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Joshi S, Shi R, Patel J. Risks of the ketogenic diet in CKD - the con part. Clin Kidney J 2024; 17:sfad274. [PMID: 38186877 PMCID: PMC10768778 DOI: 10.1093/ckj/sfad274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Indexed: 01/09/2024] Open
Abstract
The ketogenic diet is a very low carbohydrate diet that has received a lot of attention for its role in the treatment of type 2 diabetes and obesity. For patients with chronic kidney disease, there is limited evidence on the risks and/or benefits of this diet. However, from the limited evidence that does exist, there are several inferences that can be drawn regarding this diet for patients with kidney disease. The ketogenic diet may not be better than comparator higher carbohydrate diets over the long term. The diet also has low adherence levels in studies lasting ≥12 months. The diet's emphasis on fat, which often comes from animal fat, increases the consumption of saturated fat, which may increase the risk of heart disease. It has the potential to worsen metabolic acidosis by increasing dietary acid load and endogenous acid production through the oxidation of fatty acids. In addition, the diet has been associated with an increased risk of kidney stones in patients using it for the treatment of refractory epilepsy. For these reasons, and for the lack of safety data on it, it is reasonable for patients with kidney disease to avoid utilizing the ketogenic diet as a first-line option given alternative dietary patterns (like the plant-dominant diet) with less theoretical risk for harm. For those adopting the ketogenic diet in kidney disease, a plant-based version of the ketogenic diet may mitigate some of the concerns with animal-based versions of the ketogenic diet.
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Affiliation(s)
- Shivam Joshi
- Department of Veterans Affairs, Orlando, FL, USA
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA (Adjunct Faculty)
| | - Rachel Shi
- University of Central Florida College of Medicine, Orlando, FL, USA
| | - Jason Patel
- University of Arizona College of Medicine – Phoenix, Phoenix, AZ, USA
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2
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Zayed S, Goldfarb DS, Joshi S. Popular Diets and Kidney Stones. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:529-536. [PMID: 38453270 DOI: 10.1053/j.akdh.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 10/04/2023] [Accepted: 10/11/2023] [Indexed: 03/09/2024]
Abstract
Popular diets often influence dietary patterns, which have different implications for kidney stone risk. Despite the wide variety of popular diets, some general principles can be gleaned from investigating their potential impact on nephrolithiasis. Plant-based diets, including Dietary Approaches to Stop Hypertension, Mediterranean, flexitarian, and vegetarian diets, may protect against nephrolithiasis when they consist largely of unprocessed plant foods, while carbohydrate-restricted diets (including high-protein diets and the ketogenic diet) may raise kidney stone risk. Patients should be advised to consume a diet rich in whole plants, particularly fruits and vegetables, and minimize their consumption of animal proteins. Accompanying fruits and vegetables that are higher in oxalate content with more water and some dairy intake may also be useful. (We address the oxalate content of fruits and vegetables further below). Calcium consumption is an important component of decreasing the risk of kidney stones, as higher dietary calcium from dairy or nondairy sources is independently associated with lower kidney stone risk. Patients should also be advised to be conscious of fat intake, as fat in the intestinal lumen may complex with calcium and therefore increase urinary oxalate excretion. Finally, patients should avoid consumption of processed foods, which often contain added fructose and high sodium content, two factors that increase kidney stone risk.
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Affiliation(s)
- Sara Zayed
- New York University Grossman School of Medicine, New York, NY; Department of Medicine, New York University Grossman School of Medicine, New York, NY.
| | - David S Goldfarb
- New York University Grossman School of Medicine, New York, NY; Department of Medicine, New York University Grossman School of Medicine, New York, NY; Nephrology Section, New York Harbor VA Healthcare System, New York, NY
| | - Shivam Joshi
- Department of Medicine, New York University Grossman School of Medicine, New York, NY; Department of Veterans Affairs, Orlando VAMC, Orlando, FL.
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3
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Pironi L, Cuerda C, Jeppesen PB, Joly F, Jonkers C, Krznarić Ž, Lal S, Lamprecht G, Lichota M, Mundi MS, Schneider SM, Szczepanek K, Van Gossum A, Wanten G, Wheatley C, Weimann A. ESPEN guideline on chronic intestinal failure in adults - Update 2023. Clin Nutr 2023; 42:1940-2021. [PMID: 37639741 DOI: 10.1016/j.clnu.2023.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND & AIMS In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines. METHODS The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly. RESULTS The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%). CONCLUSIONS It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.
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Affiliation(s)
- Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Center for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy.
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Francisca Joly
- Center for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Cora Jonkers
- Nutrition Support Team, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - Željko Krznarić
- Center of Clinical Nutrition, Department of Medicine, University Hospital Center, Zagreb, Croatia
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, United Kingdom
| | | | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | | | - Geert Wanten
- Intestinal Failure Unit, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carolyn Wheatley
- Support and Advocacy Group for People on Home Artificial Nutrition (PINNT), United Kingdom
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany
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4
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Norsa L, Goulet O, Alberti D, DeKooning B, Domellöf M, Haiden N, Hill S, Indrio F, Kӧglmeier J, Lapillonne A, Luque V, Moltu SJ, Saenz De Pipaon M, Savino F, Verduci E, Bronsky J. Nutrition and Intestinal Rehabilitation of Children With Short Bowel Syndrome: A Position Paper of the ESPGHAN Committee on Nutrition. Part 1: From Intestinal Resection to Home Discharge. J Pediatr Gastroenterol Nutr 2023; 77:281-297. [PMID: 37256827 DOI: 10.1097/mpg.0000000000003849] [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: 06/02/2023]
Abstract
Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The mainstay of treatment for IF is parenteral nutrition (PN). The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their experience. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. The first part of this position paper focuses on the physiological mechanism of intestinal adaptation after surgical resection. It subsequently provides some clinical practice recommendations for the primary management of children with SBS from surgical resection until discharged home on PN.
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Affiliation(s)
- Lorenzo Norsa
- From the Department of Paediatric Hepatology, Gastroenterology and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Olivier Goulet
- the Department of Pediatric Gastroenterology-Hepatology-Nutrition, Necker-Enfants Malades Hospital, Université Paris Descartes, Paris, France
| | - Daniele Alberti
- the Department of Pediatric Surgery, ASST Spedali Civili, Brescia, Italy
- the Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Barbara DeKooning
- the Paediatric Gastroenterology, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Magnus Domellöf
- the Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Nadja Haiden
- the Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Susan Hill
- the Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Flavia Indrio
- the Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Jutta Kӧglmeier
- the Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Alexandre Lapillonne
- the Neonatal Intensive Care Unit, Necker-Enfants Malades Hospital, Paris University, Paris, France
- the CNRC, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Veronica Luque
- Serra Hunter, Universitat Rovira I Virgili, IISPV, Tarragona, Spain
| | - Sissel J Moltu
- the Department of Neonatology, Oslo University Hospital, Oslo, Norway
| | - Miguel Saenz De Pipaon
- the Department of Neonatology, Instituto de Investigación Sanitaria del Hospital Universitario La Paz - IdiPAZ, Hospital Universitario La Paz - Universidad Autónoma de Madrid, Madrid, Spain
| | - Francesco Savino
- the Dipartimento di Patologia e cura del bambino "Regina Margherita", A.U.O. Città delle Salute e della Scienza di Torino, Torino, Italy
| | - Elvira Verduci
- the Department of Pediatrics, Ospedale dei Bambini Vittore Buzzi University of Milan, Milan, Italy
| | - Jiri Bronsky
- the Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
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5
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Bering J, DiBaise JK. Short bowel syndrome: Complications and management. Nutr Clin Pract 2023; 38 Suppl 1:S46-S58. [PMID: 37115034 DOI: 10.1002/ncp.10978] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 04/29/2023] Open
Abstract
Short bowel syndrome (SBS) occurs when a patient loses bowel length or function significantly enough to cause malabsorption, oftentimes requiring lifelong parenteral support. In adults, this occurs most commonly in the setting of massive intestinal resection, whereas congenital anomalies and necrotizing enterocolitis predominate in children. Many patients with SBS develop long-term clinical complications over time related to their altered intestinal anatomy and physiology or to various treatment interventions such as parenteral nutrition and the central venous catheter through which it is administered. Identifying, preventing, and treating these complications can be challenging. This review will focus on the diagnosis, treatment, and prevention of several complications that can occur in this patient population, including diarrhea, fluid and electrolyte imbalance, vitamin and trace element derangements, metabolic bone disease, biliary disorders, small intestinal bacterial overgrowth, d-lactic acidosis, and complications of central venous catheters.
