogenic diet. The term Ketogenic Diet or Ketogenic Diet Therapy (KDT) refers to any diet therapy in which dietary composition results in a ketogenic state of human metabolism. Currently, there are 4 major Ketogenic diet therapies—the classic ketogenic diet (cKD), the modified Atkins diet (MAD), the medium chain triglyceride ketogenic diet (MCTKD) and the low glycemic index treatment (LGIT). The compositions of the 4 main KDTs differ and limited evidence to distinguish the efficacy among different diets currently exists. Although it is apparent that more randomized controlled trials (RCTs) and long-term studies are needed to evaluate efficacy, side effects and individual response to the diet, it is imperative to study and understand the metabolic profiles of patients with epilepsy in order to isolate which dietary restrictions are necessary to maximize clinical benefit.

Safety and Effectiveness of the Prolonged Treatment of Children with a Ketogenic Diet

Background: The ketogenic diet (KD) is an effective treatment against drug-resistant epilepsy in children. The KD is a diet rich in fats that produces anticonvulsant and neuroprotective effects that reduces seizures and improves the cognitive state. Nevertheless, it can produce side effects that sometimes can be serious. Further, the effect on growth is quite controversial when used for an extended period of time. The aim of this paper was to assess the effectiveness, side effects, and repercussions in the development of children who have been treated with a KD for more than 2 years. Methods: Observational descriptive study of 26 pediatric patients on a KD, with data collection at baseline, at 3, 6, and 12 months, and then once a year. Number of seizures, type of seizures, anti-seizure drugs, anthropometry, side effects, and alterations in laboratory assessment were monitored. Results: In every assessment, about 60%–75% of the patients experienced a reduction in number of seizures of over 90%, and at least 50% experienced side effects, of which digestive issues, alteration in the lipid metabolism, and hypercalciuria were the most common. The KD significantly affected height after 2 years of treatment. Conclusions: The KD is an effective treatment for drug-resistant epilepsy. Its side effects, although common, are very mild; therefore, this constitutes a very safe treatment for children of all ages. More studies are needed to identify and prevent potential causes of growth retardation in children on the KD.

The management of very low-calorie ketogenic diet in obesity outpatient clinic: a practical guide

The epidemic of obesity is growing steadily across the whole world. Obesity is not only a merely aesthetic disease but is the “mother” of most chronic diseases such as associated with a range of type 2 diabetes, cardiovascular disease, obstructive sleep apnea, and cancer. However, although there is a need to find a strategy to stop this epidemic disease, most of the times the current nutritional strategies are not effective in weight loss and in long term weight maintenance. Very low-calorie ketogenic diets (VLCKD) is increasingly establishing as a successful nutritional pattern to manage obesity; this is due to rapid weight loss that gives rise to a positive psychological cycle which in turn increases the compliance to diet. Another important key point of VLCKD is the ability to preserve fatty free mass which is known to play a role of paramount importance in glucose metabolism. Despite the clinical evidence of VLCKD there are paucity of data regarding to its management. Therefore, we will provide a useful guide to be used by nutrition experts taking care of subjects with obesity. In particular, we will report recommendations on the correct use of this therapeutic approach for weight loss and management of side effects.

Food and Food Products on the Italian Market for Ketogenic Dietary Treatment of Neurological Diseases

The ketogenic diet (KD) is the first line intervention for glucose transporter 1 deficiency syndrome and pyruvate dehydrogenase deficiency, and is recommended for refractory epilepsy. It is a normo-caloric, high-fat, adequate-protein, and low-carbohydrate diet aimed at switching the brain metabolism from glucose dependence to the utilization of ketone bodies. Several variants of KD are currently available. Depending on the variant, KDs require the almost total exclusion, or a limited consumption of carbohydrates. Thus, there is total avoidance, or a limited consumption of cereal-based foods, and a reduction in fruit and vegetable intake. KDs, especially the more restrictive variants, are characterized by low variability, palatability, and tolerability, as well as by side-effects, like gastrointestinal disorders, nephrolithiasis, growth retardation, hyperlipidemia, and mineral and vitamin deficiency. In recent years, in an effort to improve the quality of life of patients on KDs, food companies have started to develop, and commercialize, several food products specific for such patients. This review summarizes the foods themselves, including sweeteners, and food products currently available for the ketogenic dietary treatment of neurological diseases. It describes the nutritional characteristics and gives indications for the use of the different products, taking into account their metabolic and health effects.

