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Mishra P, Singh SC, Ramadass B. Drug resistant epilepsy and ketogenic diet: A narrative review of mechanisms of action. World Neurosurg X 2024; 22:100328. [PMID: 38444870 PMCID: PMC10914588 DOI: 10.1016/j.wnsx.2024.100328] [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: 06/27/2023] [Accepted: 02/21/2024] [Indexed: 03/07/2024] Open
Abstract
Drug-resistant epilepsy (DRE) poses a significant global challenge, impacting the well-being of patients. Anti-epileptic drugs often fail to effectively control seizures in individuals with DRE. This condition not only leads to persistent seizures but also induces neurochemical imbalances, elevating the risk of sudden unexpected death in epilepsy and comorbidities. Moreover, patients experience mood and personality alterations, educational and vocational setbacks, social isolation, and cognitive impairments. Ketogenic diet has emerged as a valuable therapeutic approach for DRE, having been utilized since 1920. Various types of ketogenic diets have demonstrated efficacy in controlling seizures. By having a multimodal mechanism of action, the ketogenic diet reduces neuronal excitability and the frequency of seizure episodes. In our narrative review, we have initially provided a concise overview of the factors contributing to drug resistance in epilepsy. Subsequently, we have discussed the different available ketogenic diets. We have reviewed the underlying mechanisms through which the ketogenic diet operates. These mechanisms encompass decreased neuronal excitability, enhanced mitochondrial function, alterations in sleep patterns, and modulation of the gut microbiome. Understanding the complex mechanisms by which this diet acts is essential as it is a rigorous diet and requires good compliance. Hence knowledge of the mechanisms may help to advance research on achieving similar therapeutic effects through other less stringent approaches.
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Affiliation(s)
- Priyadarshini Mishra
- Department of Physiology, All India Institute of Medical Sciences Bhubaneswar, Odisha, India
| | - Sajal Clarence Singh
- Department of Physiology, Institute of Medical Sciences & SUM Hospital, Odisha, India
| | - Balamurugan Ramadass
- Department of Biochemistry, All India Institute of Medical Sciences Bhubaneswar, Odisha, India
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Sijbesma JWA, van Waarde A, Klooster A, Kion I, Slart RHJA, Lammertsma AA, Giacobbo BL, Boersma HH, Dierckx RAJO, van Goor H, Bakker SJL. Caloric restriction reduces proteinuria in male rats with established nephropathy. Physiol Rep 2024; 12:e15942. [PMID: 38439743 PMCID: PMC10912948 DOI: 10.14814/phy2.15942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/15/2024] [Accepted: 01/15/2024] [Indexed: 03/06/2024] Open
Abstract
Reducing proteinuria is a crucial approach in preventing kidney function loss. Previous preclinical studies indicated that caloric restriction (CR) imposed at a young age protects against age-related proteinuria. However, these studies have not explored CR in established renal disease. Therefore, this study aimed to investigate the impact of CR on established proteinuria. Rats, aged 12 ± 2 weeks, were administered 2.1 mg/kg of Adriamycin. Six weeks after injection, protein excretion was measured, and a [13 N]ammonia positron emission tomography (PET) scan was conducted to assess kidney perfusion. After 7 weeks rats were divided into four groups: ad libitum (AL) and CR groups fed either a 12% or a 20% protein diet. All groups were treated for 12 weeks. Blood pressure was measured and a second PET scan was acquired at the end of the study. The animals subjected to CR exhibited a 20.3% decrease in protein excretion (p = 0.003) compared to those in the AL groups. Additionally, blood pressure in the CR group was 21.2% lower (p < 0.001) than in the AL groups. While kidney function declined over time in all groups, the 20% CR group demonstrated the smallest decline. Thus CR effectively reduces urinary protein excretion and lowers blood pressure in rats with established proteinuria.
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Affiliation(s)
- J. W. A. Sijbesma
- Department of Nuclear Medicine and Molecular ImagingUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - A. van Waarde
- Department of Nuclear Medicine and Molecular ImagingUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - A. Klooster
- Department of PathologyPathologie FrieslandLeeuwardenThe Netherlands
| | - I. Kion
- Department of Nuclear Medicine and Molecular ImagingUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - R. H. J. A. Slart
- Department of Nuclear Medicine and Molecular ImagingUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
- Department of Biomedical Photonic Imaging, Faculty of Science and TechnologyUniversity of TwenteEnschedeThe Netherlands
| | - A. A. Lammertsma
- Department of Nuclear Medicine and Molecular ImagingUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - B. Lima Giacobbo
- Department of Nuclear Medicine and Molecular ImagingUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - H. H. Boersma
- Department of Nuclear Medicine and Molecular ImagingUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
- Department of Clinical Pharmacy and PharmacologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - R. A. J. O. Dierckx
- Department of Nuclear Medicine and Molecular ImagingUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - H. van Goor
- Department of Pathology and Medical BiologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - S. J. L. Bakker
- Department of NephrologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
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Falsaperla R, Sortino V, Collotta AD, Privitera GF, Palmeri A, Mauceri L, Ruggieri M. Ketogenic Diet in Neonates with Drug-Resistant Epilepsy: Efficacy and Side Effects-A Single Center's Initial Experience. Neuropediatrics 2023; 54:315-321. [PMID: 37321250 DOI: 10.1055/s-0043-1769505] [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: 06/17/2023]
Abstract
BACKGROUND For patients with pharmacoresistant epilepsy, a therapeutic option is ketogenic diet. Currently, data on young infants are scarce, particularly during hospitalization in the neonatal intensive care unit (NICU). OBJECTIVE The aim of the present study was to evaluate the short-term (3-month) efficacy and side effects of ketogenic diet in infants with "drugs-resistant" epilepsy treated during NICU stay. METHODS This retrospective study included infants aged under 2 months started on ketogenic diet during NICU hospitalization to treat drug-resistant epilepsy from April 2018 to November 2022. RESULTS Thirteen term-born infants were included, three (23.1%) of whom were excluded because they did not respond to the ketogenic diet. Finally, we included 10 infants. Six (60%) patients took three antiepileptics before starting the ketogenic diet, while four (40%) took more drugs. Diet had a good response in four (40%) patients. In four patients, the ketogenic diet was suspended because of the onset of serious side effects. The emetic levels of sodium, potassium, and chlorine, pH, and onset of diarrhea, constipation, and gastroesophageal reflux showed significant differences. Ketonuria was higher and blood pH lower in the group that took more than three drugs than in the group taking fewer than three drugs. CONCLUSION The ketogenic diet is efficacious and safe in infants, but the early and aggressive management of adverse reactions is important to improve the safety and effectiveness of the ketogenic treatment.
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Affiliation(s)
- Raffaele Falsaperla
- Neonatal Intensive Care Unit and Neonatal Accompaniment Unit, Azienda Ospedaliero-Universitaria Policlinico "Rodolico-San Marco," San Marco Hospital, University of Catania, Catania, Italy
- Unit of Pediatrics and Pediatric Emergency, Azienda Ospedaliero-Universitaria Policlinico, "Rodolico-San Marco," San Marco Hospital, Catania, Italy
| | - Vincenzo Sortino
- Unit of Pediatrics and Pediatric Emergency, Azienda Ospedaliero-Universitaria Policlinico, "Rodolico-San Marco," San Marco Hospital, Catania, Italy
- Postgraduate Training Program in Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Ausilia Desiree Collotta
- Unit of Pediatrics and Pediatric Emergency, Azienda Ospedaliero-Universitaria Policlinico, "Rodolico-San Marco," San Marco Hospital, Catania, Italy
- Postgraduate Training Program in Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Grete Francesca Privitera
- Unit of Math and Comp Science, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Antonio Palmeri
- Postgraduate Training Program in Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Laura Mauceri
- Neonatal Intensive Care Unit and Neonatal Accompaniment Unit, Azienda Ospedaliero-Universitaria Policlinico "Rodolico-San Marco," San Marco Hospital, University of Catania, Catania, Italy
| | - Martino Ruggieri
- Unit of Clinical Pediatrics and Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Policlinico Hospital, Catania, Italy
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Oehm S, Steinke K, Schmidt J, Arjune S, Todorova P, Heinrich Lindemann C, Wöstmann F, Meyer F, Siedek F, Weimbs T, Müller RU, Grundmann F. RESET-PKD: a pilot trial on short-term ketogenic interventions in autosomal dominant polycystic kidney disease. Nephrol Dial Transplant 2023; 38:1623-1635. [PMID: 36423335 PMCID: PMC10435930 DOI: 10.1093/ndt/gfac311] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Ketogenic dietary interventions (KDI) have been shown to be effective in animal models of polycystic kidney disease (PKD), but data from clinical trials are lacking. METHODS Ten autosomal dominant PKD (ADPKD) patients with rapid disease progression were enrolled at visit V1 and initially maintained a carbohydrate-rich diet. At V2, patients entered one of the two KDI arms: a 3-day water fast (WF) or a 14-day ketogenic diet (KD). At V3, they resumed their normal diet for 3-6 weeks until V4. At each visit, magnetic resonance imaging kidney and liver volumetry was performed. Ketone bodies were evaluated to assess metabolic efficacy and questionnaires were used to determine feasibility. RESULTS All participants [KD n = 5, WF n = 5; age 39.8 ± 11.6 years; estimated glomerular filtration rate 82 ± 23.5 mL/min/1.73 m2; total kidney volume (TKV) 2224 ± 1156 mL] were classified as Mayo Class 1C-1E. Acetone levels in breath and beta-hydroxybutyrate (BHB) blood levels increased in both study arms (V1 to V2 average acetone: 2.7 ± 1.2 p.p.m., V2 to V3: 22.8 ± 11.9 p.p.m., P = .0006; V1 to V2 average BHB: 0.22 ± 0.08 mmol/L, V2 to V3: 1.88 ± 0.93 mmol/L, P = .0008). Nine of 10 patients reached a ketogenic state and 9/10 evaluated KDIs as feasible. TKV did not change during this trial. However, we found a significant impact on total liver volume (ΔTLV V2 to V3: -7.7%, P = .01), mediated by changes in its non-cystic fraction. CONCLUSIONS RESET-PKD demonstrates that short-term KDIs potently induce ketogenesis and are feasible for ADPKD patients in daily life. While TLV quickly changed upon the onset of ketogenesis, changes in TKV may require longer-term interventions.