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Affiliation(s)
- Jamie Bering
- Division of Gastroenterology and Hepatology, Mayo Clinic in Arizona, Scottsdale, Arizona, USA
| | - John K DiBaise
- Division of Gastroenterology and Hepatology, Mayo Clinic in Arizona, Scottsdale, Arizona, USA
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6
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Wauters L, Joly F. Treatment of short bowel syndrome: Breaking the therapeutic ceiling? Nutr Clin Pract 2023; 38 Suppl 1:S76-S87. [PMID: 37115030 DOI: 10.1002/ncp.10974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/26/2023] [Accepted: 02/04/2023] [Indexed: 04/29/2023] Open
Abstract
Short bowel syndrome (SBS) is the most common cause of chronic intestinal failure, requiring home parenteral support (intravenous fluid, parenteral nutrition, or parenteral nutrition with intravenous fluid) to compensate for severe malabsorption. The loss of mucosal absorptive area after extensive intestinal resection is accompanied by an accelerated transit and hypersecretion. Changes in physiology and clinical outcomes differ between patients with SBS with or without the distal ileum and/or colon-in-continuity. This narrative review summarizes the treatments used in SBS, with a focus on novel approaches with intestinotrophic agents. During the early postoperative years, spontaneous adaptation occurs and can be induced or accelerated with conventional therapies, which include dietary and fluid modifications and antidiarrheal and antisecretory drugs. Based on the proadaptive role of enterohormones (eg, glucagon-like peptide [GLP]-2), analogues have been developed to allow enhanced or hyperadaptation after a period of stabilization. Teduglutide is the first GLP-2 analogue developed and commercialized with proadaptive effects resulting in reduced parenteral support needs; however, the potential for weaning of parenteral support is variable. Whether early treatment with enterohormones or accelerated hyperadaptation would further improve absorption and outcomes remains to be shown. Longer-acting GLP-2 analogues are currently being investigated. Encouraging reports with GLP-1 agonists require confirmation in randomized trials, and dual GLP-1 and GLP-2 analogues have yet to be clinically investigated. Future studies will prove whether the timing and/or combinations of different enterohormones will be able to break the ceiling of intestinal rehabilitation in SBS.
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Affiliation(s)
- Lucas Wauters
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Gastroenterology and Nutrition Support, Assistance Publique des Hopitaux de Paris, University of Paris, Clichy, France
| | - Francisca Joly
- Department of Gastroenterology and Nutrition Support, Assistance Publique des Hopitaux de Paris, University of Paris, Clichy, France
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7
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Ermer T, Nazzal L, Tio MC, Waikar S, Aronson PS, Knauf F. Oxalate homeostasis. Nat Rev Nephrol 2023; 19:123-138. [PMID: 36329260 DOI: 10.1038/s41581-022-00643-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2022] [Indexed: 11/06/2022]
Abstract
Oxalate homeostasis is maintained through a delicate balance between endogenous sources, exogenous supply and excretion from the body. Novel studies have shed light on the essential roles of metabolic pathways, the microbiome, epithelial oxalate transporters, and adequate oxalate excretion to maintain oxalate homeostasis. In patients with primary or secondary hyperoxaluria, nephrolithiasis, acute or chronic oxalate nephropathy, or chronic kidney disease irrespective of aetiology, one or more of these elements are disrupted. The consequent impairment in oxalate homeostasis can trigger localized and systemic inflammation, progressive kidney disease and cardiovascular complications, including sudden cardiac death. Although kidney replacement therapy is the standard method for controlling elevated plasma oxalate concentrations in patients with kidney failure requiring dialysis, more research is needed to define effective elimination strategies at earlier stages of kidney disease. Beyond well-known interventions (such as dietary modifications), novel therapeutics (such as small interfering RNA gene silencers, recombinant oxalate-degrading enzymes and oxalate-degrading bacterial strains) hold promise to improve the outlook of patients with oxalate-related diseases. In addition, experimental evidence suggests that anti-inflammatory medications might represent another approach to mitigating or resolving oxalate-induced conditions.
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Affiliation(s)
- Theresa Ermer
- Department of Surgery, Division of Thoracic Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Lama Nazzal
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Maria Clarissa Tio
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Sushrut Waikar
- Department of Medicine, Section of Nephrology, Boston University, Boston, MA, USA
| | - Peter S Aronson
- Department of Internal Medicine, Section of Nephrology, Yale School of Medicine, New Haven, CT, USA
| | - Felix Knauf
- Department of Internal Medicine, Section of Nephrology, Yale School of Medicine, New Haven, CT, USA. .,Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany.
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8
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Storr M, Gross M, Madisch A, von Arnim U, Mönnikes H, Walters J, Krammer H, Keller J. Chologene Diarrhö, Stiefkind der chronischen Diarrhö
– Prävalenz, Diagnostik und Therapie. AKTUELLE ERNÄHRUNGSMEDIZIN 2022. [DOI: 10.1055/a-1923-0760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Die chologene Diarrhö ist eine der häufigsten nicht
diagnostizierten Ursachen der chronischen Diarrhö, der zahlreiche
verschiedene Pathophysiologien zugrunde liegen können. Auch nach
Ausschlussdiagnostik der häufigeren Ursachen verbleiben bis zu
5% der Bevölkerung von einer ungeklärten chronischen
Diarrhö betroffen. In diesem Kollektiv findet sich in bis zu 50%
als Ursache eine chologene Diarrhö.
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9
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Cai J, Rimal B, Jiang C, Chiang JYL, Patterson AD. Bile acid metabolism and signaling, the microbiota, and metabolic disease. Pharmacol Ther 2022; 237:108238. [PMID: 35792223 DOI: 10.1016/j.pharmthera.2022.108238] [Citation(s) in RCA: 69] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/13/2022] [Accepted: 06/27/2022] [Indexed: 11/24/2022]
Abstract
The diversity, composition, and function of the bacterial community inhabiting the human gastrointestinal tract contributes to host health through its role in producing energy or signaling molecules that regulate metabolic and immunologic functions. Bile acids are potent metabolic and immune signaling molecules synthesized from cholesterol in the liver and then transported to the intestine where they can undergo metabolism by gut bacteria. The combination of host- and microbiota-derived enzymatic activities contribute to the composition of the bile acid pool and thus there can be great diversity in bile acid composition that depends in part on the differences in the gut bacteria species. Bile acids can profoundly impact host metabolic and immunological functions by activating different bile acid receptors to regulate signaling pathways that control a broad range of complex symbiotic metabolic networks, including glucose, lipid, steroid and xenobiotic metabolism, and modulation of energy homeostasis. Disruption of bile acid signaling due to perturbation of the gut microbiota or dysregulation of the gut microbiota-host interaction is associated with the pathogenesis and progression of metabolic disorders. The metabolic and immunological roles of bile acids in human health have led to novel therapeutic approaches to manipulate the bile acid pool size, composition, and function by targeting one or multiple components of the microbiota-bile acid-bile acid receptor axis.
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Affiliation(s)
- Jingwei Cai
- Department of Veterinary and Biomedical Sciences, The Pennsylvania State University, University Park, PA, USA
| | - Bipin Rimal
- Department of Veterinary and Biomedical Sciences, The Pennsylvania State University, University Park, PA, USA
| | - Changtao Jiang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Peking University, and the Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, PR China
| | - John Y L Chiang
- Department of Integrative Medical Sciences, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Andrew D Patterson
- Department of Veterinary and Biomedical Sciences, The Pennsylvania State University, University Park, PA, USA.
