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Vendramini THA, Amaral AR, Rentas MF, Nogueira JPDS, Pedrinelli V, de Oliveira VV, Zafalon RVA, Brunetto MA. Ketogenic diets: A systematic review of current scientific evidence and possible applicability in dogs and cats. J Anim Physiol Anim Nutr (Berl) 2024; 108:541-556. [PMID: 38091342 DOI: 10.1111/jpn.13913] [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] [Received: 08/24/2022] [Revised: 10/16/2023] [Accepted: 11/22/2023] [Indexed: 03/06/2024]
Abstract
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.
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Affiliation(s)
- Thiago H A Vendramini
- Pet Nutrology Research Center, Department of Animal Nutrition and Production of the School of Veterinary Medicine and Animal Science, University of São Paulo, Pirassununga, São Paulo, Brazil
- Veterinary Nutrology Service, Teaching Veterinary Hospital, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, Brazil
| | - Andressa R Amaral
- Veterinary Nutrology Service, Teaching Veterinary Hospital, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, Brazil
| | - Mariana F Rentas
- Pet Nutrology Research Center, Department of Animal Nutrition and Production of the School of Veterinary Medicine and Animal Science, University of São Paulo, Pirassununga, São Paulo, Brazil
| | - Juliana P D S Nogueira
- Department of Research & Development, Archer Daniels Midland Company (ADM), Animal Nutrition, Paulínia, Brazil
| | - Vivian Pedrinelli
- Veterinary Nutrology Service, Teaching Veterinary Hospital, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, Brazil
| | - Vinicius V de Oliveira
- Veterinary Nutrology Service, Teaching Veterinary Hospital, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, Brazil
| | - Rafael V A Zafalon
- Pet Nutrology Research Center, Department of Animal Nutrition and Production of the School of Veterinary Medicine and Animal Science, University of São Paulo, Pirassununga, São Paulo, Brazil
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Factors associated with mortality in patients with super-refractory status epilepticus. Sci Rep 2022; 12:9670. [PMID: 35690663 PMCID: PMC9188563 DOI: 10.1038/s41598-022-13726-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/26/2022] [Indexed: 11/08/2022] Open
Abstract
Super-refractory status epilepticus (SRSE) is a critical condition in which seizures persist despite anesthetic use for 24 h or longer. High mortality has been reported in patients with SRSE, but the cause of death remains unclear. We investigated the factors associated with mortality, including clinical characteristics, SE etiologies and severities, treatments, and responses in patients with SRSE in a 13-year tertiary hospital-based retrospective cohort study comparing these parameters between deceased and surviving patients. SRSE accounted for 14.2% of patients with status epilepticus, and 28.6% of SRSE patients died. Deceased patients were mostly young or middle-aged without known systemic diseases or epilepsy. All deceased patients experienced generalized convulsive status epilepticus and failure of anesthetic tapering-off, significantly higher than survivors. An increased number of second-line anesthetics besides midazolam was observed in the deceased (median, 3, interquartile range 2–3) compared to surviving (1, 1–1; p = 0.0006) patients with prolonged use durations (p = 0.047). For mortality, the cut-off number of second-line anesthetics was 1.5 (AUC = 0.906, p = 0.004). Deceased patients had significantly higher renal and cardiac complications and metabolic acidosis than survivors. In SRSE management, multi-anesthetic use should be carefully controlled to avoid systemic complications and mortality.
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Tong X, Cai Q, Cao D, Yu L, Sun D, Yang G, Wang J, Li H, Li Z, Wang J, Huang S, Ding M, Fang F, Wang Q, Luo R, Liao J, Qin J. Chinese expert recommendations on ketogenic diet therapy for super-refractory status epilepticus. ACTA EPILEPTOLOGICA 2022. [DOI: 10.1186/s42494-021-00078-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractSuper-refractory status epilepticus (SRSE) is a serious and life-threatening neurological condition. Ketogenic diet (KD) is a diet characterized by high fat, low carbohydrate, and moderate protein. As KD shows effectiveness in controlling seizures in more than half of SRSE patients, it can be a treatment option for SRSE. Currently, KD treatment for SRSE is based on personal experience and observational evidence has been published. In the context of a lack of a validated guideline, we convened a multicenter expert panel within the China Association Against Epilepsy (CAAE) Ketogenic Diet Commission to work out the Chinese expert recommendations on KD for SRSE. We summarize and discuss the latest clinical practice of KD for SRSE in critical care settings. Recommendations are given on patient selection, the timing of KD, diet implementation, and follow-up. More research data are needed in this area to support better clinical practice.
