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Hasbaoui BE, Boujrad S, Abilkacem R, Agadr A. [Vomiting associated with weight stagnation and convulsions: urea cycle disorder should be suspected]. Pan Afr Med J 2019; 31:103. [PMID: 31037164 PMCID: PMC6462384 DOI: 10.11604/pamj.2018.31.103.11403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 08/02/2017] [Indexed: 11/11/2022] Open
Abstract
Dans certaines maladies métaboliques héréditaires, les vomissements peuvent apparaître comme un symptôme étant au premier plan, en particulier les anomalies du cycle de l'urée, qui sont habituellement diagnostiqués en période néonatale ou dans l'enfance. Nous en rapportons un cas de révélation tardive par un état de mal convulsif. Nous rapportons le cas d'une patiente âgée de 13 ans, qui a été hospitalisé pour prise en charge d'un état de mal convulsif et un retard staturo-pondéral. L'interrogatoire a révélé la notion de vomissements chroniques avec des troubles du comportement, ralentissement idéomoteur et céphalées. L'examen a trouvé une ataxie. La ponction lombaire et le scanner cérébral sont normaux. Une ammoniémie nettement augmentée est mise en évidence 75 micromoles/l (11-50). La chromatographie des acides aminés dans le sang a montré une augmentation de la glutamine et de l'alanine, La chromatographie des acides aminés dans les urines a montré une augmentation des acides aminés basiques évoquant un déficit du cycle de l'urée par déficit de l'enzyme Argininosuccinate lyase. La patiente a été traité en urgence par une alimentation exclusivement glucidolipidique, et par benzoate de sodium permettant une amélioration de l'état clinique, et une reprise de poids. Les crises convulsives ont été maîtrisées par le phénobarbital. L'enquête familiale a trouvé une sœur âgée de 20 ans suivie depuis l'âge de 3 ans pour crises convulsives traité par le phénobarbital dont le bilan métabolique réalisé dans notre service a objectivé la même anomalie du cycle de l'urée que sa sœur. A tout âge, devant une encéphalopathie avec épilepsie, vomissement, stagnation pondérale et hyperammoniémie, il faut penser à un déficit du cycle de l'urée. Le diagnostic est très souvent posé lors d'un accès neuro-digestif aigue associant vomissements, troubles de conscience et/ou crises convulsives.
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Affiliation(s)
- Brahim El Hasbaoui
- Service de Pédiatrie, Hôpital Militaire d'Instruction Mohammed V, Faculté de Médecine et de Pharmacie, Université Mohammed V, Rabat, Maroc
| | - Saloua Boujrad
- Service de Pédiatrie, Hôpital Militaire d'Instruction Mohammed V, Faculté de Médecine et de Pharmacie, Université Mohammed V, Rabat, Maroc
| | - Rachid Abilkacem
- Service de Pédiatrie, Hôpital Militaire d'Instruction Mohammed V, Faculté de Médecine et de Pharmacie, Université Mohammed V, Rabat, Maroc
| | - Aomar Agadr
- Service de Pédiatrie, Hôpital Militaire d'Instruction Mohammed V, Faculté de Médecine et de Pharmacie, Université Mohammed V, Rabat, Maroc
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Bigot A, Brunault P, Lavigne C, Feillet F, Odent S, Kaphan E, Thauvin C, Leguy V, Broué P, Tchan MC, Maillot F. Psychiatric adult-onset of urea cycle disorders: A case-series. Mol Genet Metab Rep 2017; 12:103-109. [PMID: 28725569 PMCID: PMC5502717 DOI: 10.1016/j.ymgmr.2017.07.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/02/2017] [Accepted: 07/02/2017] [Indexed: 12/30/2022] Open
Abstract
Adult onset urea cycle disorders (UCD) may present with psychiatric symptoms, occasionally as the initial presentation. We aimed to describe the characteristics of patients presenting with a psychiatric adult-onset of UCDs, to discuss which signs could suggest this diagnosis in such a situation, and to determine which tests should be conducted. A survey of psychiatric symptoms occurring in teenagers or adults with UCD was conducted in 2010 among clinicians involved in the French society for the study of inborn errors of metabolism (SFEIM). Fourteen patients from 14 to 57 years old were reported. Agitation was reported in 10 cases, perseveration in 5, delirium in 4, and disinhibition in 3 cases. Three patients had pre-existing psychiatric symptoms. All patients had neurological symptoms associated with psychiatric symptoms, such as ataxia or dysmetria, psychomotor slowing, seizures, or hallucinations. Fluctuations of consciousness and coma were reported in 9 cases. Digestive symptoms were reported in 7 cases. 9 patients had a personal history suggestive of UCD. The differential diagnoses most frequently considered were exogenous intoxication, non-convulsive status epilepticus, and meningoencephalitis. Hyperammonemia (180-600 μmol/L) was found in all patients. The outcome was severe: mechanical ventilation was required in 10 patients, 5 patients died, and only 4 patients survived without sequelae. Adult onset UCDs can present with predominant psychiatric symptoms, associated with neurological involvement. These patients, as well as patients presenting with a suspicion of intoxication, must have UCD considered and ammonia measured without delay.