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Affiliation(s)
- Simon Oehm
- University of Cologne, Faculty of Medicine and University Hospital, Department 2 of Internal Medicine and Center for Molecular Medicine, Cologne, Germany
| | - Konstantin Steinke
- University of Cologne, Faculty of Medicine and University Hospital, Department 2 of Internal Medicine and Center for Molecular Medicine, Cologne, Germany
| | - Johannes Schmidt
- University of Cologne, Faculty of Medicine and University Hospital, Department 2 of Internal Medicine and Center for Molecular Medicine, Cologne, Germany
| | - Sita Arjune
- University of Cologne, Faculty of Medicine and University Hospital, Department 2 of Internal Medicine and Center for Molecular Medicine, Cologne, Germany
| | - Polina Todorova
- University of Cologne, Faculty of Medicine and University Hospital, Department 2 of Internal Medicine and Center for Molecular Medicine, Cologne, Germany
| | - Christoph Heinrich Lindemann
- University of Cologne, Faculty of Medicine and University Hospital, Department 2 of Internal Medicine and Center for Molecular Medicine, Cologne, Germany
| | - Fabian Wöstmann
- University of Cologne, Faculty of Medicine and University Hospital, Department 2 of Internal Medicine and Center for Molecular Medicine, Cologne, Germany
| | - Franziska Meyer
- University of Cologne, Faculty of Medicine and University Hospital, Institute of Diagnostic and Interventional Radiology, Cologne, Germany
| | - Florian Siedek
- University of Cologne, Faculty of Medicine and University Hospital, Institute of Diagnostic and Interventional Radiology, Cologne, Germany
| | - Thomas Weimbs
- Department of Molecular, Cellular and Developmental Biology and Neuroscience Research Institute, University of California Santa Barbara, Santa Barbara, CA, USA
| | - Roman-Ulrich Müller
- University of Cologne, Faculty of Medicine and University Hospital, Department 2 of Internal Medicine and Center for Molecular Medicine, Cologne, Germany
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Franziska Grundmann
- University of Cologne, Faculty of Medicine and University Hospital, Department 2 of Internal Medicine and Center for Molecular Medicine, Cologne, Germany
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Avila A, Málaga I, Sirsi D, Kayani S, Primeaux S, Kathote GA, Jakkamsetti V, Kallem RR, Putnam WC, Park JY, Shinnar S, Pascual JM. Combination of triheptanoin with the ketogenic diet in Glucose transporter type 1 deficiency (G1D). Sci Rep 2023; 13:8951. [PMID: 37268656 DOI: 10.1038/s41598-023-36001-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 05/27/2023] [Indexed: 06/04/2023] Open
Abstract
Fuel influx and metabolism replenish carbon lost during normal neural activity. Ketogenic diets studied in epilepsy, dementia and other disorders do not sustain such replenishment because their ketone body derivatives contain four carbon atoms and are thus devoid of this anaplerotic or net carbon donor capacity. Yet, in these diseases carbon depletion is often inferred from cerebral fluorodeoxyglucose-positron emission tomography. Further, ketogenic diets may prove incompletely therapeutic. These deficiencies provide the motivation for complementation with anaplerotic fuel. However, there are few anaplerotic precursors consumable in clinically sufficient quantities besides those that supply glucose. Five-carbon ketones, stemming from metabolism of the food supplement triheptanoin, are anaplerotic. Triheptanoin can favorably affect Glucose transporter type 1 deficiency (G1D), a carbon-deficiency encephalopathy. However, the triheptanoin constituent heptanoate can compete with ketogenic diet-derived octanoate for metabolism in animals. It can also fuel neoglucogenesis, thus preempting ketosis. These uncertainties can be further accentuated by individual variability in ketogenesis. Therefore, human investigation is essential. Consequently, we examined the compatibility of triheptanoin at maximum tolerable dose with the ketogenic diet in 10 G1D individuals using clinical and electroencephalographic analyses, glycemia, and four- and five-carbon ketosis. 4 of 8 of subjects with pre-triheptanoin beta-hydroxybutyrate levels greater than 2 mM demonstrated a significant reduction in ketosis after triheptanoin. Changes in this and the other measures allowed us to deem the two treatments compatible in the same number of individuals, or 50% of persons in significant beta-hydroxybutyrate ketosis. These results inform the development of individualized anaplerotic modifications to the ketogenic diet.ClinicalTrials.gov registration NCT03301532, first registration: 04/10/2017.
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Affiliation(s)
- Adrian Avila
- Rare Brain Disorders Program, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390, USA
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Ignacio Málaga
- Rare Brain Disorders Program, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390, USA
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Deepa Sirsi
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Saima Kayani
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Sharon Primeaux
- Rare Brain Disorders Program, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390, USA
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Gauri A Kathote
- Rare Brain Disorders Program, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390, USA
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Vikram Jakkamsetti
- Rare Brain Disorders Program, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390, USA
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Raja Reddy Kallem
- Department of Pharmacy Practice and Clinical Pharmacology, Experimental Therapeutics Center, Texas Tech University Health Sciences Center, Dallas, TX, 75235, USA
| | - William C Putnam
- Department of Pharmacy Practice and Clinical Pharmacology, Experimental Therapeutics Center, Texas Tech University Health Sciences Center, Dallas, TX, 75235, USA
- Department of Pharmaceutical Science, Texas Tech University Health Sciences Center, Dallas, TX, 75235, USA
| | - Jason Y Park
- Department of Pathology, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Shlomo Shinnar
- Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Bronx, NY, 10467, USA
| | - Juan M Pascual
- Rare Brain Disorders Program, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390, USA.
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA.
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA.
- Department of Physiology, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA.
- Eugene McDermott Center for Human Growth & Development/Center for Human Genetics, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA.
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de Brito Sampaio LP, Henriques-Souza AMDM, Lin K, Neri LDCL, Inuzuka LM, Uchôa LIDL, Gregório MMDO, Guilhoto LM, Montenegro MA, Lunardi M, Veiga M, de Lima PA, Braatz V. Ketogenic therapy in childhood and adolescence: recommendations of the Brazilian experts group. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:597-606. [PMID: 37379871 PMCID: PMC10658610 DOI: 10.1055/s-0043-1768676] [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: 11/17/2022] [Accepted: 02/15/2023] [Indexed: 06/30/2023]
Abstract
Ketogenic dietary therapies (KDTs) are a safe and effective treatment for pharmacoresistant epilepsy in children. There are four principal types of KDTs: the classic KD, the modified Atkins diet (MAD), the medium-chain triglyceride (MCT) diet, and the low glycemic index diet (LGID). The International Ketogenic Diet Study Group recommends managing KDTs in children with epilepsy. However, there are no guidelines that address the specific needs of the Brazilian population. Thus, the Brazilian Child Neurology Association elaborated on these recommendations with the goal of stimulating and expanding the use of the KD in Brazil.
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Affiliation(s)
- Letícia Pereira de Brito Sampaio
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas,
Instituto da Criança e Adolescente, São Paulo SP, Brazil.
| | | | - Katia Lin
- Universidade Federal de Santa Catarina, Departamento de Medicina Interna,
Divisão de Neurologia, Florianópolis SC, Brazil.
| | - Lenycia de Cassya Lopes Neri
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas,
Instituto da Criança e Adolescente, São Paulo SP, Brazil.
| | | | | | | | - Laura Maria Guilhoto
- Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo,
Brazil.
- Universidade de São Paulo, Hospital Universitário, Divisão de Clínica
Pediátrica, São Paulo SP, Brazil.
| | | | - Mariana Lunardi
- Universidade Federal de Santa Catarina, Programa de Pós-Graduação em Ciências
Médicas, Florianópolis SC, Brazil.
| | - Marielza Veiga
- Hospital Universitário Professor Edgard Santos, Salvador BA,
Brazil.
| | | | - Vera Braatz
- Universidade da Região de Joinville, Departamento de Medicina, Divisão de
Neurologia, Joinville SC, Brazil.
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Maximum dose, safety, tolerability and ketonemia after triheptanoin in glucose transporter type 1 deficiency (G1D). Sci Rep 2023; 13:3465. [PMID: 36859467 PMCID: PMC9977760 DOI: 10.1038/s41598-023-30578-z] [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: 01/05/2023] [Accepted: 02/27/2023] [Indexed: 03/03/2023] Open
Abstract
Augmentation of anaplerosis, or replenishment of carbon lost during intermediary metabolic transitions, is desirable in energy metabolism defects. Triheptanoin, the triglyceride of 7-carbon heptanoic acid, is anaplerotic via direct oxidation or 5-carbon ketone body generation. In this context, triheptanoin can be used to treat Glucose transporter type 1 deficiency encephalopathy (G1D). An oral triheptanoin dose of 1 g/Kg/day supplies near 35% of the total caloric intake and impacted epilepsy and cognition in G1D. This provided the motivation to establish a maximum, potentially greater dose. Using a 3 + 3 dose-finding approach useful in oncology, we studied three age groups: 4-6, 6.8-10 and 11-16 years old. This allowed us to arrive at a maximum tolerated dose of 45% of daily caloric intake for each group. Safety was ascertained via analytical blood measures. One dose-limiting toxicity, occurring in 1 of 6 subjects, was encountered in the middle age group in the context of frequently reduced gastrointestinal tolerance for all groups. Ketonemia following triheptanoin was determined in another group of G1D subjects. In them, β-ketopentanoate and β-hydroxypentanoate concentrations were robustly but variably increased. These results enable the rigorous clinical investigation of triheptanoin in G1D by providing dosing and initial tolerability, safety and ketonemic potential.ClinicalTrials.gov registration: NCT03041363, first registration 02/02/2017.
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Kumar A, Kumari S, Singh D. Insights into the Cellular Interactions and Molecular Mechanisms of Ketogenic Diet for Comprehensive Management of Epilepsy. Curr Neuropharmacol 2022; 20:2034-2049. [PMID: 35450526 PMCID: PMC9886834 DOI: 10.2174/1570159x20666220420130109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 01/27/2022] [Accepted: 03/25/2022] [Indexed: 11/22/2022] Open
Abstract
A high-fat diet with appropriate protein and low carbohydrate content, widely known as the ketogenic diet (KD), is considered as an effective non-pharmacotherapeutic treatment option for certain types of epilepsies. Several preclinical and clinical studies have been carried out to elucidate its mechanism of antiepileptic action. Ketone bodies produced after KD's breakdown interact with cellular excito-inhibitory processes and inhibit abnormal neuronal firing. The generated ketone bodies decrease glutamate release by inhibiting the vesicular glutamate transporter 1 and alter the transmembrane potential by hyperpolarization. Apart from their effect on the well-known pathogenic mechanisms of epilepsy, some recent studies have shown the interaction of KD metabolites with novel neuronal targets, particularly adenosine receptors, adenosine triphosphate-sensitive potassium channel, mammalian target of rapamycin, histone deacetylase, hydroxycarboxylic acid receptors, and the NLR family pyrin domain containing 3 inflammasomes to suppress seizures. The role of KD in augmenting gut microbiota as a potential mechanism for epileptic seizure suppression has been established. Furthermore, some recent findings also support the beneficial effect of KD against epilepsy- associated comorbidities. Despite several advantages of the KD in epilepsy management, its use is also associated with a wide range of side effects. Hypoglycemia, excessive ketosis, acidosis, renal stones, cardiomyopathies, and other metabolic disturbances are the primary adverse effects observed with the use of KD. However, in some recent studies, modified KD has been tested with lesser side effects and better tolerability. The present review discusses the molecular mechanism of KD and its role in managing epilepsy and its associated comorbidities.