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Dozières-Puyravel B, Höhn S, Auvin S. Considering safety and patient tolerance in the use of ketogenic diet in the management of refractory and super-refractory status epilepticus: a systematic review. Expert Rev Neurother 2021; 21:1303-1308. [PMID: 34275391 DOI: 10.1080/14737175.2021.1956905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Early use of the ketogenic diet (KD) is described as having a particular interest for super-refractory status epilepticus and febrile infection-related epilepsy syndrome. The authors conducted a systematic review of the available data on the KD for refractory and super-refractory status epilepticus. AREAS COVERED Following a systematic bibliographic search, the authors found 15 published papers: 2 prospective and 13 retrospective studies. Most often, the primary aim of the retrospective studies was the efficacy evaluation of the KD for refractory or super-refractory status epilepticus. Four studies focused on the use of KD for NORSE/FIRES. These initial studies suggested that KD was effective in these conditions, and that it showed mild and manageable side effects. EXPERT OPINION The published studies provided enough preliminary data to validate the feasibility and safety of the use of KD for refractory and super-refractory status epilepticus. Further studies demonstrating the efficacy of the KD in these indications are needed. Possible design and endpoints are discussed.
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Affiliation(s)
- Blandine Dozières-Puyravel
- Service de Neurologie Pédiatrique, Hôpital Robert-Debré, APHP, Paris, France.,Université de Paris, Paris, France
| | - Sophie Höhn
- Service de Neurologie Pédiatrique, Hôpital Robert-Debré, APHP, Paris, France.,Université de Paris, Paris, France
| | - Stéphane Auvin
- Service de Neurologie Pédiatrique, Hôpital Robert-Debré, APHP, Paris, France.,Université de Paris, Paris, France.,Institut Universitaire de France (IUF), Paris, France
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Schoeler NE, Simpson Z, Zhou R, Pujar S, Eltze C, Cross JH. Dietary Management of Children With Super-Refractory Status Epilepticus: A Systematic Review and Experience in a Single UK Tertiary Centre. Front Neurol 2021; 12:643105. [PMID: 33776895 PMCID: PMC7994594 DOI: 10.3389/fneur.2021.643105] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 02/17/2021] [Indexed: 12/16/2022] Open
Abstract
Ketogenic diet therapies (KDT) are high-fat, low carbohydrate diets used as an effective treatment option for drug-resistant epilepsy. There is limited research on the efficacy of KDT for super-refractory status epilepticus (SRSE). We systematically review evidence for use of KDT in children with SRSE and present a single UK tertiary centre's experience. Thirty one articles were included, of which 24 were “medium” or “low” quality. One hundred and forty seven children with SRSE started KDT, of which 141 (96%) achieved ketosis. KDT was started mean 5.3 days (range 1–420) after status epilepticus (SE) started. SRSE resolved in 85/141 (60%) children after mean 6.3 days (range 0–19) post SE onset, but it is unclear whether further treatments were initiated post-KDT. 13/141 (9%) children died. Response to KDT was more likely when initiated earlier (p = 0.03) and in females (p = 0.01). Adverse side effects were reported in 48/141 (34%), mostly gastrointestinal; potentially serious adverse effects occurred in ≤4%. Eight children with SRSE, all diagnosed with febrile infection-related epilepsy syndrome, were treated with KDT at Great Ormond Street Hospital for Children. KDT was initiated enterally at mean day 13.6+/− 5.1 of admission. Seven of 8 (88%) children reported adverse side effects, which were potentially serious in 4/8 (50%), including metabolic acidosis, hypoglycaemia and raised amylase. SE ceased in 6/8 (75%) children after mean 25+/− 9.4 days post onset, but other treatments were often started concomitantly and all children started other treatments post-KDT. Two of 8 (25%) children died during admission and another died post-admission. Four of the remaining 5 children continue to have drug-resistant seizures, one of whom remains on KDT; seizure burden was unknown for one child. Our findings indicate that KDT is possible and safe in children with SRSE. Cessation of SRSE may occur in almost two-thirds of children initiated with KDT, but a causal effect is difficult to determine due to concomitant treatments, treatments started post-KDT and the variable length of time post-KDT onset when SRSE cessation occurs. Given that serious adverse side effects seem rare and response rates are (cautiously) favorable, KDT should be considered as an early treatment option in this group.
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Affiliation(s)
- Natasha E Schoeler
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Zoe Simpson
- Department of Dietetics, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Runming Zhou
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Suresh Pujar
- Department of Paediatric and Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Christin Eltze
- Department of Paediatric and Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - J H Cross
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, United Kingdom.,Department of Paediatric and Neurology, Great Ormond Street Hospital for Children, London, United Kingdom.,Young Epilepsy, Lingfield, United Kingdom
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