The Therapeutic Potential of Ketogenic Diet Throughout Life: Focus on Metabolic, Neurodevelopmental and Neurodegenerative Disorders

This chapter reviews the efficacy of the ketogenic diet in a variety of neurodegenerative, neurodevelopmental and metabolic conditions throughout different stages of life. It describes conditions affecting children, metabolic disorders in adults and disorderrs affecting the elderly. We have focused on application of the ketogenic diet in clinical studies and in preclinical models and discuss the benefits and negative aspects of the diet. Finally, we highlight the need for further research in this area with a view of discovering novel mechanistic targets of the ketogenic diet, as a means of maximising the potential benefits/risks ratio.

Effect of low-carbohydrate diet on markers of renal function in patients with type 2 diabetes: A meta-analysis

Meta-analysis was conducted to clarify the effect of low-carbohydrate diet (LCD) on renal function in patients with type 2 diabetes. An extensive literature search was conducted on scientific databases including PubMed, Scopus, and Cochrane Library until September 2017. Only controlled trials on human subjects written in English were included in this meta-analysis. Several markers of renal function were compared between subjects who adopted an LCD or control diet, including estimated glomerular filtration rate, creatinine clearance, urinary albumin, serum creatinine, and serum uric acid. Random effect model was used in the analysis of each marker. In this meta-analysis, 12 controlled trials were selected, which involved 942 participants (500 received LCD and 442 received a control diet). The pooled standardized mean difference (SMD) of estimated glomerular filtration rate from LCD vs control diet was not different (pooled SMD: 0.26; 95% CI, -0.03 to 0.55; P = .08). Investigation on creatinine clearance also showed no significant difference (pooled SMD: 0.51; 95% CI, -0.38 to 1.40; P = .26). Other comparisons from urinary albumin (pooled SMD: -0.04; 95% CI, -0.75 to 0.67; P = .90), serum creatinine (pooled SMD: -0.57; 95% CI, -1.51 to 0.38; P = .24), and serum uric acid (pooled SMD: -0.86; 95% CI, -4.00 to 2.28; P = .59) also showed no significant difference in the results. In the present meta-analysis, no effect on markers of renal function was found after provision of a LCD compared with a control diet in patients with type 2 diabetes.

Ketogenic Diets for Adult Neurological Disorders

The current review highlights the evidence supporting the use of ketogenic diet therapies in the management of a growing number of neurological disorders in adults. An overview of the scientific literature supporting posited mechanisms of therapeutic efficacy is presented including effects on neurotransmission, oxidative stress, and neuro-inflammation. The clinical evidence supporting ketogenic diet use in the management of adult epilepsy, malignant glioma, Alzheimer's disease, migraine headache, motor neuron disease, and other neurologic disorders is highlighted and reviewed. Lastly, common adverse effects of ketogenic therapy in adults, including gastrointestinal symptoms, weight loss, and transient dyslipidemia are discussed.

Effect of modified Atkins diet in adults with drug-resistant focal epilepsy: A randomized clinical trial

OBJECTIVE

Ketogenic diets reduce seizures in children with drug-resistant epilepsy. Whether adults benefit from similar treatment has not been clarified. We therefore examined the efficacy of the modified Atkins diet in adults with drug-resistant focal epilepsy.

METHODS

We performed a randomized clinical trial (RCT) with patients >16 years who had at least 3 seizures per month despite having tried at least 3 antiepileptic drugs. They were randomized to either 12 weeks on the modified Atkins diet (diet group) or habitual diet (control group). Primary endpoint was a change in seizure frequency from baseline to the intervention period, comparing those on diet with controls.

RESULTS

We assigned 37 patients to the diet group and 38 to the control group. Nine of the patients in the diet group and 4 controls were excluded. Of those who completed the dietary intervention (n = 24), median seizure change was -1.0 (interquartile range [IQR] -13.7-8.8), while in the control group (n = 32) the median change was 4.5 (IQR -4.8-33.5). The median difference between the groups was -7.0 (95% confidence interval [CI] -37.0-3.0; P = .21). In the intention-to-treat analysis, the relative risk (RR) for achieving >50% seizure reduction was 1.8 (95% CI 0.3-10.2; P = .65), while for achieving >25% seizure reduction RR was 2.43 (95% CI 0.94-6.28; P = .06). We observed no serious adverse events.