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10
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Dietary Management of Chronic Kidney Disease and Secondary Hyperoxaluria in Patients with Short Bowel Syndrome and Type 3 Intestinal Failure. Nutrients 2022; 14:nu14081646. [PMID: 35458207 PMCID: PMC9030588 DOI: 10.3390/nu14081646] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/09/2022] [Accepted: 04/12/2022] [Indexed: 11/18/2022] Open
Abstract
Short gut syndrome can lead to type 3 intestinal failure, and nutrition and hydration can only be achieved with parenteral nutrition (PN). While this is a lifesaving intervention, it carries short- and long-term complications leading to complex comorbidities, including chronic kidney disease. Through a patient with devastating inflammatory bowel disease’s journey, this review article illustrates the effect of short gut and PN on kidney function, focusing on secondary hyperoxaluria and acute precipitants of glomerular filtration. In extensive small bowel resections colon in continuity promotes fluid reabsorption and hydration but predisposes to hyperoxaluria and stone disease through the impaired gut permeability and fat absorption. It is fundamental, therefore, for dietary intervention to maintain nutrition and prevent clinical deterioration (i.e., sarcopenia) but also to limit the progression of renal stone disease. Adaptation of both enteral and parenteral nutrition needs to be individualised, keeping in consideration not only patient comorbidities (short gut and jejunostomy, cirrhosis secondary to PN) but also patients’ wishes and lifestyle. A balanced multidisciplinary team (renal physician, gastroenterologist, dietician, clinical biochemist, pharmacist, etc.) plays a core role in managing complex patients, such as the one described in this review, to improve care and overall outcomes.
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11
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Wang Y, Zheng L, Zhou Z, Yao D, Huang Y, Liu B, Duan Y, Li Y. Review article: insights into the bile acid-gut microbiota axis in intestinal failure-associated liver disease-redefining the treatment approach. Aliment Pharmacol Ther 2022; 55:49-63. [PMID: 34713470 DOI: 10.1111/apt.16676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 06/04/2021] [Accepted: 10/15/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Intestinal failure-associated liver disease (IFALD) increases mortality of patients with intestinal failure (IF), but lacks effective prevention or treatment approaches. Bile acids, gut microbiota and the host have close and complex interactions, which play a central role in modulating host immune and metabolic homeostasis. Increasing evidence suggests that derangement of the bile acid-gut microbiota (BA-GM) axis contributes to the development of IFALD. AIMS To review the BA-GM axis in the pathogenesis and clinical applications of IFALD, and to explore future directions for effective disease management. METHODS We conducted a literature search on bile acid and gut microbiota in IF and liver diseases. RESULTS The BA-GM axis demonstrates a unique IF signature manifesting as an increase in primary-to-secondary bile acids ratio, disturbed enterohepatic circulation, blunted bile acid signalling pathways, gut microbial dysbiosis, and altered microbial metabolic outputs. Bile acids and gut microbiota shape the compositional and functional alterations of each other in IF; collaboratively, they promote immune dysfunction and metabolic aberration in the liver. Diagnostic markers and treatments targeting the BA-GM axis showed promising potential in the management of IFALD. CONCLUSIONS Bile acids and gut microbiota play a central role in the development of IFALD and make attractive biomarkers as well as therapeutic targets. A multitarget, individualised therapy aiming at different parts of the BA-GM axis may provide optimal clinical benefits and requires future investigation.
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Affiliation(s)
- Yaoxuan Wang
- Department of General Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Lei Zheng
- Department of General Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Zhiyuan Zhou
- Department of General Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Danhua Yao
- Department of General Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Yuhua Huang
- Department of General Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Bin Liu
- Department of General Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Yantao Duan
- Department of General Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Yousheng Li
- Department of General Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
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12
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Small intestine resection increases oxalate and citrate transporter expression and calcium oxalate crystal formation in rat hyperoxaluric kidneys. Clin Sci (Lond) 2021; 134:2565-2580. [PMID: 33006369 PMCID: PMC7557498 DOI: 10.1042/cs20200973] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/29/2020] [Accepted: 10/02/2020] [Indexed: 12/11/2022]
Abstract
Short bowel (SB) increases the risk of kidney stones. However, the underlying mechanism is unclear. Here, we examined how SB affected renal oxalate and citrate handlings for in vivo hyperoxaluric rats and in vitro tubular cells. SB was induced by small intestine resection in male Wistar rats. Sham-operated controls had no resection. After 7 days of recovery, the rats were divided into control, SB (both fed with distilled water), ethylene glycol (EG), and SB+EG (both fed with 0.75% EG for hyperoxaluric induction) groups for 28 days. We collected the plasma, 24 h of urine, kidney, and intestine tissues for analysis. Hypocitraturia was found and persisted up to 28 days for the SB group. Hypocalcemia and high plasma parathyroid hormone (PTH) levels were found in the 28-day SB rats. SB aggravated EG-mediated oxalate nephropathy by fostering hyperoxaluria and hypocitraturia, and increasing the degree of supersaturation and calcium oxalate (CaOx) crystal deposition. These effects were associated with renal up-regulations of the oxalate transporter solute carrier family 26 (Slc26)a6 and citrate transporter sodium-dependent dicarboxylate cotransporter-1 (NaDC-1) but not Slc26a2. The effects of PTH on the SB kidneys were then examined in NRK-52E tubular cells. Recombinant PTH attenuated oxalate-mediated cell injury and up-regulated NaDC-1 via protein kinase A (PKA) activation. PTH, however, showed no additive effects on oxalate-induced Slc26a6 and NaDC-1 up-regulation. Together, these results demonstrated that renal NaDC-1 upregulation-induced hypocitraturia weakened the defense against Slc26a6-mediated hyperoxaluria in SB kidneys for excess CaOx crystal formation. Increased tubular NaDC-1 expression caused by SB relied on PTH.
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13
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Witting C, Langman CB, Assimos D, Baum MA, Kausz A, Milliner D, Tasian G, Worcester E, Allain M, West M, Knauf F, Lieske JC. Pathophysiology and Treatment of Enteric Hyperoxaluria. Clin J Am Soc Nephrol 2021; 16:487-495. [PMID: 32900691 PMCID: PMC8011014 DOI: 10.2215/cjn.08000520] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Enteric hyperoxaluria is a distinct entity that can occur as a result of a diverse set of gastrointestinal disorders that promote fat malabsorption. This, in turn, leads to excess absorption of dietary oxalate and increased urinary oxalate excretion. Hyperoxaluria increases the risk of kidney stones and, in more severe cases, CKD and even kidney failure. The prevalence of enteric hyperoxaluria has increased over recent decades, largely because of the increased use of malabsorptive bariatric surgical procedures for medically complicated obesity. This systematic review of enteric hyperoxaluria was completed as part of a Kidney Health Initiative-sponsored project to describe enteric hyperoxaluria pathophysiology, causes, outcomes, and therapies. Current therapeutic options are limited to correcting the underlying gastrointestinal disorder, intensive dietary modifications, and use of calcium salts to bind oxalate in the gut. Evidence for the effect of these treatments on clinically significant outcomes, including kidney stone events or CKD, is currently lacking. Thus, further research is needed to better define the precise factors that influence risk of adverse outcomes, the long-term efficacy of available treatment strategies, and to develop new therapeutic approaches.
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Affiliation(s)
- Celeste Witting
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Craig B. Langman
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois,Division of Kidney Diseases, Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Dean Assimos
- Department of Urology, University of Alabama-Birmingham, Birmingham, Alabama
| | - Michelle A. Baum
- Division of Nephrology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Dawn Milliner
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Greg Tasian
- Department of Surgery, Division of Urology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elaine Worcester
- Department of Medicine, University of Chicago, Chicago, Illinois
| | | | | | - Felix Knauf
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - John C. Lieske
- Allena Pharmaceuticals, Inc., Newton, Massachusetts,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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14
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Storr M, Gross M, Madisch A, von Arnim U, Mönnikes H, Walters J, Krammer H, Keller J. [Bile acid diarrhea, stepchild of chronic diarrhea - prevalence, diagnosis and treatment. Update 2021]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:580-591. [PMID: 33634438 DOI: 10.1055/a-1378-9627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Bile acid diarrhea is one of the most frequently undiagnosed causes of chronic diarrhea. A variety of different pathophysiologic causes can underlie chronic diarrhea. Even after exclusion of the more frequent causes, up to 5 % of the population remains affected by unexplained chronic diarrhea. In up to 50 % within this cohort, bile acid diarrhea is the underlying cause.The various pathophysiologies leading to bile acid diarrhea are well characterized. In this way, bile acid diarrhea can be divided into primary, secondary and tertiary subtypes. Common to all causes is the increased amount of bile acids in the colon and in the faeces and the resulting secretory-osmotic diarrhea, in more severe forms in combination with steatorrhea. The diagnosis of bile acid diarrhea follows a clear algorithm which, in addition to the search for the cause and possibly a therapeutic trial, recognizes the 75SeHCAT test as the reference method for the detection of an increased loss of bile acids. In view of the chronic nature of the symptoms and the need for permanent, lifelong therapy, the use of a one-time, reliable diagnostic test is justified, though the test is currently only available at a few centers. In addition to the treatment of identifiable underlying diseases, the current treatment includes the use of drugs that bind bile acids, with additional nutritional recommendations and vitamin substitutions.The present review article summarizes the pathophysiology and importance of bile acid diarrhea and discusses the current approach towards diagnosis and treatment.