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Affiliation(s)
- Amit Kumar
- Pharmacology and Toxicology Laboratory, Dietetics and Nutrition Technology Division, CSIR- Institute of Himalayan Bioresource Technology, Palampur 176061, Himachal Pradesh, India; ,Academy of Scientific and Innovative Research (AcSIR), Ghaziabad-201002, India
| | - Savita Kumari
- Pharmacology and Toxicology Laboratory, Dietetics and Nutrition Technology Division, CSIR- Institute of Himalayan Bioresource Technology, Palampur 176061, Himachal Pradesh, India; ,Academy of Scientific and Innovative Research (AcSIR), Ghaziabad-201002, India
| | - Damanpreet Singh
- Pharmacology and Toxicology Laboratory, Dietetics and Nutrition Technology Division, CSIR- Institute of Himalayan Bioresource Technology, Palampur 176061, Himachal Pradesh, India; ,Academy of Scientific and Innovative Research (AcSIR), Ghaziabad-201002, India,Address correspondence to this author at the Pharmacology and Toxicology Laboratory, Dietetics and Nutrition Technology Division, CSIR-Institute of Himalayan Bioresource Technology, Palampur-176061, Himachal Pradesh, India; Tel: +91-9417923132; E-mails: ;
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Lkhagva B, Lee TW, Lin YK, Chen YC, Chung CC, Higa S, Chen YJ. Disturbed Cardiac Metabolism Triggers Atrial Arrhythmogenesis in Diabetes Mellitus: Energy Substrate Alternate as a Potential Therapeutic Intervention. Cells 2022; 11:cells11182915. [PMID: 36139490 PMCID: PMC9497243 DOI: 10.3390/cells11182915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/10/2022] [Accepted: 09/16/2022] [Indexed: 11/20/2022] Open
Abstract
Atrial fibrillation (AF) is the most common type of sustained arrhythmia in diabetes mellitus (DM). Its morbidity and mortality rates are high, and its prevalence will increase as the population ages. Despite expanding knowledge on the pathophysiological mechanisms of AF, current pharmacological interventions remain unsatisfactory; therefore, novel findings on the underlying mechanism are required. A growing body of evidence suggests that an altered energy metabolism is closely related to atrial arrhythmogenesis, and this finding engenders novel insights into the pathogenesis of the pathophysiology of AF. In this review, we provide comprehensive information on the mechanistic insights into the cardiac energy metabolic changes, altered substrate oxidation rates, and mitochondrial dysfunctions involved in atrial arrhythmogenesis, and suggest a promising advanced new therapeutic approach to treat patients with AF.
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Affiliation(s)
- Baigalmaa Lkhagva
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Ting-Wei Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei 11696, Taiwan
| | - Yung-Kuo Lin
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Yao-Chang Chen
- Department of Biomedical Engineering, National Defense Medical Center, Taipei 11490, Taiwan
| | - Cheng-Chih Chung
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Satoshi Higa
- Cardiac Electrophysiology and Pacing Laboratory, Division of Cardiovascular Medicine, Makiminato Central Hospital, Okinawa 901-2131, Japan
| | - Yi-Jen Chen
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Cardiovascular Research Center, Wan-Fang Hospital, Taipei Medical University, Taipei 11696, Taiwan
- Correspondence:
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10
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A Review of the Multi-Systemic Complications of a Ketogenic Diet in Children and Infants with Epilepsy. CHILDREN 2022; 9:children9091372. [PMID: 36138681 PMCID: PMC9498174 DOI: 10.3390/children9091372] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 09/08/2022] [Accepted: 09/08/2022] [Indexed: 11/23/2022]
Abstract
Ketogenic diets (KDs) are highly effective in the treatment of epilepsy. However, numerous complications have been reported. During the initiation phase of the diet, common side effects include vomiting, hypoglycemia, metabolic acidosis and refusal of the diet. While on the diet, the side effects involve the following systems: gastrointestinal, hepatic, cardiovascular, renal, dermatological, hematologic and bone. Many of the common side effects can be tackled easily with careful monitoring including blood counts, liver enzymes, renal function tests, urinalysis, vitamin levels, mineral levels, lipid profiles, and serum carnitine levels. Some rare and serious side effects reported in the literature include pancreatitis, protein-losing enteropathy, prolonged QT interval, cardiomyopathy and changes in the basal ganglia. These serious complications may need more advanced work-up and immediate cessation of the diet. With appropriate monitoring and close follow-up to minimize adverse effects, KDs can be effective for patients with intractable epilepsy.
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11
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Dietary Treatments for Epilepsy. Neurol Clin 2022; 40:785-797. [DOI: 10.1016/j.ncl.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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12
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Manolis AS, Manolis TA, Manolis AA, Melita H. Diet and Sudden Death: How to Reduce the Risk. Curr Vasc Pharmacol 2022; 20:383-408. [PMID: 35726434 DOI: 10.2174/1570161120666220621090343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/13/2022] [Accepted: 05/20/2022] [Indexed: 01/25/2023]
Abstract
In addition to the association of dietary patterns, specific foods and nutrients with several diseases, including cardiovascular disease and mortality, there is also strong emerging evidence of an association of dietary patterns with the risk of sudden cardiac death (SCD). In this comprehensive review, data are presented and analyzed about foods and diets that mitigate the risk of ventricular arrhythmias (VAs) and SCD, but also about arrhythmogenic nutritional elements and patterns that seem to enhance or facilitate potentially malignant VAs and SCD. The antiarrhythmic or protective group comprises fish, nuts and other foods enriched in omega-3 polyunsaturated fatty acids, the Mediterranean and other healthy diets, vitamins E, A and D and certain minerals (magnesium, potassium, selenium). The arrhythmogenic-food group includes saturated fat, trans fats, ketogenic and liquid protein diets, the Southern and other unhealthy diets, energy drinks and excessive caffeine intake, as well as heavy alcohol drinking. Relevant antiarrhythmic mechanisms include modification of cell membrane structure by n-3 polyunsaturated fatty acids, their direct effect on calcium channels and cardiomyocytes and their important role in eicosanoid metabolism, enhancing myocyte electric stability, reducing vulnerability to VAs, lowering heart rate, and improving heart rate variability, each of which is a risk factor for SCD. Contrarily, saturated fat causes calcium handling abnormalities and calcium overload in cardiomyocytes, while a high-fat diet causes mitochondrial dysfunction that dysregulates a variety of ion channels promoting VAs and SCD. Free fatty acids have been considered proarrhythmic and implicated in facilitating SCD; thus, diets increasing free fatty acids, e.g., ketogenic diets, should be discouraged and replaced with diets enriched with polyunsaturated fatty acids, which can also reduce free fatty acids. All available relevant data on this important topic are herein reviewed, large studies and meta-analyses and pertinent advisories are tabulated, while protective (antiarrhythmic) and arrhythmogenic specific diet constituents are pictorially illustrated.
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Affiliation(s)
- Antonis S Manolis
- First Department of Cardiology, Athens University School of Medicine, Athens, Greece
| | | | | | - Helen Melita
- Central Laboratories, Onassis Cardiac Surgery Center, Athens, Greece
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13
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Zhu H, Bi D, Zhang Y, Kong C, Du J, Wu X, Wei Q, Qin H. Ketogenic diet for human diseases: the underlying mechanisms and potential for clinical implementations. Signal Transduct Target Ther 2022; 7:11. [PMID: 35034957 PMCID: PMC8761750 DOI: 10.1038/s41392-021-00831-w] [Citation(s) in RCA: 84] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/21/2021] [Accepted: 11/09/2021] [Indexed: 02/06/2023] Open
Abstract
The ketogenic diet (KD) is a high-fat, adequate-protein, and very-low-carbohydrate diet regimen that mimics the metabolism of the fasting state to induce the production of ketone bodies. The KD has long been established as a remarkably successful dietary approach for the treatment of intractable epilepsy and has increasingly garnered research attention rapidly in the past decade, subject to emerging evidence of the promising therapeutic potential of the KD for various diseases, besides epilepsy, from obesity to malignancies. In this review, we summarize the experimental and/or clinical evidence of the efficacy and safety of the KD in different diseases, and discuss the possible mechanisms of action based on recent advances in understanding the influence of the KD at the cellular and molecular levels. We emphasize that the KD may function through multiple mechanisms, which remain to be further elucidated. The challenges and future directions for the clinical implementation of the KD in the treatment of a spectrum of diseases have been discussed. We suggest that, with encouraging evidence of therapeutic effects and increasing insights into the mechanisms of action, randomized controlled trials should be conducted to elucidate a foundation for the clinical use of the KD.
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Affiliation(s)
- Huiyuan Zhu
- Department of Pathology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Dexi Bi
- Department of Pathology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Youhua Zhang
- Department of Pathology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Cheng Kong
- Research Institute of Intestinal Diseases, Tongji University School of Medicine, Shanghai, China
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jiahao Du
- Research Institute of Intestinal Diseases, Tongji University School of Medicine, Shanghai, China
| | - Xiawei Wu
- Research Institute of Intestinal Diseases, Tongji University School of Medicine, Shanghai, China
- Shanghai Clinical College, Anhui Medical University, Hefei, China
| | - Qing Wei
- Department of Pathology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.
| | - Huanlong Qin
- Research Institute of Intestinal Diseases, Tongji University School of Medicine, Shanghai, China.
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.
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14
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Taha A, Ahmed S, Ahmed Mbbs R, Mohammed Md A. Type 2 Myocardial Infarction Related to Very Low Carbohydrate Ketogenic Diet. J Investig Med High Impact Case Rep 2022; 10:23247096221074879. [PMID: 35272529 PMCID: PMC8921742 DOI: 10.1177/23247096221074879] [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] [Indexed: 12/07/2022] Open
Abstract
A 38-year-old male with no history of cardiac disease presented with chest pain typical of acute coronary syndrome. He assumed very-low-carbohydrate ketogenic diet (VLC-KD) 4 weeks prior to admission but no other lifestyle change. Workup showed dynamic ST-T changes on electrocardiogram, significantly elevated troponins, ketonuria, and mild rhabdomyolysis. Transthoracic echocardiogram revealed mild inferior wall hypokinesia and cardiac catheterization showed normal coronaries; hence, the diagnosis of type II myocardial infarction (MI) was established. Although the pathogenesis remains unclear, this temporal association between VLC-KD and type 2 MI raised some concerns about VLC-KD’s cardiovascular safety profile.