SIGNIFICANCE

In this RCT investigating the effect of an adjunctive modified Atkins diet on seizure frequency in adults with difficult-to-treat focal epilepsy, we found a significant reduction in seizure frequency in the diet group compared to the controls, but only for moderate benefit (>25% seizure reduction) among those who completed the intervention. However, seizure response varied considerably between individuals, perhaps negatively influenced by a drop in serum concentrations of antiepileptic drugs.

Optimal clinical management of children receiving dietary therapies for epilepsy: Updated recommendations of the International Ketogenic Diet Study Group

Ketogenic dietary therapies (KDTs) are established, effective nonpharmacologic treatments for intractable childhood epilepsy. For many years KDTs were implemented differently throughout the world due to lack of consistent protocols. In 2009, an expert consensus guideline for the management of children on KDT was published, focusing on topics of patient selection, pre‐KDT counseling and evaluation, diet choice and attributes, implementation, supplementation, follow‐up, side events, and KDT discontinuation. It has been helpful in outlining a state‐of‐the‐art protocol, standardizing KDT for multicenter clinical trials, and identifying areas of controversy and uncertainty for future research. Now one decade later, the organizers and authors of this guideline present a revised version with additional authors, in order to include recent research, especially regarding other dietary treatments, clarifying indications for use, side effects during initiation and ongoing use, value of supplements, and methods of KDT discontinuation. In addition, authors completed a survey of their institution's practices, which was compared to responses from the original consensus survey, to show trends in management over the last 10 years.

Safety and tolerability of the ketogenic diet used for the treatment of refractory childhood epilepsy: a systematic review of published prospective studies

BACKGROUND

To review the available evidence from prospective studies on the safety and tolerability of the ketogenic diet (KD) for the treatment of refractory childhood epilepsy.

METHODS

A comprehensive bibliographic search was performed with the aim of retrieving prospective studies that monitored adverse effects (AEs) in children after receiving the classic or medium-chain triglyceride KD therapy for refractory epilepsy.

RESULTS

A total of 45 studies were retrieved, including 7 randomized controlled trials. More than 40 categories of AEs were reported. The most common AEs included gastrointestinal disturbances (40.6%), hyperlipidemia (12.8%), hyperuricemia (4.4%), lethargy (4.1%), infectious diseases (3.8%) and hypoproteinemia (3.8%). Severe AEs, such as respiratory failure and pancreatitis, occurred in no more than 0.5% of children. Specifically, patients receiving KD therapy should be monitored for osteopenia, urological stones, right ventricular diastolic dysfunction, and growth disturbance. The total retention rates of the diet for 1 year and 2 years were 45.7% and 29.2%, respectively. Nearly half of the patients discontinued the diet because of lack of efficacy. AEs were not the main reason for the KD discontinuation. None of the 24 deaths reported after initiation of the diet was attributed to the KD.

CONCLUSIONS

KD is a relatively safe dietary therapy. However, because the KD can cause various AEs, it should be implemented under careful medical supervision. Continuous follow-up is needed to address the long-term impact of the diet on the overall health of children.

The role for ketogenic diets in epilepsy and status epilepticus in adults

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Ketogenic diets offer adjunctive therapy for chronic epilepsy and refractory status epilepticus.

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Studies support feasibility and efficacy of the classic ketogenic diet and its variants in adults.

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Potential complications and side effects of diet therapy are often preventable and manageable.

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Strategies are needed to improve diet adherence.

Ketogenic diet (KD) therapies are high fat, low carbohydrate diets designed to mimic a fasting state. Although studies demonstrate KD’s success in reducing seizures stretching back nearly a century, the last 25 years have seen a resurgence in diet therapy for the management of drug-resistant epilepsy in children as well as adults. With ≥50% seizure reduction efficacy rates in adults of 22–55% for the classic KD and 12–67% for the modified Atkins diet, diet therapy may be in many instances comparable to a trial of an additional anti-epileptic medication and potentially with fewer side effects and other health benefits. Moreover, ketogenic diets offer promising new adjunctive strategies for the treatment of acute status epilepticus in the intensive care setting. Here, we review the efficacy and utility of ketogenic diets for the management of chronic epilepsy and refractory status epilepticus in adults and offer practical guidelines for diet implementation and maintenance.