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Affiliation(s)
| | - Manfred Gross
- Internistisches Klinikum München Süd, Klinik für Gastroenterologie, München
| | - Ahmed Madisch
- Klinikum Siloah, Gastroenterologie, interventionelle Endoskopie, Diabetologie und Akutgeriatrie, Hannover
| | - Ulrike von Arnim
- Universitätsklinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum, Magdeburg
| | - Hubert Mönnikes
- Klinik für Innere Medizin, Martin Luther Krankenhaus, Berlin
| | | | - Heiner Krammer
- Praxis für Gastroenterologie und Ernährungsmedizin am Deutschen End- und Dickdarmzentrum Mannheim
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15
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di Gregorio MC, Cautela J, Galantini L. Physiology and Physical Chemistry of Bile Acids. Int J Mol Sci 2021; 22:1780. [PMID: 33579036 PMCID: PMC7916809 DOI: 10.3390/ijms22041780] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 02/04/2021] [Indexed: 02/06/2023] Open
Abstract
Bile acids (BAs) are facial amphiphiles synthesized in the body of all vertebrates. They undergo the enterohepatic circulation: they are produced in the liver, stored in the gallbladder, released in the intestine, taken into the bloodstream and lastly re-absorbed in the liver. During this pathway, BAs are modified in their molecular structure by the action of enzymes and bacteria. Such transformations allow them to acquire the chemical-physical properties needed for fulling several activities including metabolic regulation, antimicrobial functions and solubilization of lipids in digestion. The versatility of BAs in the physiological functions has inspired their use in many bio-applications, making them important tools for active molecule delivery, metabolic disease treatments and emulsification processes in food and drug industries. Moreover, moving over the borders of the biological field, BAs have been largely investigated as building blocks for the construction of supramolecular aggregates having peculiar structural, mechanical, chemical and optical properties. The review starts with a biological analysis of the BAs functions before progressively switching to a general overview of BAs in pharmacology and medicine applications. Lastly the focus moves to the BAs use in material science.
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Affiliation(s)
- Maria Chiara di Gregorio
- Department of Molecular Chemistry and Materials Science, Weizmann Institute of Science, Rehovot 7610001, Israel
| | - Jacopo Cautela
- Department of Chemistry, Sapienza University of Rome, 00185 Rome, Italy;
| | - Luciano Galantini
- Department of Chemistry, Sapienza University of Rome, 00185 Rome, Italy;
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16
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Höllwarth ME, Solari V. Nutritional and pharmacological strategy in children with short bowel syndrome. Pediatr Surg Int 2021; 37:1-15. [PMID: 33392698 DOI: 10.1007/s00383-020-04781-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 12/11/2022]
Abstract
Short bowel syndrome in neonates is a severe and life-threatening disease after a major loss of small bowel with or without large bowel. Intestinal adaptation, by which the organism tries to restore digestive and absorptive capacities, is entirely dependent on stimulation of the active enterocytes by enteral nutrition. This review summarizes recent knowledge about the pathophysiologic consequences after the loss of different intestinal parts and outlines the options for enteral nutrition and pharmacological therapies to support the adaptation process.
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Affiliation(s)
- Michael E Höllwarth
- Univ. Clinic of Pediatric and Adolescent Surgery, Medical University, Graz, Austria.
| | - Valeria Solari
- Department of Pediatric Surgery, Klinik Donaustadt, 1220, Vienna, Austria
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17
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Combining Acute Kidney Injury with Gastrointestinal Pathology: A Clue to Acute Oxalate Nephropathy. Case Rep Nephrol 2019; 2018:8641893. [PMID: 30675407 PMCID: PMC6323504 DOI: 10.1155/2018/8641893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/24/2018] [Accepted: 11/13/2018] [Indexed: 11/18/2022] Open
Abstract
Acute oxalate nephropathy (AON) is an increasingly recognized cause of acute kidney injury (AKI). Herein, we present two cases of biopsy-proven acute oxalate nephropathy in patients with gastrointestinal malabsorption, coincidentally both stemming from cholangiocarcinoma. The first is a 73-year-old male who presented with syncope and was found to have severe, oliguric AKI in the setting of newly diagnosed, nonresectable cholangiocarcinoma. The second is a 64-year-old man with remote resection of cholangiocarcinoma who presented after routine laboratory monitoring showed significant AKI. Temporary dialysis was required in both cases before renal recovery occurred. Together, these cases should increase physicians' suspicion of AON in the presence of malabsorption. By doing so, the workup of oxalate nephropathy can be expedited with prompt initiation of treatment.
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18
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Hashimoto S, Yamamoto R, Maoka T, Fukasawa Y, Koike T, Shigematsu T. A Case of Chronic Calcium Oxalate Nephropathy due to Short Bowel Syndrome and Cholecystectomy. Case Rep Nephrol Dial 2018; 8:147-154. [PMID: 30197903 PMCID: PMC6120416 DOI: 10.1159/000491630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 06/28/2018] [Indexed: 11/28/2022] Open
Abstract
Background Oxalate nephropathy is a rare disease. Especially chronic oxalate nephropathy still has many unknown aspects as compared to acute oxalate nephropathy with relatively well-known causality. Case Presentation The patient was a 70-year-old woman who had a history of small bowel resection 25 years before, cholecystectomy 10 years before, and renal stones (calcium oxalate stones) 7 years before. She had been suffering from chronic diarrhea and had been treated by a local physician. The patient was found to have renal dysfunction (creatinine 3.09 mg/dL, eGFR 12.3 mL/min/1.73 m2, hemoglobin 7.8 g/dL) and was referred to our department. The patient was admitted to our hospital for further investigation. Renal ultrasound showed hepatorenal echo contrast in an opposite manner and clear contrast between the renal cortex and medullary pyramid. Renal biopsy was performed, and histological examination showed tubulointerstitial disorder due to deposition of calcium oxalate. Daily urinary excretion of calcium oxalate was significantly increased. The patient was encouraged to drink water and administered vitamin B6, citric acid, K and Na hydrate. Thereafter, her symptoms improved. Conclusion Case reports of chronic oxalate neuropathy are rare in the literature, and its underlying mechanism has not been understood. Our patient had a history of small bowel resection and cholecystectomy. We considered that her short bowel syndrome had influenced the development of calcium oxalate nephropathy.
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Affiliation(s)
| | - Rie Yamamoto
- Department of Nephrology, NTT East Japan Sapporo Hospital, Sapporo, Japan
| | - Tomochika Maoka
- Department of Nephrology, NTT East Japan Sapporo Hospital, Sapporo, Japan
| | - Yuichiro Fukasawa
- Department of Pathology Diagnosis, Sapporo City General Hospital, Sapporo, Japan
| | - Takao Koike
- Department of lnternal Medicine II, Hokkaido University School of Medicine, Sapporo, Japan
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19
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Abstract
Peroxisomal biogenesis disorders due to PEX gene defects are classified into many subgroups, of which Zellweger spectrum disorders (ZSDs) represent the major subgroup. The ZSDs are clinical and biochemical disorders divided into three phenotypes: neonatal, adolescence, or adult. Clinical presentations vary with severity of the condition. Metabolic abnormalities occur due to functional peroxisomal defects that could be detected in blood and urine. No cure or definitive management exists to date; only supportive and palliative measures are applied to prevent worse sequelae. We experienced a case of oxalate renal stones in a patient with ZSD. This patient had hyperoxaluria and hyperglycolic aciduria with clinically associated clues that correlate with urinary oxalate load. Urinary oxalate and glycolate excretion were assessed. Radiological workup revealed renal involvement with urolithiasis and nephrocalcinosis. Urinalysis and ultrasonography for stones and hyperoxaluria should be used to screen patients with ZSD for early intervention to prevent renal damage.