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Affiliation(s)
- Ahmed Taha
- School of Medicine, Indiana University, Indianapolis, IN, USA.,Deaconess Hospital, Evansville, IN, USA
| | - Selma Ahmed
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Roaa Ahmed Mbbs
- School of Medicine, Ahfad University for Women, Omdurman, Sudan
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15
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Calcaterra V, Verduci E, Pascuzzi MC, Magenes VC, Fiore G, Di Profio E, Tenuta E, Bosetti A, Todisco CF, D'Auria E, Zuccotti G. Metabolic Derangement in Pediatric Patient with Obesity: The Role of Ketogenic Diet as Therapeutic Tool. Nutrients 2021; 13:2805. [PMID: 34444964 PMCID: PMC8400548 DOI: 10.3390/nu13082805] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/22/2021] [Accepted: 08/12/2021] [Indexed: 12/11/2022] Open
Abstract
Obesity is defined as a condition characterized by an excessive fat accumulation that has negative health consequences. Pediatric obesity is associated with an increased risk for many diseases, including impaired glycemic and lipidic control that may lead to the development of chronic, and potentially disabling, pathologies, such as type 2 diabetes mellitus (T2DM) and cardiovascular events, in adult life. The therapeutic strategy initially starts with interventions that are aimed at changing lifestyle and eating behavior, to prevent, manage, and potentially reverse metabolic disorders. Recently, the ketogenic diet (KD) has been proposed as a promising dietary intervention for the treatment of metabolic and cardiovascular risk factors related to obesity in adults, and a possible beneficial role has also been proposed in children. KD is very low in carbohydrate, high in fat, and moderate to high in protein that may have the potential to promote weight loss and improve lipidic derangement, glycemic control, and insulin sensitivity. In this review, we present metabolic disorders on glycemic and lipidic control in children and adolescents with obesity and indication of KD in pediatrics, discussing the role of KD as a therapeutic tool for metabolic derangement. The results of this review may suggest the validity of KD and the need to further research its potential to address metabolic risk factors in pediatric obesity.
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Affiliation(s)
- Valeria Calcaterra
- Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
| | - Elvira Verduci
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
- Department of Health Sciences, University of Milano, 20142 Milano, Italy
| | - Martina Chiara Pascuzzi
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
- Department of Biomedical and Clinical Science "L. Sacco", University of Milan, 20157 Milan, Italy
| | - Vittoria Carlotta Magenes
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
- Department of Biomedical and Clinical Science "L. Sacco", University of Milan, 20157 Milan, Italy
| | - Giulia Fiore
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
- Department of Health Sciences, University of Milano, 20142 Milano, Italy
| | - Elisabetta Di Profio
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
- Department of Biomedical and Clinical Science "L. Sacco", University of Milan, 20157 Milan, Italy
| | - Elisavietta Tenuta
- Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
| | - Alessandra Bosetti
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
| | - Carolina Federica Todisco
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
- Department of Biomedical and Clinical Science "L. Sacco", University of Milan, 20157 Milan, Italy
| | - Enza D'Auria
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
- Department of Biomedical and Clinical Science "L. Sacco", University of Milan, 20157 Milan, Italy
| | - Gianvincenzo Zuccotti
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
- Department of Biomedical and Clinical Science "L. Sacco", University of Milan, 20157 Milan, Italy
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16
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Impact of Dietary Factors on Brugada Syndrome and Long QT Syndrome. Nutrients 2021; 13:nu13082482. [PMID: 34444641 PMCID: PMC8401538 DOI: 10.3390/nu13082482] [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: 06/24/2021] [Revised: 07/16/2021] [Accepted: 07/19/2021] [Indexed: 12/14/2022] Open
Abstract
A healthy regime is fundamental for the prevention of cardiovascular diseases (CVD). In inherited channelopathies, such as Brugada syndrome (BrS) and Long QT syndrome (LQTS), unfortunately, sudden cardiac death could be the first sign for patients affected by these syndromes. Several known factors are used to stratify the risk of developing cardiac arrhythmias, although none are determinative. The risk factors can be affected by adjusting lifestyle habits, such as a particular diet, impacting the risk of arrhythmogenic events and mortality. To date, the importance of understanding the relationship between diet and inherited channelopathies has been underrated. Therefore, we describe herein the effects of dietary factors on the development of arrhythmia in patients affected by BrS and LQTS. Modifying the diet might not be enough to fully prevent arrhythmias, but it can help lower the risk.
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17
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Mierziak J, Burgberger M, Wojtasik W. 3-Hydroxybutyrate as a Metabolite and a Signal Molecule Regulating Processes of Living Organisms. Biomolecules 2021; 11:biom11030402. [PMID: 33803253 PMCID: PMC8000602 DOI: 10.3390/biom11030402] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 02/06/2023] Open
Abstract
3-hydroxybutyrate (3-HB) as a very important metabolite occurs in animals, bacteria and plants. It is well known that in animals, 3-HB is formed as a product of the normal metabolism of fatty acid oxidation and can therefore be used as an energy source in the absence of sufficient blood glucose. In microorganisms, 3-HB mainly serves as a substrate for the synthesis of polyhydroxybutyrate, which is a reserve material. Recent studies show that in plants, 3-HB acts as a regulatory molecule that most likely influences the expression of genes involved in DNA methylation, thereby altering DNA methylation levels. Additionally, in animals, 3-HB is not only an intermediate metabolite, but also an important regulatory molecule that can influence gene expression, lipid metabolism, neuronal function, and overall metabolic rate. Some of these effects are the direct effects of 3-HB itself, while others are indirect effects, regulated by the metabolites into which 3-HB is converted. One of the most important regulatory functions of 3-HB is the inhibition of the activity of histone deacetylases and thus the epigenetic regulation of many genes. Due to the number of functions of this compound, it also shows promising therapeutic properties.
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18
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Xu S, Tao H, Cao W, Cao L, Lin Y, Zhao SM, Xu W, Cao J, Zhao JY. Ketogenic diets inhibit mitochondrial biogenesis and induce cardiac fibrosis. Signal Transduct Target Ther 2021; 6:54. [PMID: 33558457 PMCID: PMC7870678 DOI: 10.1038/s41392-020-00411-4] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/31/2020] [Accepted: 11/03/2020] [Indexed: 02/05/2023] Open
Abstract
In addition to their use in relieving the symptoms of various diseases, ketogenic diets (KDs) have also been adopted by healthy individuals to prevent being overweight. Herein, we reported that prolonged KD exposure induced cardiac fibrosis. In rats, KD or frequent deep fasting decreased mitochondrial biogenesis, reduced cell respiration, and increased cardiomyocyte apoptosis and cardiac fibrosis. Mechanistically, increased levels of the ketone body β-hydroxybutyrate (β-OHB), an HDAC2 inhibitor, promoted histone acetylation of the Sirt7 promoter and activated Sirt7 transcription. This in turn inhibited the transcription of mitochondrial ribosome-encoding genes and mitochondrial biogenesis, leading to cardiomyocyte apoptosis and cardiac fibrosis. Exogenous β-OHB administration mimicked the effects of a KD in rats. Notably, increased β-OHB levels and SIRT7 expression, decreased mitochondrial biogenesis, and increased cardiac fibrosis were detected in human atrial fibrillation heart tissues. Our results highlighted the unknown detrimental effects of KDs and provided insights into strategies for preventing cardiac fibrosis in patients for whom KDs are medically necessary.
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Affiliation(s)
- Sha Xu
- Zhongshan Hospital of Fudan University, Obstetrics & Gynecology Hospital of Fudan University, State Key Lab of Genetic Engineering, School of Life Sciences, Key Laboratory of Reproduction Regulation of NPFPC, and Institutes of Biomedical Sciences, Fudan University, 200438, Shanghai, China.,Collaborative Innovation Center for Biotherapy, West China Hospital, Sichuan University, 610041, Chengdu, China
| | - Hui Tao
- Department of Cardiothoracic Surgery, Second Hospital of Anhui Medical University, and Cardiovascular Research Center, Anhui Medical University, 230601, Hefei, China
| | - Wei Cao
- Department of Cardiothoracic Surgery, Second Hospital of Anhui Medical University, and Cardiovascular Research Center, Anhui Medical University, 230601, Hefei, China
| | - Li Cao
- Zhongshan Hospital of Fudan University, Obstetrics & Gynecology Hospital of Fudan University, State Key Lab of Genetic Engineering, School of Life Sciences, Key Laboratory of Reproduction Regulation of NPFPC, and Institutes of Biomedical Sciences, Fudan University, 200438, Shanghai, China
| | - Yan Lin
- Zhongshan Hospital of Fudan University, Obstetrics & Gynecology Hospital of Fudan University, State Key Lab of Genetic Engineering, School of Life Sciences, Key Laboratory of Reproduction Regulation of NPFPC, and Institutes of Biomedical Sciences, Fudan University, 200438, Shanghai, China
| | - Shi-Min Zhao
- Zhongshan Hospital of Fudan University, Obstetrics & Gynecology Hospital of Fudan University, State Key Lab of Genetic Engineering, School of Life Sciences, Key Laboratory of Reproduction Regulation of NPFPC, and Institutes of Biomedical Sciences, Fudan University, 200438, Shanghai, China.,Collaborative Innovation Center for Biotherapy, West China Hospital, Sichuan University, 610041, Chengdu, China
| | - Wei Xu
- Zhongshan Hospital of Fudan University, Obstetrics & Gynecology Hospital of Fudan University, State Key Lab of Genetic Engineering, School of Life Sciences, Key Laboratory of Reproduction Regulation of NPFPC, and Institutes of Biomedical Sciences, Fudan University, 200438, Shanghai, China.,Collaborative Innovation Center for Biotherapy, West China Hospital, Sichuan University, 610041, Chengdu, China
| | - Jing Cao
- Department of Anatomy and Neuroscience Research Institute, School of Basic Medical Sciences, Zhengzhou University, 450001, Zhengzhou, China
| | - Jian-Yuan Zhao
- Zhongshan Hospital of Fudan University, Obstetrics & Gynecology Hospital of Fudan University, State Key Lab of Genetic Engineering, School of Life Sciences, Key Laboratory of Reproduction Regulation of NPFPC, and Institutes of Biomedical Sciences, Fudan University, 200438, Shanghai, China. .,Collaborative Innovation Center for Biotherapy, West China Hospital, Sichuan University, 610041, Chengdu, China. .,Department of Anatomy and Neuroscience Research Institute, School of Basic Medical Sciences, Zhengzhou University, 450001, Zhengzhou, China.
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19
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Perez MM, Medar S, Quigley L, Clark BC. QTc Prolongation in Pediatric Patients with Diabetic Ketoacidosis. J Pediatr 2021; 228:235-239.e2. [PMID: 32890580 DOI: 10.1016/j.jpeds.2020.08.085] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/25/2020] [Accepted: 08/27/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To investigate the association between diabetic ketoacidosis (DKA) and prolonged QTc interval and to assess for correlation between DKA severity and QTc prolongation. STUDY DESIGN Retrospective observational study in a pediatric hospital. Patients admitted with DKA diagnosed by laboratory criteria and an electrocardiogram (ECG) performed during a period of acidosis were identified using Looking Glass Clinical Analytics. Data including age, sex, pH, electrolytes, anion gap, and ECG variables were collected. Patients were excluded if they had a prior diagnosis of prolonged QTc or were taking QTc prolonging medications. Severity of DKA was classified as mild (pH 7.24-7.3), moderate (pH 7-7.24), or severe (pH <7). ECGs were read by a pediatric electrophysiologist and QTc interval was manually calculated utilizing the Bazett formula. RESULTS Ninety-six patients were included (mean age 15.2 ± 4.2 years, pH 7.12 ± 0.12, bicarbonate 8.6 ± 3.7 mmol/L, potassium 5.3 ± 1.1 mEq/L). Mean QTc interval for all patients in DKA was 454 ± 32 msec. Mean QTc in the mild group was 441 ± 22 msec, moderate group 460 ± 36 msec, and severe group 461 ± 34 msec. There was a significant difference in QTc interval across DKA severity groups (P = .05). There was a significant association between higher anion gaps and greater QTc intervals (r = 0.21, P = .04). CONCLUSIONS Thirty-one percent of pediatric patients with DKA demonstrated QTc prolongation on ECG. Severity of DKA and worsening acidosis were associated with increased prolongation of the QTc. Further study is required to evaluate the clinical impact of these findings.