Ketogenic diet guidelines for infants with refractory epilepsy

BACKGROUND

The ketogenic diet (KD) is an established, effective non-pharmacologic treatment for drug resistant childhood epilepsy. For a long time, the KD was not recommended for use in infancy (under the age of 2 years) because this is such a crucial period in development and the perceived high risk of nutritional inadequacies. Indeed, infants are a vulnerable population with specific nutritional requirements. But current research shows that the KD is highly effective and well tolerated in infants with epilepsy. Seizure freedom is often achieved and maintained in this specific patient group. There is a need for standardised protocols and management recommendations for clinical use.

METHOD

In April 2015, a project group of 5 experts was established in order to create a consensus statement regarding the clinical management of the KD in infants. The manuscript was reviewed and amended by a larger group of 10 international experts in the KD field. Consensus was reached with regard to guidance on how the diet should be administered and in whom.

RESULTS

The resulting recommendations include patient selection, pre-KD counseling and evaluation, specific nutritional requirements, preferred initiation, monitoring of adverse effects at initiation and follow-up, evaluation and KD discontinuation.

CONCLUSION

This paper highlights recommendations based on best evidence, combined with expert opinions and gives directions for future research.

The Short-Term Effects of Ketogenic Diet on Cardiac Ventricular Functions in Epileptic Children

OBJECTIVE

Our primary aim was to determine the short-term effects of a ketogenic diet on cardiac ventricular function in patients with refractory epilepsy.

METHODS

Thirty-eight drug-resistant epileptic patients who were treated with a ketogenic diet were enrolled in this prospective study. Echocardiography was performed on all patients before beginning the ketogenic diet and after the sixth month of therapy. Two-dimensional, M-mode, color flow, spectral Doppler, and pulsed-wave tissue Doppler imaging measurements were performed on all patients.

RESULTS

The median age of the 32 patients was 45.5 months, and 22 (57.8%) of them were male. Body weight, height, and body mass index increased significantly at the sixth month of therapy when compared with baseline values (P < 0.05). Baseline variables assessed by conventional M-mode echocardiography showed no significant difference at month 6 (P > 0.05). Doppler flow indices of mitral annulus and tricuspid annulus velocity of patients at baseline and month 6 showed no significant differences (P > 0.05). Tricuspid annular E/A ratio was lower at month 6 (P < 0.05). Although mitral annulus tissue Doppler imaging studies showed no significant difference (P > 0.05), there was a decrease in Ea velocity and Ea/Aa ratio gathered from tricuspid annulus at month 6 compared with baseline (P < 0.05).

CONCLUSION

A 6-month duration ketogenic diet does not impair left ventricular functions in children with refractory epilepsy; however, it may be associated with a right ventricular diastolic dysfunction.

Trends in pediatric urolithiasis: patient characteristics, associated diagnoses, and financial burden

BACKGROUND

The goal of this study was to examine national trends in hospitalization, emergency department (ED) utilization, secondary diagnoses, and charges associated with pediatric urolithiasis.

METHODS

Data were evaluated from the Kids' Inpatient Database of the Healthcare Costs and Utilization Project (HCUP) database from 1997 to 2012 and the HCUP National ED Sample from 2006 to 2011.

RESULTS

Pediatric nephrolithiasis discharges increased by 18%, while ureterolithiasis discharges decreased by 17%. Hospital charges increased by 20% when accounting for inflation, despite an overall decrease in discharges by 2.5%. Female patients and those aged 15-17 years were more commonly affected. Pediatric ED visits increased by 9%. The most common secondary diagnoses during 2003-2009 were urinary tract infections (UTI) (13%), asthma (9%), epilepsy (4%), and paralysis (4%).