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Affiliation(s)
- Hamdan Hammad Alhazmi
- Department of Surgery, Division of Urology, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
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20
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Hofmann AF. Bile Acid Replacement in Bile Acid Synthesis Defects. J Pediatr Gastroenterol Nutr 2017; 65:e134. [PMID: 28800025 DOI: 10.1097/mpg.0000000000001709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Alan F Hofmann
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, CA
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21
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Moreland AM, Santa Ana CA, Asplin JR, Kuhn JA, Holmes RP, Cole JA, Odstrcil EA, Van Dinter TG, Martinez JG, Fordtran JS. Steatorrhea and Hyperoxaluria in Severely Obese Patients Before and After Roux-en-Y Gastric Bypass. Gastroenterology 2017; 152:1055-1067.e3. [PMID: 28089681 DOI: 10.1053/j.gastro.2017.01.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 12/22/2016] [Accepted: 01/03/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Hyperoxaluria after Roux-en-Y gastric bypass (RYGB) is generally attributed to fat malabsorption. If hyperoxaluria is indeed caused by fat malabsorption, magnitudes of hyperoxaluria and steatorrhea should correlate. Severely obese patients, prior to bypass, ingest excess dietary fat that can produce hyperphagic steatorrhea. The primary objective of the study was to determine whether urine oxalate excretion correlates with elements of fat balance in severely obese patients before and after RYGB. METHODS Fat balance and urine oxalate excretion were measured simultaneously in 26 severely obese patients before and 1 year after RYGB, while patients consumed their usual diet. At these time points, stool and urine samples were collected. Steatorrhea and hyperoxaluria were defined as fecal fat >7 g/day and urine oxalate >40 mg/day. Differences were evaluated using paired 2-tailed t tests. RESULTS Prior to RYGB, 12 of 26 patients had mild to moderate steatorrhea. Average urine oxalate excretion was 61 mg/day; there was no correlation between fecal fat and urine oxalate excretion. After RYGB, 24 of 26 patients had steatorrhea and urine oxalate excretion averaged 69 mg/day, with a positive correlation between fecal fat and urine oxalate excretions (r = 0.71, P < .001). For each 10 g/day increase in fecal fat output, fecal water excretion increased only 46 mL/day. CONCLUSIONS Steatorrhea and hyperoxaluria were common in obese patients before bypass, but hyperoxaluria was not caused by excess unabsorbed fatty acids. Hyperphagia, obesity, or metabolic syndrome could have produced this previously unrecognized hyperoxaluric state by stimulating absorption or endogenous synthesis of oxalate. Hyperoxaluria after RYGB correlated with steatorrhea and was presumably caused by excess fatty acids in the intestinal lumen. Because post-bypass steatorrhea caused little increase in fecal water excretion, most patients with steatorrhea did not consider themselves to have diarrhea. Before and after RYGB, high oxalate intake contributed to the severity of hyperoxaluria.
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Affiliation(s)
- Amber M Moreland
- Division of Gastroenterology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas
| | - Carol A Santa Ana
- Division of Gastroenterology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas
| | - John R Asplin
- Litholink Corporation, Laboratory Corporation of America® Holdings, Chicago, Illinois
| | - Joseph A Kuhn
- Division of Gastroenterology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas
| | - Ross P Holmes
- Department of Urology, University of Alabama, Birmingham, Alabama
| | - Jason A Cole
- Division of Gastroenterology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas
| | - Elizabeth A Odstrcil
- Division of Gastroenterology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas
| | - Thomas G Van Dinter
- Division of Gastroenterology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas
| | - Juan G Martinez
- Division of Gastroenterology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas
| | - John S Fordtran
- Division of Gastroenterology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas.
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22
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Gao S, Yang R, Peng Z, Lu H, Li N, Ding J, Cui X, Chen W, Dong X. Metabolomics analysis for hydroxy-L-proline-induced calcium oxalate nephrolithiasis in rats based on ultra-high performance liquid chromatography quadrupole time-of-flight mass spectrometry. Sci Rep 2016; 6:30142. [PMID: 27443631 PMCID: PMC4957101 DOI: 10.1038/srep30142] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/28/2016] [Indexed: 12/25/2022] Open
Abstract
About 80% of kidney stones are composed of calcium oxalate (CaOx) with variable amounts of calcium phosphate, and hyperoxaluria is considered as an important factor of CaOx nephrolithiasis. However, the underlying metabolic mechanisms of CaOx nephrolithiasis remain undefined. In this study, we successfully developed a rat model with hydroxy-L-proline (HLP) -induced CaOx nephrolithiasis. Rats were continuously orally administrated with HLP for 28 days. Urine and blood samples were collected from the rats treated with or without HLP at four different time points. UPLC-Q-TOF/MS was applied to profile the abundances of metabolites. To obtain more comprehensive analysis of metabolic profiling spectrum, combination of RP-LC and HILIC were applied. We identify 42 significant differential metabolites in the urine, and 13 significant differential metabolites in the blood. Pathway analysis revealed that the pathways involved in amino acid metabolism, taurine metabolism, bile acid synthesis, energy metabolism, TCA cycle, purine metabolism, vitamin metabolism, nicotinic acid and nicotinamide metabolism have been modulated by HLP treatment. This study suggested that a number of metabolic pathways are dysfunctional in the HLP induced crystal kidney injury, and further studies on those pathways are warranted to better understand the metabolic mechanism of CaOx nephrolithiasis.
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Affiliation(s)
- Songyan Gao
- School of Pharmacy, Second Military Medical University, Shanghai 200433, China
| | - Rui Yang
- Brigade of undergraduate student, Second Military Medical University, Shanghai 200433, China
| | - Zhongjiang Peng
- Department of Nephrology, Changhai Hospital, Shanghai 200433, China
| | - Hongtao Lu
- Brigade of undergraduate student, Second Military Medical University, Shanghai 200433, China
| | - Na Li
- School of Pharmacy, Second Military Medical University, Shanghai 200433, China
| | - Jiarong Ding
- Department of Nephrology, Changhai Hospital, Shanghai 200433, China
| | - Xingang Cui
- Department of Urology, The Third Affiliated hospital, Second Military Medical University, Shanghai 200433, China
| | - Wei Chen
- Department of Nephrology, Changhai Hospital, Shanghai 200433, China
| | - Xin Dong
- School of Pharmacy, Second Military Medical University, Shanghai 200433, China
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23
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Carroll RE, Benedetti E, Schowalter JP, Buchman AL. Management and Complications of Short Bowel Syndrome: an Updated Review. Curr Gastroenterol Rep 2016; 18:40. [PMID: 27324885 DOI: 10.1007/s11894-016-0511-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Short bowel syndrome (SBS) is defined as loss of bowel mass from surgical resection, congenital defects, or disease. Intestinal failure (IF) includes the subset of SBS unable to meet nutrition needs with enteral supplements and requires parenteral nutrition (PN). The parenteral treatment of SBS is now a half-century old. Recent pharmacologic treatment (GLP-2 analogues) has begun to make a significant impact in the care and ultimate management of these patients such that the possibility of reducing PN requirements in formerly PN-dependent patients is a now a real possibility. Finally, newer understanding and possible treatment for some of the complications related to IF have more recently evolved and will be an emphasis of this report. This review will focus on developments over the last 10 years with the goal of updating the reader to new advances in our understanding of the care and feeding of the SBS patient.
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Affiliation(s)
- Robert E Carroll
- Intestinal Rehabilitation and Transplant Center, Departments of Medicine and Surgery, University of Illinois at Chicago and Chicago Veterans Administration Medical Center (West Side Division), 840 South Wood Street (M/C 787), Chicago, IL, 60612, USA.
| | - Enrico Benedetti
- Intestinal Rehabilitation and Transplant Center, Departments of Medicine and Surgery, University of Illinois at Chicago and Chicago Veterans Administration Medical Center (West Side Division), 840 South Wood Street (M/C 787), Chicago, IL, 60612, USA
| | - Joseph P Schowalter
- Intestinal Rehabilitation and Transplant Center, Departments of Medicine and Surgery, University of Illinois at Chicago and Chicago Veterans Administration Medical Center (West Side Division), 840 South Wood Street (M/C 787), Chicago, IL, 60612, USA
| | - Alan L Buchman
- Intestinal Rehabilitation and Transplant Center, Departments of Medicine and Surgery, University of Illinois at Chicago and Chicago Veterans Administration Medical Center (West Side Division), 840 South Wood Street (M/C 787), Chicago, IL, 60612, USA
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24
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Pironi L. Definitions of intestinal failure and the short bowel syndrome. Best Pract Res Clin Gastroenterol 2016; 30:173-85. [PMID: 27086884 DOI: 10.1016/j.bpg.2016.02.011] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 02/02/2016] [Accepted: 02/11/2016] [Indexed: 02/07/2023]
Abstract
The European Society for Clinical Nutrition and Metabolism defined intestinal failure (IF) as "the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth". IF is classified as type 1-acute, type 2-prolonged acute and type 3-chronic IF. A short bowel syndrome (SBS) due to the intestinal malabsorption associated with a functional small intestine length of less than 200 cm is the most frequent mechanism of IF. SBS is a difficult and multifaced disease. Complications due to SBS itself and to treatments, such as long term home parenteral nutrition, can adversely affect the patient outcome. The care of SBS requires complex technologies and multidisciplinary and multiprofessional activity and expertise. Patient outcome is strongly dependent on care and support from an expert specialist team. This paper focuses on the aspects of the pathophysiology and on the complications of SBS, which are most relevant in the clinical practice, such as intestinal failure associated liver disease, renal failure, biliary and renal stones, dehydration and electrolyte depletion, magnesium deficiency and D-lactic acidosis.