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Affiliation(s)
- Adrien Bigot
- CHRU de Tours, Médecine interne, Tours, France
- CHRU de Toulouse, Service de pédiatrie, Toulouse, France
- Genetic Medicine, Westmead Hospital, NSW, Australia
| | - Paul Brunault
- CHRU de Tours, Clinique Psychiatrique Universitaire, Tours, France
- CHRU de Tours, Équipe de Liaison et de Soins en Addictologie, Tours, France
| | | | - François Feillet
- CHRU de Nancy, Centre de références des maladies héréditaires du métabolisme, Nancy, France
| | - Sylvie Odent
- CHRU de Rennes, Service de génétique, Rennes, France
| | - Elsa Kaphan
- CHRU de Marseille, Service de neurologie, La Timone, Marseille, France
| | | | - Vanessa Leguy
- CHRU de Dijon, Service de Médecine Interne, Dijon, France
| | - Pierre Broué
- CHRU de Toulouse, Service de pédiatrie, Toulouse, France
| | | | - François Maillot
- CHRU de Tours, Médecine interne, Tours, France
- Université François-Rabelais, INSERM 1069, Tours, France
- Corresponding author at: Service de Médecine Interne, Hopital Bretonneau, 2bd Tonnellé, 37044 Tours CEDEX 9, France.Service de Médecine InterneHopital Bretonneau2bd TonnelléTours CEDEX 937044France
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Watt P, lordache S, Russell P. Ornithine Transcarbamylase Deficiency: Diagnostic and Management Challenges in the ICU. J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A young male patient presented with altered sensorium and rapid clinical deterioration following a short period of nonspecific illness and was subsequently diagnosed with ornithine transcarbamylase deficiency (OTCD). We discuss the pathophysiology of OTCD, the difficulties surrounding diagnosis and treatment, and highlight some of the controversies and general management issues of the disease.
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Affiliation(s)
- Philip Watt
- Consultant Anaesthetist with interest in ICM, Lead Clinician for ICU, Kettering General Hospital NHS Foundation Trust
| | - Sabina lordache
- Specialist Trainee Year 3 Anaesthesia, Central Middlesex Hospital, The North West London Hospitals NHS Trust
| | - Philip Russell
- Core Trainee Year 2 Anaesthetics, Pilgrim Hospital, Boston
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Pillai U, Kahlon R, Sondheimer J, Cadnapaphorncai P, Bhat Z. A rare case of hyperammonemia complication of high-protein parenteral nutrition. JPEN J Parenter Enteral Nutr 2012; 37:134-7. [PMID: 22610979 DOI: 10.1177/0148607112447815] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Hyperammonemia is a metabolic derangement that can be potentially fatal. Primary hyperammonemia due to urea cycle enzyme deficiency is usually discovered in neonates but rarely can present in adulthood. Late-onset manifestations of urea cycle disorders can go unnoticed, until they become life threatening. The authors report a 28-year-old man who developed hyperammonemia in the hospital following parenteral nutrition (PN), leading to cerebral edema, which was fatal despite resolution of the hyperammonemia with cessation of PN and the use of continuous renal replacement therapy.
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Abstract
Adult hyperammonaemia is associated with severe liver disease in 90% of cases. In the remainder, noncirrhotic causes should be considered. Measurements of serum ammonia level must be part of the basic work-up in all patients presenting with encephalopathy of unknown origin, even when liver function is normal. Clinician awareness of noncirrhotic hyperammonaemic encephalopathy can contribute to early diagnosis and the initiation of sometimes life-saving treatment. This review focuses on the physiology, aetiology and underlying mechanisms of noncirrhotic hyperammonaemic encephalopathy and discusses the available treatment modalities.