CONCLUSIONS

Decreased hospitalizations and increased ED visits indicate a shift to outpatient care. Inpatient health care charges associated with pediatric urolithiasis continue to rise. Comorbidities include UTI, asthma, epilepsy, attention deficit hyperactivity disorder (ADHD), and mood disorders. Because of the significant health care burden and the increased risk to children of developing long-term sequelae there is a strong need for increased research into the mechanism of this systemic inflammatory disease and improved therapeutic targets.

Short-term effects of ketogenic diet on anthropometric parameters, body fat distribution, and inflammatory cytokine production in GLUT1 deficiency syndrome

OBJECTIVE

The aim of this study was to evaluate the effects of a 12-wk ketogenic diet (KD) on inflammatory status, adipose tissue activity biomarkers, and abdominal visceral (VAT) and subcutaneous fat (SAT) in children affected by glucose transporter 1 deficiency syndrome GLUT1 DS.

METHODS

We carried out a short-term longitudinal study on 10 children (mean age: 8.4 y, range 3.3-12 y, 5 girls, 5 boys) to determine fasting serum proinflammatory cytokines (high sensitivity C-reactive protein, tumor necrosis factor-α interleukin-6), adipocyte-derived chemokines (leptin and adiponectin), lipid profile, homeostatic model assessment-insulin resistance (HOMA-IR), quantitative insulin sensitivity index (QUICKI), anthropometric measurements, and VAT and SAT (by ultrasonography).

RESULTS

Children showed no significant changes in inflammatory and adipose tissue activity biomarkers, blood glucose, lipid profile, anthropometric measurements, VAT, and SAT. Fasting insulin decreased (6 ± 3.2 μU/mL versus 3 ± 2 μU/mL; P = 0.001), and both HOMA-IR and QUICKI indexes were significantly modified (1.2 ± 0.6 versus 0.6 ± 0.4; P = 0.002; 0.38 ± 0.03 versus 0.44 ± 0.05; P = 0.002, respectively).

CONCLUSIONS

Only HOMA-IR and QUICKI indexes changed after 12 wk on a KD, suggesting that over a short period of time KD does not affect inflammatory cytokines production and abdominal fat distribution despite being a high-fat diet. Long-term studies are needed to provide answers concerning adaptive metabolic changes during KD.

Assessing parents' attitudes towards ketogenic dietary therapies

We aimed to assess and quantify parental beliefs regarding ketogenic dietary therapies (KDTs). We also aimed to determine whether beliefs were related to response to KDTs. Adapted versions of the Beliefs about Medicine Questionnaire were completed by parents of children following KDTs for epilepsy. Demographic and clinical data were collected from hospital records. Ketogenic dietary therapy response was defined as ≥50% seizure reduction compared to baseline. Many parents had a positive perception of KDTs and were convinced of the necessity of KDTs for their children, although beliefs were wide-ranging. Over half of parents reported concerns about the potential long-term effects of KDTs. Parental beliefs about KDTs were significantly correlated with patient response. This was an attempt to quantify parents' beliefs regarding the use of KDTs for their child's epilepsy. The questionnaire may be used to identify individuals with a less positive attitude towards KDTs and who may be less likely to report a favorable response to KDTs. It is unknown whether people who have positive beliefs about KDTs engage in less nonadherent behavior or whether beliefs regarding KDTs simply reflect outcomes. The evidence behind the long-term side effects of KDTs should be emphasized when counseling patients and their families.

Ketotic hypercalcemia: a case series and description of a novel entity

CONTEXT

The ketogenic diet is increasingly used in refractory epilepsy and is associated with clinically significant effects on bone and mineral metabolism. Although hypercalciuria and loss of bone mineral density are common in patients on the ketogenic diet, hypercalcemia has not previously been described.

OBJECTIVE

The aim of the study was to describe three children who developed hypercalcemia while on the ketogenic diet.

DESIGN

A retrospective chart review of three children on the ketogenic with severe hypercalcemia was conducted.

RESULTS

We describe three children on the ketogenic diet for refractory seizures who presented with hypercalcemia. Case 1 was a 5.5-year-old male with an undiagnosed, rapidly progressive seizure disorder associated with developmental regression. Case 2 was a 2.5-year-old male with a chromosomal deletion of 2q24.3, and case 3 was a 4.6-year-old male with cerebral cortex dysplasia. Patients had been on a ketogenic diet for 6 to 12 months before presentation. Daily intake of calcium and vitamin D was not excessive, and all three patients were not acidotic because they were taking supplemental bicarbonate. Each child had elevated serum levels of calcium and normal serum phosphate levels, moderately elevated urinary calcium excretion, and low levels of serum alkaline phosphatase, PTH, and 1,25-dihydroxyvitamin D. All patients responded to calcitonin.