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Affiliation(s)
- Loris Pironi
- Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy.
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25
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Pironi L, Arends J, Bozzetti F, Cuerda C, Gillanders L, Jeppesen PB, Joly F, Kelly D, Lal S, Staun M, Szczepanek K, Van Gossum A, Wanten G, Schneider SM. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr 2016; 35:247-307. [PMID: 26944585 DOI: 10.1016/j.clnu.2016.01.020] [Citation(s) in RCA: 448] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 01/27/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Chronic Intestinal Failure (CIF) is the long-lasting reduction of gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. CIF is the rarest organ failure. Home parenteral nutrition (HPN) is the primary treatment for CIF. No guidelines (GLs) have been developed that address the global management of CIF. These GLs have been devised to generate comprehensive recommendations for safe and effective management of adult patients with CIF. METHODS The GLs were developed by the Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds, and accepted in an online survey of ESPEN members. RESULTS The following topics were addressed: management of HPN; parenteral nutrition formulation; intestinal rehabilitation, medical therapies, and non-transplant surgery, for short bowel syndrome, chronic intestinal pseudo-obstruction, and radiation enteritis; intestinal transplantation; prevention/treatment of CVC-related infection, CVC-related occlusion/thrombosis; intestinal failure-associated liver disease, gallbladder sludge and stones, renal failure and metabolic bone disease. Literature search provided 623 full papers. Only 12% were controlled studies or meta-analyses. A total of 112 recommendations are given: grade of evidence, very low for 51%, low for 39%, moderate for 8%, and high for 2%; strength of recommendation: strong for 63%, weak for 37%. CONCLUSIONS CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.
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Affiliation(s)
- Loris Pironi
- Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola-Malpighi University Hospital, Bologna, Italy.
| | - Jann Arends
- Department of Medicine, Oncology and Hematology, University of Freiburg, Germany
| | | | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Lyn Gillanders
- Nutrition Support Team, Auckland City Hospital, (AuSPEN) Auckland, New Zealand
| | | | - Francisca Joly
- Centre for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Darlene Kelly
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA; Oley Foundation for Home Parenteral and Enteral Nutrition, Albany, NY, USA
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Michael Staun
- Rigshospitalet, Department of Gastroenterology, Copenhagen, Denmark
| | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - André Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Stéphane Michel Schneider
- Gastroenterology and Clinical Nutrition, CHU of Nice, University of Nice Sophia Antipolis, Nice, France
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Glew RH, Sun Y, Horowitz BL, Konstantinov KN, Barry M, Fair JR, Massie L, Tzamaloukas AH. Nephropathy in dietary hyperoxaluria: A potentially preventable acute or chronic kidney disease. World J Nephrol 2014; 3:122-142. [PMID: 25374807 PMCID: PMC4220346 DOI: 10.5527/wjn.v3.i4.122] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 06/12/2014] [Accepted: 08/29/2014] [Indexed: 02/06/2023] Open
Abstract
Hyperoxaluria can cause not only nephrolithiasis and nephrocalcinosis, but also renal parenchymal disease histologically characterized by deposition of calcium oxalate crystals throughout the renal parenchyma, profound tubular damage and interstitial inflammation and fibrosis. Hyperoxaluric nephropathy presents clinically as acute or chronic renal failure that may progress to end-stage renal disease (ESRD). This sequence of events, well recognized in the past in primary and enteric hyperoxalurias, has also been documented in a few cases of dietary hyperoxaluria. Estimates of oxalate intake in patients with chronic dietary hyperoxaluria who developed chronic kidney disease or ESRD were comparable to the reported average oxalate content of the diets of certain populations worldwide, thus raising the question whether dietary hyperoxaluria is a primary cause of ESRD in these regions. Studies addressing this question have the potential of improving population health and should be undertaken, alongside ongoing studies which are yielding fresh insights into the mechanisms of intestinal absorption and renal excretion of oxalate, and into the mechanisms of development of oxalate-induced renal parenchymal disease. Novel preventive and therapeutic strategies for treating all types of hyperoxaluria are expected to develop from these studies.
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Karaolanis G, Lionaki S, Moris D, Palla VV, Vernadakis S. Secondary hyperoxaluria: a risk factor for kidney stone formation and renal failure in native kidneys and renal grafts. Transplant Rev (Orlando) 2014; 28:182-7. [PMID: 24999029 DOI: 10.1016/j.trre.2014.05.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 05/18/2014] [Accepted: 05/21/2014] [Indexed: 12/22/2022]
Abstract
Secondary hyperoxaluria is a multifactorial disease affecting several organs and tissues, among which stand native and transplanted kidneys. Nephrocalcinosis and nephrolithiasis may lead to renal insufficiency. Patients suffering from secondary hyperoxaluria, should be promptly identified and appropriately treated, so that less renal damage occurs. The aim of this review is to underline the causes of hyperoxaluria and the related pathophysiologic mechanisms, which are involved, along with the description of seven cases of irreversible renal graft injury due to secondary hyperoxaluria.
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Affiliation(s)
- Georgios Karaolanis
- Transplantation Unit, Laiko General Hospital, Medical School of Athens, Athens, Greece.
| | - Sophia Lionaki
- Nephrology and Transplantation Unit, Laiko Hospital, Athens, Greece
| | - Demetrios Moris
- Transplantation Unit, Laiko General Hospital, Medical School of Athens, Athens, Greece
| | | | - Spiridon Vernadakis
- Transplantation Unit, Laiko General Hospital, Medical School of Athens, Athens, Greece
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Ceulemans LJ, Nijs Y, Nuytens F, De Hertogh G, Claes K, Bammens B, Naesens M, Evenepoel P, Kuypers D, Vanrenterghem Y, Monbaliu D, Pirenne J. Combined kidney and intestinal transplantation in patients with enteric hyperoxaluria secondary to short bowel syndrome. Am J Transplant 2013; 13:1910-4. [PMID: 23730777 DOI: 10.1111/ajt.12305] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 03/25/2013] [Accepted: 04/10/2013] [Indexed: 01/25/2023]
Abstract
Kidney transplantation is the treatment of choice for end-stage renal disease whereas indications for intestinal transplantation are currently restricted to patients with irreversible small bowel failure and severe complications of total parenteral nutrition (mostly shortage and infection of venous accesses, major electrolyte disturbances and liver failure). Enteric hyperoxaluria is secondary to certain intestinal diseases like intestinal resections, chronic inflammatory bowel disease and other malabsorption syndromes and can lead to end-stage renal disease requiring kidney transplantation. We report two patients suffering from renal failure due to enteric hyperoxaluria (secondary to extensive intestinal resection) in whom we elected to replace not only the kidney but also the intestine to prevent recurrence of hyperoxaluria in the transplanted kidney.