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Affiliation(s)
- Ido Laish
- Department of Internal Medicine A and Rabin Medical Center, Beilinson Hospital, Petah Tiqwa, Israel
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Continuous venovenous hemodiafiltration in severe metabolic acidosis secondary to ethylene glycol ingestion. South Med J 2010; 103:846-7. [PMID: 20622722 DOI: 10.1097/smj.0b013e3181e4c70a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Thurlow VR, Asafu-Adjaye M, Agalou S, Rahman Y. Fatal ammonia toxicity in an adult due to an undiagnosed urea cycle defect: under-recognition of ornithine transcarbamylase deficiency. Ann Clin Biochem 2010; 47:279-81. [PMID: 20406775 DOI: 10.1258/acb.2010.009250] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
There is a lack of awareness of acutely presenting inborn errors of metabolism in adults, of which the X-linked urea cycle defect ornithine transcarbamylase (OTC) deficiency is an example, many comparatively mild mutations having been identified. In male hemizygotes clinical manifestations and age at presentation vary and depend on the mutation. In female heterozygotes the clinical spectrum depends on the extent to which the abnormal gene is expressed. Milder versions of the defect may not cause clear clinical symptoms and may remain unrecognized until the person is subjected to an unusually high nitrogen load when they develop severe hyperammonaemia. During acute episodes liver enzymes may be normal or only slightly elevated and occasionally accompanied by coagulopathy, but the key finding is hyperammonaemia. Boys with these milder forms may exhibit abnormal behaviour and be diagnosed with attention deficit hyperactivity disorder. This case illustrates how late presentation of OTC deficiency in a non-specialist centre can be difficult to differentiate from drug abuse, psychiatric illness or encephalopathy. Failure to measure blood ammonia in adults with unexplained key symptoms - particularly prolonged vomiting without diarrhoea and altered mental state/hallucinations, or to recognize the significance of elevated blood ammonia without evidence of liver decompensation can lead to delayed or missed diagnosis.
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Affiliation(s)
- Vanessa R Thurlow
- Department of Chemical Pathology, St Luke's Hospital, 801 Ostrum Street, Bethlehem, PA 18015, USA.
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Collen JF, Das NP, Koff JM, Neff RT, Abbott KC. Hemodialysis for hyperammonemia associated with ornithine transcarbamylase deficiency. APPLICATION OF CLINICAL GENETICS 2008; 1:1-5. [PMID: 23776342 DOI: 10.2147/tacg.s3536] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Acute hyperammonemia is a medical emergency requiring rapid recognition and treatment to prevent devastating neurologic sequelae. Its varying etiologies include primary hepatic failure, drug toxicity, infection, and inherited disorders of metabolism. Ornithine transcarbamylase (OTC) deficiency is the most common inherited urea cycle disorder and can result in hyperammonemic encephalopathy and coma, often presenting in the newborn or early childhood. Partial deficiencies of the enzyme can present later in adulthood with protean neuropsychiatric signs and symptoms. Early recognition and management of metabolic encephalopathy is crucial to avoid neurologic damage, and may require hemodialysis for rapid removal of ammonia, with adjunctive medications and dietary modifications to decrease endogenous nitrogen production and activate alternate pathways of nitrogen excretion. We present the case of an adult patient with partial OTC deficiency who presented with encephalopathy, coma, and seizures, accompanied by hyperammonemia and treated acutely with hemodialysis.
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Acute hyperammonemic encephalopathy in adult onset ornithine transcarbamylase deficiency. Intensive Care Med 2008; 34:1922-4. [PMID: 18651132 DOI: 10.1007/s00134-008-1217-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Accepted: 06/19/2008] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To report the clinical manifestations of acute hyperammonemic encephalopathy in adult onset ornithine transcarbamylase deficiency (OTCD). DESIGN Case report. SETTING Intensive care unit of a tertiary medical centre. PATIENT A 48-year-old Caucasian male body builder who developed acute loss of consciousness after a febrile illness. INTERVENTIONS The patient was immediately started on hemodia-filtration, protein elimination and ammonia scavenging medications. MEASUREMENTS AND RESULTS Serum ammonium was elevated and plasma and urine amino acids had a pattern indicative of a urea cycle defect. DNA studies revealed a mutation of the urea cycle enzyme, ornithine transcarbamylase. The encephalopathy resolved and the patient slowly recovered though with some cognitive impairment. CONCLUSIONS Adult presentation of OTCD is rare and the mortality and morbidity rates are high. However, survival is possible with rapid correction of hyperammonemia. As the clinical manifestations are non-specific, a high index of suspicion is necessary for the correct diagnosis and management.