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Affiliation(s)
- Michelle M Perez
- Division of Pediatric Critical Care, Children's Hospital at Montefiore, Bronx, NY.
| | - Shivanand Medar
- Division of Pediatric Critical Care, Children's Hospital at Montefiore, Bronx, NY; Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY
| | - Leanne Quigley
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
| | - Bradley C Clark
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY; Division of Cardiology, Children's Hospital at Montefiore, Bronx, NY
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20
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Conover ZR, Talai A, Klockau KS, Ing RJ, Chatterjee D. Perioperative Management of Children on Ketogenic Dietary Therapies. Anesth Analg 2020; 131:1872-1882. [PMID: 32769381 DOI: 10.1213/ane.0000000000005018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Ketogenic diet therapy (KDT) is an effective treatment modality for children with drug-resistant epilepsy and certain other metabolic and neurologic disorders. With a resurgence of interest in KDT, pediatric anesthesiologists are increasingly encountering children on KDT for a variety of surgical and medical procedures. Maintenance of ketosis is critical throughout the perioperative period, and if not managed appropriately, these patients are at an increased risk of seizures. This review article provides an overview of the clinical indications, contraindications, proposed anticonvulsant mechanisms, initiation, and monitoring of children on KDTs. Recommendations for the perioperative anesthetic management of children on KDT are summarized. A comprehensive table listing the carbohydrate content of common anesthetic drugs is also included.
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Affiliation(s)
| | | | - Katherine S Klockau
- Pharmacy, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
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21
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D'Souza MS, Dong TA, Ragazzo G, Dhindsa DS, Mehta A, Sandesara PB, Freeman AM, Taub P, Sperling LS. From Fad to Fact: Evaluating the Impact of Emerging Diets on the Prevention of Cardiovascular Disease. Am J Med 2020; 133:1126-1134. [PMID: 32569590 DOI: 10.1016/j.amjmed.2020.05.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 02/06/2023]
Abstract
Cardiovascular disease remains one of the most prevalent and preventable chronic conditions worldwide. Diet modification is the foundation of cardiovascular disease prevention. Several dietary approaches have emerged to promote better cardiovascular health. The rapid dissemination of anecdotal and observational data through the internet and social media has caused confusion amongst providers and patients. The aim of this comprehensive review is to present objective insights into 2 of today's most popular fad diets: ketogenic diet and intermittent fasting. We will evaluate the performance of these diets based on their impact on cardiovascular risk factors.
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Affiliation(s)
- Melroy S D'Souza
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, Ga
| | - Tiffany A Dong
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, Ga
| | | | - Devinder S Dhindsa
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, Ga
| | - Anurag Mehta
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, Ga
| | - Pratik B Sandesara
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, Ga
| | - Andrew M Freeman
- Division of Cardiology, Department of Medicine, National Jewish Health, Denver, Colo
| | - Pam Taub
- Stepfamily Foundation Cardiovascular Wellness and Rehabilitation Center, Division of Cardiovascular Medicine, University of California San Diego
| | - Laurence S Sperling
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, Ga.
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22
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Wells J, Swaminathan A, Paseka J, Hanson C. Efficacy and Safety of a Ketogenic Diet in Children and Adolescents with Refractory Epilepsy-A Review. Nutrients 2020; 12:nu12061809. [PMID: 32560503 PMCID: PMC7353240 DOI: 10.3390/nu12061809] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/11/2020] [Accepted: 06/15/2020] [Indexed: 02/06/2023] Open
Abstract
Epilepsy in the pediatric and adolescent populations is a devastating condition where individuals are prone to recurrent epileptic seizures or changes in behavior or movement that is the direct result of a primary change in the electrical activity in the brain. Although many children with epilepsy will have seizures controlled with antiseizure medications (ASMs), a large percentage of patients are refractory to drug therapy and may consider initiating a ketogenic diet. The term Ketogenic Diet or Ketogenic Diet Therapy (KDT) refers to any diet therapy in which dietary composition results in a ketogenic state of human metabolism. Currently, there are 4 major Ketogenic diet therapies—the classic ketogenic diet (cKD), the modified Atkins diet (MAD), the medium chain triglyceride ketogenic diet (MCTKD) and the low glycemic index treatment (LGIT). The compositions of the 4 main KDTs differ and limited evidence to distinguish the efficacy among different diets currently exists. Although it is apparent that more randomized controlled trials (RCTs) and long-term studies are needed to evaluate efficacy, side effects and individual response to the diet, it is imperative to study and understand the metabolic profiles of patients with epilepsy in order to isolate which dietary restrictions are necessary to maximize clinical benefit.
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Affiliation(s)
- Jana Wells
- College of Allied Health Professions, University of Nebraska Medical Center, 984045 Nebraska Medical Center, Omaha, NE 68198-4045, USA;
- Correspondence:
| | - Arun Swaminathan
- Department of Neurological Sciences, University of Nebraska Medical Center, 988440 Nebraska Medical Center, Omaha, NE 68198-8440, USA;
| | - Jenna Paseka
- Department of Pharmaceutical and Nutrition Care, Nebraska Medicine 4350 Dewey Ave, Omaha, NE 68105, USA;
| | - Corrine Hanson
- College of Allied Health Professions, University of Nebraska Medical Center, 984045 Nebraska Medical Center, Omaha, NE 68198-4045, USA;
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23
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Merrill JD, Soliman D, Kumar N, Lim S, Shariff AI, Yancy WS. Low-Carbohydrate and Very-Low-Carbohydrate Diets in Patients With Diabetes. Diabetes Spectr 2020; 33:133-142. [PMID: 32425450 PMCID: PMC7228825 DOI: 10.2337/ds19-0070] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Low-carbohydrate diets have been advocated as an effective method for promoting weight loss in overweight and obese individuals and preventing and treating type 2 diabetes. This article reviews the differences between various low-carbohydrate eating plans and discusses the benefits and drawbacks of such a diet based on available evidence. It also offers practical pointers for clinicians.
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Affiliation(s)
- Jennifer D. Merrill
- Division of Endocrinology, Diabetes and Metabolism, Duke University School of Medicine, Durham, NC
| | - Diana Soliman
- Division of Endocrinology, Diabetes and Metabolism, Duke University School of Medicine, Durham, NC
| | - Nitya Kumar
- Division of Endocrinology, Diabetes and Metabolism, Duke University School of Medicine, Durham, NC
| | - Sooyoung Lim
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC
| | - Afreen I. Shariff
- Division of Endocrinology, Diabetes and Metabolism, Duke University School of Medicine, Durham, NC
| | - William S. Yancy
- Duke Diet and Fitness Center, Department of Medicine, Duke University Health System, Durham, NC
- Durham Veterans Affairs Medical Center, Durham, NC
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Wang X, Gao X, Lu G, Lu Z, Zhou S, Wang Y, Zhou Y. The ketogenic diet for paediatric patients with super-refractory status epilepticus in febrile infection-related epilepsy syndrome. ACTA EPILEPTOLOGICA 2020. [DOI: 10.1186/s42494-020-00013-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Abstract
Objective
To investigate the effect and safety of ketogenic diet (KD) for the treatment of paediatric patients with super-refractory status epilepticus (SRSE) in febrile infection-related epilepsy syndrome (FIRES).
Method
From January 1, 2015 to October 31, 2017, ten critically ill paediatric patients with SRSE in FIRES were included in this study and treated with KD. The treatment effects of KD were evaluated by using continuous encephalography (CEEG) and amplitude-integrated electro-encephalography (aEEG).
Results
All 10 patients fulfilled the diagnostic criteria of SRSE in FIRES and achieved ketosis within 24–72 h following the administration of KD. CEEG and aEEG were monitored for several weeks to assess the efficacy of KD on status epilepticus (SE). SE was contained in 8 patients within 2 to 19 days after initiation of KD, and KD was discontinued in the other 2 patients. One of the 10 patients demonstrated severe adverse effects.
Conclusion
KD may be an alternative and safe treatment option in critical paediatric patients with SRSE in FIRES.
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Schoeler NE, Simpson Z, Whiteley VJ, Nguyen P, Meskell R, Lightfoot K, Martin-McGill KJ, Olpin S, Ivison F. Biochemical assessment of patients following ketogenic diets for epilepsy: Current practice in the UK and Ireland. Epilepsia Open 2019; 5:73-79. [PMID: 32140645 PMCID: PMC7049795 DOI: 10.1002/epi4.12371] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 11/05/2019] [Accepted: 11/12/2019] [Indexed: 11/09/2022] Open
Abstract
Objective Biochemical assessment is recommended for patients prior to initiating and following a ketogenic diet (KD). There is no published literature regarding current practice in the UK and Ireland. We aimed to explore practice in comparison with international guidelines, determine approximate costs of biochemical testing in KD patients across the UK and Ireland, and promote greater consistency in KD services nationally. Methods A survey was designed to determine the biochemical tests requested for patients at baseline, 3, 6, 12, 18, and 24 months + on KD. The survey was circulated to 39 centers across the UK and Ireland. Results Sixteen centers completed the survey. Full blood count, electrolytes, calcium, liver function tests (LFTs), lipid profile, and vitamin D were requested at all centers at baseline, in keeping with international guidelines. Bicarbonate, total protein, and urinalysis were less consistently requested. Magnesium and zinc were requested by all centers, despite not being specifically recommended for pre‐diet evaluation in guidelines. Urea and electrolyte profiles and some LFTs were consistently requested at follow‐up, in accordance with guidelines. Other LFTs and renal tests, full blood count, lipid profile, acylcarnitine profile, selenium, vitamin D, and urinalysis were less consistently requested at follow‐up. The mean costs of the lowest and highest number of tests requested at baseline in our participating centers were £167.54 and £501.93; the mean costs of the lowest and highest number of tests requested at 3‐month follow‐up were £19.17 and £450.06. Significance Biochemical monitoring of KD patients varies widely across the UK and Ireland and does not fully correspond to international best practice guidelines. With an ongoing drive for cost‐effectiveness within health care, further work is needed to streamline practice while ensuring patient safety.