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Affiliation(s)
- L J Ceulemans
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
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A review of enteral strategies in infant short bowel syndrome: evidence-based or NICU culture? J Pediatr Surg 2013; 48:1099-112. [PMID: 23701789 DOI: 10.1016/j.jpedsurg.2013.01.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 01/01/2013] [Accepted: 01/09/2013] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Short bowel syndrome (SBS) is an increasingly common condition encountered across neonatal intensive care units. Improvements in parenteral nutrition (PN), neonatal intensive care and surgical techniques, in addition to an improved understanding of SBS pathophysiology, have contributed in equal parts to the survival of this fragile subset of infants. Prevention of intestinal failure associated liver disease (IFALD) and promotion of intestinal adaptation are primary goals of all involved in the care of these patients. While enteral nutritional and pharmacological strategies are necessary to achieve these goals, there remains great variability in the application of therapeutic strategies in units that are not necessarily evidence-based. MATERIALS AND METHODS A search of major English language medical databases (SCOPUS, Index Medicus, Medline, and the Cochrane database) was conducted for the key words short bowel syndrome, medical management, nutritional management and intestinal adaptation. All pharmacological and nutritional agents encountered in the literature search were classified based on their effects on absorptive capacity, intestinal adaptation and bowel motility that are the three major strategies employed in the management of SBS. The Oxford Center for Evidence-Based Medicine (CEBM) classification for levels of evidence was used to develop grades of clinical recommendation for each variable studied. RESULTS We reviewed various medications used and nutritional strategies included soluble fiber, enteral fat, glutamine, probiotics and sodium supplementation. Most interventions have scientific rationale but little evidence to support their role in the management of infant SBS. While some of these agents symptomatically improve diarrhea, they can adversely influence pancreatico-biliary function or actually impair intestinal adaptation. Surgical anatomy and liver function are two important variables that should determine the selection of pharmacological and nutritional interventions. DISCUSSION There is a paucity of research investigating optimal clinical practice in infant SBS and the little evidence available is consistently of lower quality, resulting in a wide variation of clinical practices among NICUs. Prospective trials should be encouraged to bridge the evidence gap between research and clinical practice to promote further progress in the field.
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Poesen R, Meijers B, Evenepoel P. The colon: an overlooked site for therapeutics in dialysis patients. Semin Dial 2013; 26:323-32. [PMID: 23458264 DOI: 10.1111/sdi.12082] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Morbidity and mortality related to chronic kidney disease remain unacceptably high, despite tremendous progress in its prevention and treatment. In an ongoing quest to improve outcome in chronic kidney disease patients, the colon might be an appealing, but largely underexplored, therapeutic target. A clear bi-directional functional relationship exists between the colon and kidney, also referred as to the colo-renal axis. Uremia has an important impact on the colonic microbiome. The microbiome, in turn, is an important source of uremic toxins, with p-cresyl sulfate and indoxyl sulfate as important prototypes. These co-metabolites accumulate in the face of a falling kidney function, and may accelerate the progression of renal and cardiovascular disease. Several therapeutic interventions, including prebiotics and adsorbants, specifically target these colon-derived uremic toxins originating from bacterial metabolism. As kidney function declines, the colon also gains importance in the homeostasis and disposal of potassium and oxalate. Their colonic secretion may be increased by drugs increasing the expression of cAMP and by probiotics (e.g., Oxalobacter formigenes).
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Affiliation(s)
- Ruben Poesen
- Division of Nephrology, Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium
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Cartery C, Faguer S, Karras A, Cointault O, Buscail L, Modesto A, Ribes D, Rostaing L, Chauveau D, Giraud P. Oxalate nephropathy associated with chronic pancreatitis. Clin J Am Soc Nephrol 2011; 6:1895-902. [PMID: 21737848 DOI: 10.2215/cjn.00010111] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Enteric overabsorption of oxalate may lead to hyperoxaluria and subsequent acute oxalate nephritis (AON). AON related to chronic pancreatitis is a rare and poorly described condition precluding early recognition and treatment. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We collected the clinical characteristics, treatment, and renal outcome of 12 patients with chronic pancreatitis-associated AON followed in four French renal units. RESULTS Before AON, mild to moderate chronic kidney disease was present in all patients, diabetes mellitus in eight (insulin [n = 6]; oral antidiabetic drugs [n = 2]), and known chronic pancreatitis in only eight. At presentation, pancreas imaging showed gland atrophy/heterogeneity, Wirsung duct dilation, calcification, or pseudocyst. Renal findings consisted of rapidly progressive renal failure with tubulointerstitial profile. Acute modification of glomerular filtration preceded the AON (i.e., diarrhea and diuretics). Increase in urinary oxalate excretion was found in all tested patients and hypocalcemia in nine (<1.5 mmol/L in four patients). Renal biopsy showed diffuse crystal deposits, highly suggestive of oxalate crystals, with tubular necrosis and interstitial inflammatory cell infiltrates. Treatment consisted of pancreatic enzyme supplementation, oral calcium intake, and an oxalate-free diet in all patients and renal replacement therapy in five patients. After a median follow-up of 7 months, three of 12 patients reached end-stage renal disease. CONCLUSION AON is an under-recognized severe crystal-induced renal disease with features of tubulointerstitial nephritis that may occur in patients with a long history of chronic pancreatitis or reveal the pancreatic disease. Extrinsic triggering factors should be prevented.
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Affiliation(s)
- Claire Cartery
- Service de Néphrologie et Immunologie Clinique, Hôpital de Rangueil, 1 avenue Jean Poulhès, TSA 50032, 31059 Toulouse Cedex 9, France
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Perrone EE, Chen C, Longshore SW, Okezie O, Warner BW, Sun CC, Alaish SM, Strauch ED. Dietary bile acid supplementation improves intestinal integrity and survival in a murine model. J Pediatr Surg 2010; 45:1256-65. [PMID: 20620329 PMCID: PMC2904360 DOI: 10.1016/j.jpedsurg.2010.02.094] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Accepted: 02/23/2010] [Indexed: 11/30/2022]
Abstract
PURPOSE In vitro supplementation of the bile salt, taurodeoxycholic acid (TDCA), has been shown to stimulate proliferation and prevent intestinal apoptosis in IEC-6 cells. We hypothesize that addition of TDCA to a rodent liquid diet will be protective against induced intestinal injury. METHODS C57Bl6 mice were fed a liquid diet with or without 50-mg/(kg d) TDCA supplementation. After 6 days, the mice were injected with lipopolysaccharide (LPS) (10 mg/kg) to induce intestinal injury. Specimens were obtained 24 hours later and evaluated for intestinal apoptosis, crypt proliferation, and villus length. A separate cohort of animals was injected with LPS (25 mg/kg) and followed 7 days for survival. RESULTS Mice whose diet was supplemented with TDCA had significantly increased survival. After LPS-induced injury, mice supplemented with TDCA showed decreased intestinal apoptosis by both H&E and caspase-3. They also had increased intestinal proliferation by 5-bromo-2'deoxyuridine staining and increased villus length. CONCLUSIONS Dietary TDCA supplementation alleviates mucosal damage and improves survival after LPS-induced intestinal injury. Taurodeoxycholic acid is protective of the intestinal mucosa by increasing resistance to injury-induced apoptosis, stimulating enterocyte proliferation, and increasing villus length. Taurodeoxycholic acid supplementation also results in an increased survival benefit. Therefore, bile acid supplementation may potentially protect the intestine from injury or infection.
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Affiliation(s)
- Erin E. Perrone
- Department of Pediatric Surgery, University of Maryland Medical Center, 22 S. Greene St, Rm N4E37, Baltimore, MD 21201,Department of Surgery, Wayne State University School of Medicine, 4201 St. Antoine, UHC-6C, Detroit, MI 48201
| | - Chen Chen
- Department of Pediatric Surgery, University of Maryland Medical Center, 22 S. Greene St, Rm N4E37, Baltimore, MD 21201
| | - Shannon W. Longshore
- Department of Pediatric Surgery, St. Louis Children's Hospital, Washington University School of Medicine, One Children's Place, Suite 5S60, St. Louis MO 63110,Department of Surgery, University of California, Davis Medical Center, 2315 Stockton Blvd., Sacramento, CA 95817
| | - Oneybuchi Okezie
- Department of Pediatric Surgery, St. Louis Children's Hospital, Washington University School of Medicine, One Children's Place, Suite 5S60, St. Louis MO 63110
| | - Brad W. Warner
- Department of Pediatric Surgery, St. Louis Children's Hospital, Washington University School of Medicine, One Children's Place, Suite 5S60, St. Louis MO 63110
| | - Chen-Chih Sun
- Department of Pathology, University of Maryland Medical Center, 22 S. Greene St, Rm N4E37, Baltimore, MD 21201
| | - Samuel M. Alaish
- Department of Pediatric Surgery, University of Maryland Medical Center, 22 S. Greene St, Rm N4E37, Baltimore, MD 21201
| | - Eric D. Strauch
- Department of Pediatric Surgery, University of Maryland Medical Center, 22 S. Greene St, Rm N4E37, Baltimore, MD 21201
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Rankin AC, Walsh SB, Summers SA, Owen MP, Mansell MA. Acute oxalate nephropathy causing late renal transplant dysfunction due to enteric hyperoxaluria. Am J Transplant 2008; 8:1755-8. [PMID: 18557738 DOI: 10.1111/j.1600-6143.2008.02288.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Calcium oxalate (CaOx) deposition in the renal allograft is an under recognized and important cause of acute tubular injury and early allograft dysfunction. We present a case of late transplant dysfunction due to acute oxalate nephropathy. The patient presented with diarrhea and deteriorating graft function, and a diagnosis of enteric hyperoxaluria secondary to pancreatic insufficiency was made. This had occurred, as the patient had been noncompliant with his pancreatic enzyme replacement therapy. Treatment to reduce his circulating oxalate load was initiated, including twice-daily hemodialysis, low fat and oxalate diet and appropriate administration of pancreatic enzyme supplements. Graft function subsequently recovered. The possibility of fat malabsorption leading to enteric hyperoxaluria should be considered in renal graft recipients presenting with loose stools and graft dysfunction.