CONCLUSIONS

Hypercalcemia is an uncommon complication of the ketogenic diet, and these children may represent the severe end of a clinical spectrum of disordered mineral metabolism. The mechanism for hypercalcemia is unknown but is consistent with excess bone resorption and impaired calcium excretion.

Dispersion durations of P-wave and QT interval in children treated with a ketogenic diet

BACKGROUND

Limited data are available on the effects of a ketogenic diet on dispersion duration of P-wave and QT-interval measures in children. We searched for the changes in these measures with serial electrocardiograms in patients treated with a ketogenic diet.

METHODS

Twenty-five drug-resistant patients with epilepsy treated with a ketogenic diet were enrolled in this study. Electrocardiography was performed in all patients before the beginning and at the sixth month after implementation of the ketogenic diet. Heart rate, maximum and minimum P-wave duration, P-wave dispersion, and maximum and minimum corrected QT interval and QT dispersion were manually measured from the 12-lead surface electrocardiogram.

RESULTS

Minimum and maximum corrected QT and QT dispersion measurements showed nonsignificant increase at month 6 compared with baseline values. Other previously mentioned electrocardiogram parameters also showed no significant changes.

CONCLUSIONS

A ketogenic diet of 6 months' duration has no significant effect on electrocardiogram parameters in children. Further studies with larger samples and longer duration of follow-up are needed to clarify the effects of ketogenic diet on P-wave dispersion and corrected QT and QT dispersion.

Ketogenic diets for weight loss: A review of their principles, safety and efficacy

SUMMARY

Low-carbohydrate "ketogenic" diets have increased in popularity over recent years as a means of weight loss. Published studies of these diets have been highly heterogeneous, and it remains unclear to what degree dietary carbohydrate intake must be restricted in order to induce ketosis. Despite concern that they are often relatively high in fat, ketogenic low-carbohydrate diets have been generally shown to compare favourably with low-fat diets in terms of weight loss and improvements in triglyceride and high-density lipoprotein levels. This review includes a brief overview of ketone body metabolism, and summarises the literature regarding the safety and efficacy of ketogenic diets for weight loss.:

Risk factors for urolithiasis in gastrostomy tube fed children: a case-control study

BACKGROUND AND OBJECTIVE

Pediatric patients who are fed primarily via gastrostomy tube (G-tube) may be at increased risk for urolithiasis, but no studies have specifically examined risk factors for stones in this population. We aimed to determine clinical differences between G-tube fed (GTF) patients with and without stones, in hopes of identifying modifiable factors associated with increased risk of urolithiasis.

METHODS

We conducted a retrospective case-control study, matching GTF patients with urolithiasis (cases) to GTF children without urolithiasis (controls) based on age (±1 year) and gender. Bivariate comparisons and matched logistic regression modeling were used to determine the unadjusted and adjusted associations between relevant clinical factors and urolithiasis.

RESULTS

Forty-one cases and 80 matched controls (mean age 12.0 ± 6.5 years) were included. On bivariate analysis, factors associated with stone formation included: white race, urinary tract infection (UTI), topiramate administration, vitamin D use, malabsorption, dehydration, 2-year duration with G-tube, and whether goal free water intake was documented in the patient chart. On regression analysis, the following factors remained significant: topiramate administration (odds ratio [OR]: 6.58 [95% confidence interval (CI): 1.76-24.59]), UTI (OR: 7.70 [95% CI: 1.59-37.17]), and <2 years with a G-tube (OR: 8.78 [95% CI: 1.27-52.50]).

CONCLUSIONS

Our findings provide a preliminary risk profile for the development of urolithiasis in GTF children. Important associations identified include UTI, topiramate administration, and shorter G-tube duration, which may reflect subclinical chronic dehydration. Of these, topiramate use represents the most promising target for risk reduction.