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Abstract
INTRODUCTION Urea cycle disorders (UCD) usually present after 24 h to 48 h of life with failure to thrive, lethargy and coma leading to death, but milder forms may occur from infancy to adulthood. STATE OF THE ART Survival of children with UCD has significantly improved and the need for transitional care to adulthood has emerged. Adult onset UCD present with chronic or acute neurological, psychiatric and digestive symptoms associated with protein avoidance. Ornithine transcarbamylase (OTC) deficiency, which is inherited as an X-linked disorder, is the most well-described UCD in adults. Acute decompensations associate the triad of encephalopathy, respiratory alkalosis and hyperammonemia. Acute encephalopathy is characterized by brain edema, which is life-threatening without treatment. Specific urea cycle enzyme deficiency can be suspected in the presence of abnormal plasma amino acids concentrations and urinary excretion of orotic acid. A measurement enzyme activity in appropriate tissue, or DNA analysis if available, is required for diagnosis. Treatment requires restriction of dietary protein intake and the use of alternative pathways of waste nitrogen excretion with sodium benzoate and sodium phenylbutyrate. Patients with acute forms may need hemodialysis or hemodiafiltration. Therapeutic goals for OTC deficiency are to maintain plasma ammonia<80 micromol/L, plasma glutamine<1,000 micromol/L, argininemia 80-150 micromol/L and branched chain amino acids within the normal range, in order to prevent episodes of potentially lethal acute hyperammonemia. CONCLUSION Potentially fatal acute hyperammonemia may occur in male or female patients at any age. Ammonia should be measured promptly in case of acute neurological and psychiatric symptoms or coma.
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Affiliation(s)
- F Maillot
- Service de Médecine Interne et Nutrition, CHRU,Tours, France.
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Abstract
Patients experiencing acute elevations of ammonia present to the ICU with encephalopathy, which may progress quickly to cerebral herniation. Patient survival requires immediate treatment of intracerebral hypertension and the reduction of ammonia levels. When hyperammonemia is not thought to be the result of liver failure, treatment for an occult disorder of metabolism must begin prior to the confirmation of an etiology. This article reviews ammonia metabolism, the effects of ammonia on the brain, the causes of hyperammonemia, and the diagnosis of inborn errors of metabolism in adult patients.
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Affiliation(s)
- Alison S Clay
- Department of Surgery and Medicine, Duke University Medical Center, Box 2945, Durham, NC 27710, USA.
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Abstract
The symptoms and signs of ornithine transcarbamylase deficiency are discussed. When the condition occurs among males in the neonatal period it is likely to be lethal. Pathological findings are non-specific. The diagnosis should be considered if coma with cerebral oedema and respiratory alkalosis occurs for no obvious reason. When hyperammonaemia is found, enzyme assay on a liver biopsy should be considered. A useful clue in an asymptomatic patient is a voluntary adoption of a vegetarian diet. Provocative tests, such as the allopurinol test can be used, but the method most frequently applied is mutation analysis. In the case of prenatal diagnosis this is possible on a chorionic villus sample. The prognosis of ornithine transcarbamylase deficiency is better for those with an onset after infancy, but morbidity from brain damage does not appear to be linked to the number of episodes of hyperammonaemia that have occurred. The syndrome results from a deficiency of the mitochondrial enzyme ornithine transcarbamylase which catalyses the conversion of ornithine and carbamoyl phosphate to citrulline. The gene responsible for this enzyme is located on Xp21.1, and is expressed in the liver and gut. Mutations can be divided into two groups: those with neonatal onset with all enzyme activity abolished, and those with later onset with partial and varying enzyme deficiency. There can be a variety of precipitating causes, for example sodium valproate. Treatment can be given with a low protein diet, and with alternate pathway drugs such as sodium benzoate and phenylbutyrate. Liver transplant can be considered when symptoms are life-threatening, although there may be severe complications.Gene replacement therapy is the hope of the future.
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Augris C, Jouvet P, Benabdelmalek F, Vauquelin P, Caramella JP. [Fulminant coma: think hyperammonemia and urea cycle disorders]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2002; 21:820-3. [PMID: 12534125 DOI: 10.1016/s0750-7658(02)00803-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The authors report the case of 14-year-old boy admitted for acute coma without neurological focal symptom. The only relevant finding was the death of one uncle after a coma in the year 1992. This coma was associated with an ammonia blood level of 344 mumol l-1 and it rapidly lead to cerebral death despite a symptomatic treatment. The diagnosis of hereditary ornithine transcarbamylase deficiency was confirmed by liver biopsy in the immediate post-mortem period. The authors recommend the measurement of blood ammonia in every coma without diagnosis, whatever patient's age.