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Affiliation(s)
- A C Rankin
- Renal Department, King's College London School of Medicine, London, UK.
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Marengo SR, Romani AMP. Oxalate in renal stone disease: the terminal metabolite that just won't go away. ACTA ACUST UNITED AC 2008; 4:368-77. [PMID: 18523430 DOI: 10.1038/ncpneph0845] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Accepted: 04/09/2008] [Indexed: 01/15/2023]
Abstract
The incidence of calcium oxalate nephrolithiasis in the US has been increasing throughout the past three decades. Biopsy studies show that both calcium oxalate nephrolithiasis and nephrocalcinosis probably occur by different mechanisms in different subsets of patients. Before more-effective medical therapies can be developed for these conditions, we must understand the mechanisms governing the transport and excretion of oxalate and the interactions of the ion in general and renal physiology. Blood oxalate derives from diet, degradation of ascorbate, and production by the liver and erythrocytes. In mammals, oxalate is a terminal metabolite that must be excreted or sequestered. The kidneys are the primary route of excretion and the site of oxalate's only known function. Oxalate stimulates the uptake of chloride, water, and sodium by the proximal tubule through the exchange of oxalate for sulfate or chloride via the solute carrier SLC26A6. Fecal excretion of oxalate is stimulated by hyperoxalemia in rodents, but no similar phenomenon has been observed in humans. Studies in which rats were treated with (14)C-oxalate have shown that less than 2% of a chronic oxalate load accumulates in the internal organs, plasma, and skeleton. These studies have also demonstrated that there is interindividual variability in the accumulation of oxalate, especially by the kidney. This Review summarizes the transport and function of oxalate in mammalian physiology and the ion's potential roles in nephrolithiasis and nephrocalcinosis.
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Affiliation(s)
- Susan R Marengo
- Department of Physiology and Biophysics at Case Western Reserve University School of Medicine, Cleveland, OH 44106-4970, USA.
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van Woerden CS, Groothoff JW, Wijburg FA, Duran M, Wanders RJA, Barth PG, Poll-The BT. High incidence of hyperoxaluria in generalized peroxisomal disorders. Mol Genet Metab 2006; 88:346-50. [PMID: 16621644 DOI: 10.1016/j.ymgme.2006.03.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2006] [Revised: 03/10/2006] [Accepted: 03/10/2006] [Indexed: 11/23/2022]
Abstract
The Zellweger spectrum disorders (ZSDs) are characterized by a generalized loss of peroxisomal functions caused by deficient peroxisomal assembly. Clinical presentation and survival are heterogeneous. Although most peroxisomal enzymes are unstable in the cytosol of peroxisome-deficient cells of ZSD patients, a few enzymes remain stable among which alanine:glyoxylate aminotransferase (AGT). Its deficiency causes primary hyperoxaluria type 1 (PH1, MIM 259900), an inborn error of glyoxylate metabolism characterized by hyperoxaluria, nephrocalcinosis, and renal insufficiency. Despite the normal level of AGT activity in ZSD patients, hyperoxaluria has been reported in several ZSD patients. We observed the unexpected occurrence of renal stones in a cohort of ZSD patients. This led us to perform a study in this cohort to determine the prevalence of hyperoxaluria in ZSDs and to find clinically relevant clues that correlate with the urinary oxalate load. We reviewed medical charts of 31 Dutch ZSD patients with prolonged survival (>1 year). Urinary oxalate excretion was assessed in 23 and glycolate in 22 patients. Hyperoxaluria was present in 19 (83%), and hyperglycolic aciduria in 14 (64%). Pyridoxine treatment in six patients did not reduce the oxalate excretion as in some PH1 patients. Renal involvement with urolithiasis and nephrocalcinosis was present in five of which one developed end-stage renal disease. The presence of hyperoxaluria, potentially leading to severe renal involvement, was statistically significant correlated with the severity of neurological dysfunction. ZSD patients should be screened by urinalysis for hyperoxaluria and renal ultrasound for nephrocalcinosis in order to take timely measures to prevent renal insufficiency.
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Affiliation(s)
- Christiaan S van Woerden
- Department of Pediatrics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Abstract
Short bowel syndrome (SBS) is the predominant cause of intestinal failure and is thus associated with a high degree of morbidity and mortality. One of the reasons this occurs is the dramatic reduction in nutrient absorptive capacity. Of the many causes of SBS, the most common cause is extensive surgical resection. The impressive ability of the bowel to adapt functionally and morphologically is critical for decreasing morbidity and mortality in these patients. The degree of adaptation is vital in decreasing the dependence on parenteral nutrition (PN) and for improving patient quality of life and long-term outcome. Provision of appropriate and sufficient nutritional and fluid support is essential for the management of these patients. The primary goal is to prevent or eliminate the need for PN. Recent developments have promoted a greater understanding of the process of intestinal adaptation. Various intestinal trophic factors have been recognized. These efforts have led to the early development of hormonal therapy to stimulate intestinal adaptation and enhance intestinal absorption. Intestinal transplantation remains an option for those who have developed life-threatening complications from PN and cannot be managed using more conservative techniques.
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Affiliation(s)
- Christian Jackson
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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Ghabril MS, Aranda-Michel J, Scolapio JS. Metabolic and catheter complications of parenteral nutrition. Curr Gastroenterol Rep 2004; 6:327-34. [PMID: 15245703 DOI: 10.1007/s11894-004-0086-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
Since its introduction in the 1960s, total parenteral nutrition (TPN) has played a vital role in improving clinical outcomes for patients with acute and chronic illnesses. The evolution of TPN solutions and vascular access techniques, combined with an increased awareness and better understanding of the physiology of TPN, have improved the safety of this therapy. Nevertheless, complications are not uncommon and can be life threatening. This article provides an updated review on the metabolic and catheter complications associated with TPN.
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Affiliation(s)
- Marwan S Ghabril
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Drive, Jacksonville, FL 32224, USA
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Vanderhoof JA, Young RJ. Enteral and parenteral nutrition in the care of patients with short-bowel syndrome. Best Pract Res Clin Gastroenterol 2003; 17:997-1015. [PMID: 14642862 DOI: 10.1016/s1521-6918(03)00082-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Short-bowel syndrome is a challenging entity for the gastroenterologist, requiring integration of medical, nutritional, surgical and psychological therapies. Treatment must be based on the patient's age, remaining gastrointestinal anatomy, baseline nutritional status and underlying general health as well as the numerous complications which may arise. This chapter reviews physiological alterations that occur with short-bowel syndrome and how therapies can be tailored to most adequately meet the needs of these patients. Emphasis on early stages of therapy to enhance intestinal adaptation is focused on as management during this time has a significant impact on the long-term outcome of these patients.
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Affiliation(s)
- Jon A Vanderhoof
- Chief Section of Pediatric Gastroenterology and Nutrition, University of Nebraska Medical Center, 985160 Nebraska Medical Center, Omaha, NE 68198-5160, USA.
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Abstract
Patients receiving long-term home parenteral nutrition tend to fall under the care of adult and pediatric gastroenterologists. This article reviews the management of potential infectious, mechanical and metabolic complications and describes common psychosocial issues related to the therapy. The point at which to refer the patient to an intestinal failure program offering autologous bowel reconstruction and small bowel transplantation is discussed.
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Affiliation(s)
- Lyn Howard
- Division of Gastroenterology and Clinical Nutrition, Albany Medical College, New York 12208, USA.
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