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Affiliation(s)
| | - Zoe Simpson
- Great Ormond Street Hospital for Children London UK
| | - Victoria J Whiteley
- Royal Manchester Children's Hospital Manchester UK.,University of Salford Salford UK
| | - Patty Nguyen
- The National Centre for Neurology and Neurosurgery London UK
| | | | | | | | | | - Fiona Ivison
- Royal Manchester Children's Hospital Manchester UK
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Cioci A, Rudnick C, Ohanisian L. Accidental ketosis-induced polyuria in a toddler: a case report. BMC Pediatr 2019; 19:395. [PMID: 31666031 PMCID: PMC6821017 DOI: 10.1186/s12887-019-1785-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 10/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the pediatric population, parental concern of recent onset frequent or large volume urination in young children is common. CASE PRESENTATION A 2-year-old male with no significant past medical history and unremarkable family history was brought to his pediatrician by his mother who reports that the child had been "soaking through his diapers" for the previous two to 3 days. Mother states that patient has not had an appreciable change in the number of wet diapers per day, just the perceived weight/volume of each diaper. The patient's mother denied any recent illness, apparent abdominal pain, dysuria, or recent changes in his bowel movements. She similarly denied polydipsia, polyphagia, or gross hematuria in the patient. Patient's diet consists of eating a low carbohydrate with mostly high protein and fat diet that was similar to the paleo-type diet consumed by her and her husband. Meals over the recent days were even lower in carbohydrates than usual as the family was actively trying to consume healthier food options. On physical exam the child was found to be afebrile with a normal physical exam. A urine dipstick was performed and was positive for 2+ ketones and 1+ protein. Urine leukocytes and nitrites were negative, as was urinary glucose. A fingerstick blood glucose sample was 83 mg/dL. Based on the patient's physical examination, laboratory findings, and the history which revealed a very-low carbohydrate diet, a preliminary diagnosis of ketosis-induced polyuria was made. The patient's mother was advised to incorporate a greater portion of carbohydrates into her son's diet, with a follow-up scheduled for the following week. At the follow-up appointment the mother reports that she had continued the patient's carbohydrate intake and the excessive urine amount per wet diaper has not returned. Repeat urine dipstick confirmed the resolution of the ketonuria and proteinuria. CONCLUSION This case illustrates the inadvertent consequences that can occur when parents impose new fad diets on their young children. The recent increase in the popularity of fad diets makes the consideration of alternative diets important to review in the patient history and subsequently include in the differential diagnosis of polyuria.
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Affiliation(s)
- Anthony Cioci
- Charles E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Road BC-71, Boca Raton, FL, 33431, USA
| | - Chad Rudnick
- Charles E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Road BC-71, Boca Raton, FL, 33431, USA. .,Charles E. Schmidt College of Medicine, Florida Atlantic University, 5458 Town Center Road Suite 13, Boca Raton, FL, USA.
| | - Levonti Ohanisian
- Charles E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Road BC-71, Boca Raton, FL, 33431, USA
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Khalil OA, Samir GM, Sadek AMEM. Prolonged QTc interval in adults with diabetic ketoacidosis: is it only electrolyte disturbance? THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2019. [DOI: 10.4103/ejim.ejim_112_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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28
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Garcia-Ropero A, Santos-Gallego CG, Zafar MU, Badimon JJ. Metabolism of the failing heart and the impact of SGLT2 inhibitors. Expert Opin Drug Metab Toxicol 2019; 15:275-285. [DOI: 10.1080/17425255.2019.1588886] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Alvaro Garcia-Ropero
- Atherothrombosis Research Unit, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Carlos G. Santos-Gallego
- Atherothrombosis Research Unit, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, USA
| | - M. Urooj Zafar
- Atherothrombosis Research Unit, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Juan J. Badimon
- Atherothrombosis Research Unit, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, USA
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Goswami JN, Sharma S. Current Perspectives On The Role Of The Ketogenic Diet In Epilepsy Management. Neuropsychiatr Dis Treat 2019; 15:3273-3285. [PMID: 31819454 PMCID: PMC6883945 DOI: 10.2147/ndt.s201862] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 10/18/2019] [Indexed: 12/31/2022] Open
Abstract
Drug-refractory epilepsy is a commonly prevalent pediatric neurological illness of global significance. Ketogenic diet (KD) is a time-tested therapeutic modality for refractory epilepsy, which has reemerged as a robust alternative to anti-epileptic pharmacotherapy. There is a growing body of evidence which supports the anti-seizure efficacy, safety profile and feasibility of KD use in childhood epilepsy. In addition, this modality has been recognized to reduce anti-epileptic exposure, improve cognition and behavioral profile of patients as well as improve the quality-of-life of care-givers. Current indications of KD include refractory epilepsy syndromes, selected metabolic disorders (such as pyruvate dehydrogenase deficiency) and a host of varied neurological entities. KD research has broadened the knowledge-base about its mechanisms of action. Four types of KD are in vogue currently with varying nutritional constitution, palatability, administration protocols and comparable efficacy. KD initiation and maintenance are the result of concerted effort of a team of pediatric neurologist/epileptologist, nutritionist and patient's primary care-giver. Consensus is being formulated about various practical aspects of KD such as patient-selection, parental counseling, baseline work-up, dietary prescription, nutritional supplementation, concurrent anti-epileptic drug administration, follow-up and treatment-duration. Novel applications of KD include its use in neonatal epilepsy and super-refractory status epilepticus and tailor-made formulations such as cooking oil-based KD in predominantly rice-fed populations. Increasing body of clinical experience, improved nutritional designs and translational research are promoting KD as a major therapeutic modality. Currently, KD forms a core essence in the armamentarium against refractory epilepsy. In this review, we summarize the recent advances and current perspectives in the use of KD in refractory epilepsy.
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Affiliation(s)
| | - Suvasini Sharma
- Neurology Division, Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi 110001, India
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30
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Kossoff EH, Zupec-Kania BA, Auvin S, Ballaban-Gil KR, Christina Bergqvist AG, Blackford R, Buchhalter JR, Caraballo RH, Cross JH, Dahlin MG, Donner EJ, Guzel O, Jehle RS, Klepper J, Kang HC, Lambrechts DA, Liu YMC, Nathan JK, Nordli DR, Pfeifer HH, Rho JM, Scheffer IE, Sharma S, Stafstrom CE, Thiele EA, Turner Z, Vaccarezza MM, van der Louw EJTM, Veggiotti P, Wheless JW, Wirrell EC. Optimal clinical management of children receiving dietary therapies for epilepsy: Updated recommendations of the International Ketogenic Diet Study Group. Epilepsia Open 2018; 3:175-192. [PMID: 29881797 PMCID: PMC5983110 DOI: 10.1002/epi4.12225] [Citation(s) in RCA: 338] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2018] [Indexed: 12/14/2022] Open
Abstract
Ketogenic dietary therapies (KDTs) are established, effective nonpharmacologic treatments for intractable childhood epilepsy. For many years KDTs were implemented differently throughout the world due to lack of consistent protocols. In 2009, an expert consensus guideline for the management of children on KDT was published, focusing on topics of patient selection, pre‐KDT counseling and evaluation, diet choice and attributes, implementation, supplementation, follow‐up, side events, and KDT discontinuation. It has been helpful in outlining a state‐of‐the‐art protocol, standardizing KDT for multicenter clinical trials, and identifying areas of controversy and uncertainty for future research. Now one decade later, the organizers and authors of this guideline present a revised version with additional authors, in order to include recent research, especially regarding other dietary treatments, clarifying indications for use, side effects during initiation and ongoing use, value of supplements, and methods of KDT discontinuation. In addition, authors completed a survey of their institution's practices, which was compared to responses from the original consensus survey, to show trends in management over the last 10 years.
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Affiliation(s)
- Eric H Kossoff
- Departments of Neurology and Pediatrics Johns Hopkins Outpatient Center Baltimore Maryland U.S.A
| | | | - Stéphane Auvin
- Department of Pediatric Neurology CHU Hôpital Robert Debré Paris France
| | - Karen R Ballaban-Gil
- Department of Neurology and Pediatrics Montefiore Medical Center/Albert Einstein College of Medicine Bronx New York U.S.A
| | - A G Christina Bergqvist
- Department of Neurology The Childrens Hospital of Philadelphia Philadelphia Pennsylvania U.S.A
| | - Robyn Blackford
- Department of Nutrition Lurie Children's Hospital Chicago Illinois U.S.A
| | | | - Roberto H Caraballo
- Department of Neurology Hospital J P Garrahan, Capital Federal Buenos Aires Argentina
| | - J Helen Cross
- Department of Clinical & Experimental Epilepsy Great Ormond Street Hospital University College London London United Kingdom
| | - Maria G Dahlin
- Department of Clinical Neuroscience, Women's and Children's Health Karolinska Institute Stockholm Sweden
| | - Elizabeth J Donner
- Division of Neurology The Hospital for Sick Children Toronto Ontario Canada
| | - Orkide Guzel
- Department of Pediatric Neurology Izmir Dr. Behcet Uz Children's Hospital Izmir Turkey
| | - Rana S Jehle
- Department of Neurology Montefiore Medical Center Bronx New York U.S.A
| | - Joerg Klepper
- Department of Pediatrics and Neuropediatrics Children's Hospital Aschaffenburg Aschaffenburg Germany
| | - Hoon-Chul Kang
- Department of Pediatrics Pediatric Epilepsy Clinic Severance Children's Hospital Seoul Korea
| | | | - Y M Christiana Liu
- Department of Neurology The Hospital for Sick Children Toronto Ontario Canada
| | - Janak K Nathan
- Department of Child Neurology Shushrusha Hospital Mumbai India
| | - Douglas R Nordli
- Department of Neurology Children's Hospital of Los Angeles Los Angeles California U.S.A
| | - Heidi H Pfeifer
- Department of Neurology Massachusetts General Hospital Boston Massachusetts U.S.A
| | - Jong M Rho
- Department of Paediatrics Alberta Children's Hospital Calgary Alberta Canada
| | - Ingrid E Scheffer
- Epilepsy Research Centre The University of Melbourne Austin Health Heidelberg Victoria Australia
| | - Suvasini Sharma
- Department of Pediatrics Lady Hardinge Medical College New Delhi India
| | - Carl E Stafstrom
- Departments of Pediatrics and Neurology Johns Hopkins Hospital Baltimore Maryland U.S.A
| | - Elizabeth A Thiele
- Department of Neurology Massachusetts General Hospital Boston Massachusetts U.S.A
| | - Zahava Turner
- Department of Pediatrics The Johns Hopkins University Baltimore Maryland U.S.A
| | - Maria M Vaccarezza
- Department of Neurology Hospital Italiano de Buenos Aires Buenos Aires Argentina
| | - Elles J T M van der Louw
- Department of Dietetics Sophia Children's Hospital Erasmus Medical Centre Rotterdam The Netherlands
| | - Pierangelo Veggiotti
- Infantile Neuropsychiatry Neurological Institute Foundation Casimiro Mondino Pavia Italy
| | - James W Wheless
- Department of Pediatric Neurology University of Tennessee Memphis Tennessee U.S.A
| | - Elaine C Wirrell
- Department of Neurology, Child and Adolescent Neurology Mayo Clinic Rochester Minnesota U.S.A
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Aygün D, Aygün F, Nişli K, Baş F, Çıtak A. Electrocardiographic changes in children with diabetic ketoacidosis and ketosis. Turk Arch Pediatr 2017; 52:194-201. [PMID: 29483798 DOI: 10.5152/turkpediatriars.2017.4917] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 06/21/2017] [Indexed: 11/22/2022]
Abstract
Aim We aimed to study electrocardiographic changes in children with diabetic ketoacidosis and ketosis and to evaluate the relation of the changes with serum electrolyte levels and ketosis. Material and Methods This study was performed in Istanbul Medical Faculty, Pediatric Emergency and Intensive Care Department between May 2008 and May 2009. The electrocardiographic parameters and QT length of children with diabetic ketoacidosis and ketosis were evaluated at diagnosis and after the treatment. Results Forty patients were included in the study; 16 (40%) were diagnosed as having diabetic ketosis and 24 (60%) had diabetic ketoacidosis. Twenty-four (60%) patients were male and 16 (40%) were female and the mean age was 9.21±4.71 years (range, 1-16 years). Twelve (30%) cases of diabetic ketoacidosis were mild, three (7.5%) were moderate, and nine (22.5%) were severe. One patient had premature ventricular beats, and four had ST depression. The electrocardiographic parameters were all normal beyond the QTC length prolongation. The mean QTC length was 447±45 ms (380-560 ms) at diagnosis and 418±32 ms (350-500 ms) after treatment. The change in the QTC length was statistically significant. None of the patients had significant electrolyte disturbance and the prolongation of QTc length was not correlated with serum electrolyte levels. The prolongation of QTc length was statistically correlated with anion gap (r=0.33, p=0.03). Conclusions In our study, we showed QTc length prolongation and the importance of performing electrocardiography during the diagnosis of diabetic ketoacidosis and ketosis. We also demonstrated that ketosis was responsible for the prolongation of QTc length.