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Affiliation(s)
- C Augris
- Service d'anesthésie, centre hospitalier de Nevers, avenue Colbert, 58000 Nevers, France
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Legras A, Labarthe F, Maillot F, Garrigue MA, Kouatchet A, Ogier de Baulny H. Late diagnosis of ornithine transcarbamylase defect in three related female patients: polymorphic presentations. Crit Care Med 2002; 30:241-4. [PMID: 11902270 DOI: 10.1097/00003246-200201000-00035] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe three female patients of one family with different phenotypes of the same mutation of the ornithine transcarbamylase gene. X-linked inherited ornithine transcarbamylase deficiency is the most frequent urea cycle disorder. Many of the hemizygous males die during the neonatal period. Women, who are mostly healthy carriers, can also develop symptomatic hyperammonemia. DESIGN Case study. SETTING Intensive care unit and internal medicine unit at a university hospital. PATIENTS The 20-yr-old female propositus was hospitalized for unexplained coma. She had a history of headaches, recurrent vomiting, specific anorexia for high-protein foods, and an acute neurologic crisis with alleged food poisoning 8 yrs before. The present episode began with psychiatric symptoms and seizures treated by diazepam and valproate. This unexplained coma, associated with respiratory alkalosis and major brain swelling on brain computed tomography scan, revealed hyperammonemia leading to the diagnosis of ornithine transcarbamylase deficiency. Continuous venovenous hemodiafiltration and treatment with sodium benzoate and phenylbutyrate improved the situation. However, the patient had some neurologic sequelae. DNA studies have disclosed a pathogenic mutation in the ornithine transcarbamylase gene of the patient, her mother, and her sister. For the mother, the disease was overlooked despite the onset of unusual headaches and neurologic signs that mimicked a cerebral tumor 12 yrs before. The 28-yr-old sister of the propositus has always been asymptomatic, even during pregnancy. CONCLUSIONS Diagnosis of urea cycle disorder should be considered in any patient with unexplained neurologic and psychiatric disorders with selective anorexia, even in adulthood. Unexplained coma with cerebral edema and respiratory alkalosis requires urgent measurement of ammonemia and metabolic work-up.
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Affiliation(s)
- Annick Legras
- Service de reanimation médicale, Hĵpital Bretonneau Tours, France.
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Chen CY, Chen YC, Fang JT, Huang CC. Continuous arteriovenous hemodiafiltration in the acute treatment of hyperammonaemia due to ornithine transcarbamylase deficiency. Ren Fail 2000; 22:823-36. [PMID: 11104170 DOI: 10.1081/jdi-100101968] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Acute hyperammonemia caused by urea cycle disorder is a medical emergency for which immediate managements should be taken to minimize permanent brain damage. Among different enzyme defects, ornithine transcarbamylase deficiency (OTC) is one of the most common enzyme defect in urea cycle disorders. We utilized continuous renal replacement therapy techniques in the acute treatment of hyperammonemia due to ornithine transcarbamylase deficiency. PATIENTS AND METHODS Three male neonates with elevated serum ammonia levels were shown, based on urine organic acid analysis and serum amino acid studies, to have OTC deficiency. Administration of sodium benzoate and sodium phenylacetate for activating alternative nitrogen waste pathway were used associated with protein restriction. Other modalities, including blood exchange transfusion, peritoneal dialysis, continuous renal replacement therapy were utilized in an attempt to lower serum ammonia concentration. RESULTS We report the successful use of continuous arteriovenous hemofiltration (CAVH), continuous arteriovenous hemodialysis (CAVHD), continuous arteriovenous hemodiafiltration (CAVHDF) in the acute management of hyperammonemia due to OTC deficiency. We also compared the ammonia clearance between peritoneal dialysis, exchange transfusion, CAVH, CAVHD and CAVHDF. It demonstrated the evidence that CAVHDF provides the best ammonia clearance. CONCLUSION Continuous renal replacement therapy including CAVH, CAVHD, and CAVHDF may be the alternative techniques for acute management of hyperammonemia in inborn error of metabolism when dialysis machine is not available. Our data suggests CAVHDF provides the best ammonia clearance.
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Affiliation(s)
- C Y Chen
- Department of Pediatrics, Chang Gung Children's Hospital, Taipei, Taiwan
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