Comparison of Nephrolithiasis Prevalence in Two Bottlenose Dolphin (Tursiops truncatus) Populations

In humans, ammonium urate (AU) nephrolithiasis is rare in the Western hemisphere and more common in Japan and developing countries. Among a variety of risk factors, insulin resistance has been associated with urate nephrolithiasis in people. Bottlenose dolphins (Tursiops truncatus) are susceptible to AU nephrolithiasis, and it is believed that some populations are more likely to develop nephrolithiasis compared to others. In an effort to better understand population-based risk factors for AU nephrolithiasis in dolphins and their comparative value to humans, sonographic evaluation was performed on dolphins from a managed collection in San Diego Bay, CA (n = 40) and dolphins from a free-ranging, nearshore population in Sarasota Bay, FL (n = 39) to look for evidence of nephrolithiasis. While 14 (35%) of San Diego Bay dolphins evaluated for the study had sonographic evidence of nephrolithiasis, none of the Sarasota Bay dolphins had evidence of disease. Presence or absence of stones was confirmed by computed tomography in a subset of the San Diego collection (n = 10; four dolphins with stones, six without stones). Age was identified as a risk factor, as dolphins with stones in the San Diego collection were significantly older than dolphins without stones (25.4 vs. 19.1 years, respectively; P = 0.04). Additionally, San Diego dolphins included in the study were significantly older than Sarasota Bay dolphins (21.3 vs. 13.8 years, respectively; P = 0.008). In addition to the previously reported risk factors of hypocitraturia and hyperinsulinemia in bottlenose dolphins, other potential factors include geographic location, managed vs. free-ranging status, prey species, and feeding schedules.

Uric acid stones and hyperuricosuria

Recent work has highlighted the strong relationships among obesity, diabetes, and the metabolic syndrome as causes of low urinary pH. Low urinary pH in turn is the major urinary risk factor for uric acid stones. Unlike calcium stones, uric acid stones can be dissolved and easily prevented with adequate urinary alkalinization. Recognizing the relevant risk factors should lead to increased identification of these radiolucent stones. The cornerstone of therapy is raising urinary pH; xanthine dehydrogenase inhibitors should be used only when urinary alkalinization cannot be achieved.

Various indications for a modified Atkins diet in intractable childhood epilepsy

PURPOSE

We reviewed retrospectively our experiences with children with intractable epilepsy who were indicated for a modified Atkins diet (MAD).

METHODS

Twenty children (8 female, 12 male) who were aged 2-17 years with intractable epilepsy and tried the MAD between September 2008 and December 2010 were enrolled. Outcome measures included seizure frequency, adverse reactions and tolerability of the diet.

RESULTS

Finally 9 patients maintained the MAD with favorable seizure outcomes (a reduction of seizure frequency by over 50%) or successfully completed the diet therapy. Two patients who required a long-term trial of the diet therapy respectively due to Leigh's syndrome and uncategorized mitochondrial cytopathy derived from cytochrome c oxidase defect, respectively, successfully maintained the diet treatment without any significant complications. In 7 patients, the ketogenic diet (KD) was not only effective but also too restrictive or caused serious unwanted events. Five of them maintained the seizure outcome previously achieved by the KD with the MAD. Ten patients began the MAD because they were reluctant to start the KD. Unfortunately, only 2 patients maintained the MAD with favorable seizure outcomes. One patient who chose the MAD to bridge the KD and complete discontinuation of the treatment successfully completed the diet therapy.

CONCLUSION

A long-term treatment with the MAD was well tolerated. Moreover, the MAD can successfully substitute the classic KD in patients who showed improvement in seizure outcomes by the KD but could not tolerate it.

Long-term monitoring of the ketogenic diet: Do's and Don'ts

The ketogenic diet (KD) is an effective treatment for epilepsy and like other treatments it is not without side effects. The side effects encountered are related to the diet composition and the radical metabolic changes that results from a high fat, low carbohydrate and protein diet. Short-term side effects are well documented. Long-term side effects are not as well documented but since the last "international symposium on dietary therapies for epilepsy and other neurological disorders", there are now more prospective and longitudinal data. Monitoring practices and treatments will be discussed and compared to the International Ketogenic Diet Consensus Statement (IKDCS) from 2008.