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Affiliation(s)
- Deniz Aygün
- Istanbul University, Istanbul Faculty of Medicine, Department of Pediatrics, Istanbul, Turkey
| | - Fatih Aygün
- Istanbul University, Istanbul Faculty of Medicine, Department of Pediatrics, Istanbul, Turkey
| | - Kemal Nişli
- Istanbul University, Istanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Cardiology, Istanbul, Turkey
| | - Firdevs Baş
- Istanbul University, Istanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, Istanbul, Turkey
| | - Agop Çıtak
- Istanbul University, Istanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Intensive Care, Istanbul, Turkey
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Yuen AWC, Walcutt IA, Sander JW. An acidosis-sparing ketogenic (ASK) diet to improve efficacy and reduce adverse effects in the treatment of refractory epilepsy. Epilepsy Behav 2017; 74:15-21. [PMID: 28667864 DOI: 10.1016/j.yebeh.2017.05.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/11/2017] [Accepted: 05/13/2017] [Indexed: 12/13/2022]
Abstract
Diets that increase production of ketone bodies to provide alternative fuel for the brain are evolving from the classic ketogenic diet for epilepsy devised nearly a century ago. The classic ketogenic diet and its more recent variants all appear to have similar efficacy with approximately 50% of users showing a greater than 50% seizure reduction. They all require significant medical and dietetic support, and there are tolerability issues. A review suggests that low-grade chronic metabolic acidosis associated with ketosis is likely to be an important contributor to the short term and long term adverse effects of ketogenic diets. Recent studies, particularly with the characterization of the acid sensing ion channels, suggest that chronic metabolic acidosis may increase the propensity for seizures. It is also known that low-grade chronic metabolic acidosis has a broad range of negative health effects and an increased risk of early mortality in the general population. The modified ketogenic dietary treatment we propose is formulated to limit acidosis by measures that include monitoring protein intake and maximizing consumption of alkaline mineral-rich, low carbohydrate green vegetables. We hypothesize that this acidosis-sparing ketogenic diet is expected to be associated with less adverse effects and improved efficacy. A case history of life-long intractable epilepsy shows this diet to be a successful long-term strategy but, clearly, clinical studies are needed.
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Affiliation(s)
- Alan W C Yuen
- NIHR University College London Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, WC1N 3BG London, UK; Chalfont Centre for Epilepsy, Chalfont St Peter, UK.
| | | | - Josemir W Sander
- NIHR University College London Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, WC1N 3BG London, UK; Chalfont Centre for Epilepsy, Chalfont St Peter, UK; Stichting Epilepsie Instellingen Nederland (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands
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Ketogenic Diet: It Has a Role in Our Armamentarium of Treatment of Refractory Seizures. Epilepsy Curr 2017; 17:278-280. [DOI: 10.5698/1535-7597.17.5.278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Lambrechts DAJE, de Kinderen RJA, Vles JSH, de Louw AJA, Aldenkamp AP, Majoie HJM. A randomized controlled trial of the ketogenic diet in refractory childhood epilepsy. Acta Neurol Scand 2017; 135:231-239. [PMID: 27027847 DOI: 10.1111/ane.12592] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2016] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To evaluate the efficacy and tolerability of the ketogenic diet (KD) during the first 4 months of a randomized controlled trial (RCT) in refractory epilepsy patients aged 1-18 years. METHODS Children and adolescents with refractory epilepsy, not eligible for epilepsy surgery, were included. Following 1 month at baseline, patients were randomized to either the KD or to care as usual (CAU).Primary outcome is the proportion of patients with at least 50% reduction in seizure frequency at 4 months. Secondary outcomes are mean percentage of baseline seizures, seizure severity, and side effects. RESULTS Fifty-seven patients were randomized; nine dropped out, leaving 48 for analysis (i.e., 26 KD, 22 CAU). In an intention-to-treat analysis, 13 patients (50%) treated with the KD and four patients (18.2%) of the CAU group were responders.Mean seizure frequency at 4 months compared to baseline, after removal of two outliers in the KD group, was significantly lower (P = 0.024) in the KD group (56%) (95% CI: 36-76) than in the CAU group (99%) (95% CI: 65-133%).Twice as many patients in the KD group had a relevant decrease in seizure severity score (P = 0.070).Patients treated with the KD had a significantly higher score for gastrointestinal symptoms (P = 0.021) without an increase in the total score of side effects. CONCLUSIONS This trial provides class I evidence that the KD is an effective therapy in children and adolescents with refractory epilepsy compared with CAU. Most often reported side effects are gastrointestinal symptoms.The study has been registered with the Netherlands Trial Registry (NTR2498).
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Affiliation(s)
- D. A. J. E. Lambrechts
- Department of Neurology; Academic Center for Epileptology Kempenhaeghe & Maastricht UMC+; Heeze The Netherlands
| | - R. J. A. de Kinderen
- Research School of Mental Health & Neuroscience; Maastricht University; Maastricht The Netherlands
- Department of Health Services Research; CAPHRI School for Public Health & Primary Care; Maastricht University; Maastricht The Netherlands
- Department of Research & Development; Academic Center for Epileptology Kempenhaeghe & Maastricht UMC+; Heeze The Netherlands
| | - J. S. H. Vles
- Department of Neurology; Academic Center for Epileptology Kempenhaeghe & Maastricht UMC+; Heeze The Netherlands
- Research School of Mental Health & Neuroscience; Maastricht University; Maastricht The Netherlands
- Department of Neurology; Maastricht University Medical Center; Maastricht The Netherlands
| | - A. J. A. de Louw
- Department of Neurology; Academic Center for Epileptology Kempenhaeghe & Maastricht UMC+; Heeze The Netherlands
- Faculty of Electrical Engineering; University of Technology; Eindhoven The Netherlands
| | - A. P. Aldenkamp
- Research School of Mental Health & Neuroscience; Maastricht University; Maastricht The Netherlands
- Department of Neurology; Maastricht University Medical Center; Maastricht The Netherlands
- Faculty of Electrical Engineering; University of Technology; Eindhoven The Netherlands
- Department of Behavioral Sciences; Academic Center for Epileptology Kempenhaeghe & Maastricht UMC+; Heeze The Netherlands
| | - H. J. M. Majoie
- Department of Neurology; Academic Center for Epileptology Kempenhaeghe & Maastricht UMC+; Heeze The Netherlands
- Research School of Mental Health & Neuroscience; Maastricht University; Maastricht The Netherlands
- Department of Neurology; Maastricht University Medical Center; Maastricht The Netherlands
- Faculty of Health, Medicine and Life Sciences; School of Health Professions Education; Maastricht UMC+; Maastricht The Netherlands
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Determining factors of electrocardiographic abnormalities in patients with epilepsy: A case-control study. Epilepsy Res 2016; 129:106-116. [PMID: 28043059 DOI: 10.1016/j.eplepsyres.2016.12.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/28/2016] [Accepted: 12/16/2016] [Indexed: 11/21/2022]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is a major cause of mortality in young patients with epilepsy (PWE). Although its mechanisms are still poorly understood, they may include cardiorespiratory dysfunction. Standard 12-lead electrocardiograms (ECGs) were obtained from 62 consecutive patients (aged 18-66y) with a definite diagnosis of epilepsy, without seizures at the day of ECG, and 57 healthy controls matched for sex, age and body mass index (BMI). All ECGs were evaluated by a blinded board-certified cardiologist. Patients with symptomatic focal epilepsy represented 90.3% (N=56), of whom 56.4% (N=35) had temporal lobe epilepsy, with a mean duration of 22.02±14.96years of epilepsy. We observed more prolonged P-wave (p<0.0001) and PR interval (p=0.01) in patients than in controls. Additionally, longer QT intervals (p<0.01), pathologic QT dispersion (p<0.01) and left atrial overload (p<0.01) were more common in PWE. Multiple linear regression analysis evidenced age, gender and polytherapy as factors associated with altered ECG. Therefore, routine ECG should be requested in PWE, especially for males, increasing age and in polytherapy. Findings such as longer PR and QT interval, and pathologic QT dispersion, may reflect cardiac structural changes and/or autonomic nervous system dysfunction and indicate a risk for SUDEP.
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van der Louw E, van den Hurk D, Neal E, Leiendecker B, Fitzsimmon G, Dority L, Thompson L, Marchió M, Dudzińska M, Dressler A, Klepper J, Auvin S, Cross JH. Ketogenic diet guidelines for infants with refractory epilepsy. Eur J Paediatr Neurol 2016; 20:798-809. [PMID: 27470655 DOI: 10.1016/j.ejpn.2016.07.009] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 07/05/2016] [Accepted: 07/11/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND The ketogenic diet (KD) is an established, effective non-pharmacologic treatment for drug resistant childhood epilepsy. For a long time, the KD was not recommended for use in infancy (under the age of 2 years) because this is such a crucial period in development and the perceived high risk of nutritional inadequacies. Indeed, infants are a vulnerable population with specific nutritional requirements. But current research shows that the KD is highly effective and well tolerated in infants with epilepsy. Seizure freedom is often achieved and maintained in this specific patient group. There is a need for standardised protocols and management recommendations for clinical use. METHOD In April 2015, a project group of 5 experts was established in order to create a consensus statement regarding the clinical management of the KD in infants. The manuscript was reviewed and amended by a larger group of 10 international experts in the KD field. Consensus was reached with regard to guidance on how the diet should be administered and in whom. RESULTS The resulting recommendations include patient selection, pre-KD counseling and evaluation, specific nutritional requirements, preferred initiation, monitoring of adverse effects at initiation and follow-up, evaluation and KD discontinuation. CONCLUSION This paper highlights recommendations based on best evidence, combined with expert opinions and gives directions for future research.
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Affiliation(s)
- Elles van der Louw
- Erasmus Medical Center Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands.
| | - Dorine van den Hurk
- Wilhelmina Children's Hospital, University Medical Center Utrecht, The Netherlands.
| | | | | | | | | | | | | | | | | | | | - Stéphane Auvin
- Pediatric Epilepsy & Child Neurology Paris-Diderot University, France.
| | - J Helen Cross
- UCL Institute of Child Health, Great Ormond Street Hospital for Children NHS Trust, London, UK.
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Ozdemir R, Kucuk M, Guzel O, Karadeniz C, Yilmaz U, Mese T. Does ketogenic diet have any negative effect on cardiac systolic and diastolic functions in children with intractable epilepsy?: One-year follow-up results. Brain Dev 2016; 38:842-7. [PMID: 27066714 DOI: 10.1016/j.braindev.2016.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/14/2016] [Accepted: 03/20/2016] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The ketogenic diet (KD) has been referred to as an "effective therapy with side effects" for children with intractable epilepsy. Among the most recognized adverse effects, there are cardiac conduction abnormalities, vascular and myocardial dysfunction. However, very limited and controversial data are available regarding the effects of the KD on cardiac functions. We sought to analyze the mid-term effect of ketogenic diet on cardiac functions in patients with intractable epilepsy who received a ketogenic diet for at least 12months using conventional and relatively new imaging techniques. METHODS This prospective study included 61 patients with intractable epilepsy who received ketogenic diet for at least 12months. Clinical examinations, serum carnitine and selenium levels as well as electrocardiographic and echocardiographic examinations were scheduled prior to the procedure and at 1, 3, 6 and 12months. We utilized two-dimensional, M-mode, colored Doppler, spectral Doppler and pulsed wave tissue Doppler imaging techniques to investigate ventricular systolic and diastolic functions of this subgroup of patients. RESULTS In our study, there was no significant difference after 1year of KD therapy compared to baseline values-except a significantly decreased A wave velocity-in terms of pulse wave Doppler echocardiographic measurements of the diastolic function. The tissue Doppler measurements obtained from the lateral wall of tricuspide and mitral annuli were not different at baseline and at month 12 of the treatment, as well. CONCLUSION The ketogenic diet appears to have no disturbing effect on ventricular functions in epileptic children in the midterm.
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Affiliation(s)
- Rahmi Ozdemir
- Izmir Dr. Behcet Uz Children's Hospital, Department of Pediatric Cardiology, Izmir, Turkey.
| | - Mehmet Kucuk
- Izmir Dr. Behcet Uz Children's Hospital, Department of Pediatric Cardiology, Izmir, Turkey
| | - Orkide Guzel
- Izmir Dr. Behcet Uz Children's Hospital, Department of Pediatric Neurology, Izmir, Turkey
| | - Cem Karadeniz
- Izmir Dr. Behcet Uz Children's Hospital, Department of Pediatric Cardiology, Izmir, Turkey
| | - Unsal Yilmaz
- Izmir Dr. Behcet Uz Children's Hospital, Department of Pediatric Neurology, Izmir, Turkey
| | - Timur Mese
- Izmir Dr. Behcet Uz Children's Hospital, Department of Pediatric Cardiology, Izmir, Turkey
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Kanikarla-Marie P, Jain SK. Hyperketonemia and ketosis increase the risk of complications in type 1 diabetes. Free Radic Biol Med 2016; 95:268-77. [PMID: 27036365 PMCID: PMC4867238 DOI: 10.1016/j.freeradbiomed.2016.03.020] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 03/16/2016] [Accepted: 03/21/2016] [Indexed: 12/19/2022]
Abstract
Diets that boost ketone production are increasingly used for treating several neurological disorders. Elevation in ketones in most cases is considered favorable, as they provide energy and are efficient in fueling the body's energy needs. Despite all the benefits from ketones, the above normal elevation in the concentration of ketones in the circulation tend to illicit various pathological complications by activating injurious pathways leading to cellular damage. Recent literature demonstrates a plausible link between elevated levels of circulating ketones and oxidative stress, linking hyperketonemia to innumerable morbid conditions. Ketone bodies are produced by the oxidation of fatty acids in the liver as a source of alternative energy that generally occurs in glucose limiting conditions. Regulation of ketogenesis and ketolysis plays an important role in dictating ketone concentrations in the blood. Hyperketonemia is a condition with elevated blood levels of acetoacetate, 3-β-hydroxybutyrate, and acetone. Several physiological and pathological triggers, such as fasting, ketogenic diet, and diabetes cause an accumulation and elevation of circulating ketones. Complications of the brain, kidney, liver, and microvasculature were found to be elevated in diabetic patients who had elevated ketones compared to those diabetics with normal ketone levels. This review summarizes the mechanisms by which hyperketonemia and ketoacidosis cause an increase in redox imbalance and thereby increase the risk of morbidity and mortality in patients.
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Affiliation(s)
- Preeti Kanikarla-Marie
- Department of Pediatrics, Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA 71130, USA
| | - Sushil K Jain
- Department of Pediatrics, Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA 71130, USA.
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Pascual JM, Ronen GM. Glucose Transporter Type I Deficiency (G1D) at 25 (1990-2015): Presumptions, Facts, and the Lives of Persons With This Rare Disease. Pediatr Neurol 2015; 53:379-93. [PMID: 26341673 PMCID: PMC4609610 DOI: 10.1016/j.pediatrneurol.2015.08.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 07/30/2015] [Accepted: 08/02/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND As is often the case for rare diseases, the number of published reviews and case reports of glucose transporter type I deficiency (G1D) approaches or exceeds that of original research. This can indicate medical interest, but also scientific stagnation. METHODS In assessing this state of affairs here, we focus not on what is peculiar or disparate about G1D, but on the assumptions that have reigned thus far undisputed, and critique them as a potential impediment to progress. To summarize the most common G1D phenotype, we trace the 25-year story of G1D in parallel with the natural history of one of two index patients, identified in 1990 by one of us (G.M.R.) and brought up to date by the other (J.M.P.) while later examining widely repeated but little-scrutinized statements. Among them are those that pertain to assumptions about brain fuels; energy failure; cerebrospinal glucose concentration; the purpose of ketogenic diet; the role of the defective blood-brain barrier; genotype-phenotype correlations; a bewildering array of phenotypes; ictogenesis, seizures, and the electroencephalograph; the use of mice to model the disorder; and what treatments may and may not be expected to accomplish. RESULTS We reach the forgone conclusion that the proper study of mankind-and of one of its ailments (G1D) -is man itself (rather than mice, isolated cells, or extrapolated inferences) and propose a framework for rigorous investigation that we hope will lead to a better understanding and to better treatments for this and for rare disorders in general. CONCLUSIONS These considerations, together with experience drawn from other disorders, lead, as a logical consequence, to the nullification of the view that therapeutic development (i.e., trials) for rare diseases could or should be accelerated without the most vigorous scientific scrutiny: trial and error constitute an inseparable couple, such that, at the present time, hastening the former is bound to precipitate the latter.
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Affiliation(s)
- Juan M. Pascual
- Rare Brain Disorders Program, Departments of Neurology and Neurotherapeutics, Physiology and Pediatrics, and Eugene McDermott Center for Human Growth and Development / Center for Human Genetics. The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Gabriel M. Ronen
- Department of Pediatrics, McMaster Child Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Lambrechts DAJE, de Kinderen RJA, Vles HSH, de Louw AJ, Aldenkamp AP, Majoie MJM. The MCT-ketogenic diet as a treatment option in refractory childhood epilepsy: A prospective study with 2-year follow-up. Epilepsy Behav 2015; 51:261-6. [PMID: 26301622 DOI: 10.1016/j.yebeh.2015.07.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/16/2015] [Accepted: 07/18/2015] [Indexed: 01/01/2023]
Abstract
The present study assessed the long-term (i.e., 24months) efficacy of the ketogenic diet (KD) as an add-on therapy in children with refractory epilepsy, with focus on seizure frequency, seizure severity, and tolerability. Most patients were treated with the MCT-diet. At one and two years, 33% and 23%, respectively, of the 48 included patients were still on the KD. After three months, one year, and two years of treatment, 16.7% of the patients were responders. The highest responder rate (i.e., 22.9%) was seen at six and nine months of treatment. Of the fifteen patients with seizure clusters during baseline, 60% were responders after three months when looking at cluster reduction and most of them were not responders for the total seizure frequency. From three months of treatment onwards, most of the patients had a relevant decrease in seizure severity which was mainly related to the most severe seizure type. Gastrointestinal dysfunction was often reported, especially in the first six weeks of treatment. Growth deceleration was present in 30% of the patients, and weight reduction in 15%. Improved arousal was mentioned in 30% of patients. No patients developed ECG abnormalities or kidney stones. Increase in lipid profile was rare. The KD is an effective therapy for children with therapy-resistant epilepsy. Effectiveness is reflected in the reduction of seizure frequency as well as in the reduction of seizure severity. After 6months of treatment, it is obvious which patients are responders and tolerate the treatment well. Most of these patients will continue to benefit from the KD for a longer time. Long-term use of the diet was well tolerated.
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Affiliation(s)
- Danielle A J E Lambrechts
- Department of Neurology, Academic Centre for Epileptology Kempenhaeghe & Maastricht UMC+, Heeze, The Netherlands.
| | - Reina J A de Kinderen
- Research School of Mental Health & Neuroscience, Maastricht University, The Netherlands; Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, The Netherlands; Department of Research & Development, Academic Centre for Epileptology Kempenhaeghe & Maastricht UMC+, Heeze, The Netherlands
| | - Hans S H Vles
- Department of Neurology, Academic Centre for Epileptology Kempenhaeghe & Maastricht UMC+, Heeze, The Netherlands; Research School of Mental Health & Neuroscience, Maastricht University, The Netherlands; Department of Neurology, Maastricht University Medical Centre, The Netherlands
| | - Anton J de Louw
- Department of Neurology, Academic Centre for Epileptology Kempenhaeghe & Maastricht UMC+, Heeze, The Netherlands; Faculty of Electrical Engineering, University of Technology, Eindhoven, The Netherlands
| | - Albert P Aldenkamp
- Research School of Mental Health & Neuroscience, Maastricht University, The Netherlands; Department of Behavioural Sciences, Academic Centre for Epileptology Kempenhaeghe & Maastricht UMC+, Heeze, The Netherlands; Department of Neurology, Maastricht University Medical Centre, The Netherlands; Faculty of Electrical Engineering, University of Technology, Eindhoven, The Netherlands
| | - Marian J M Majoie
- Department of Neurology, Academic Centre for Epileptology Kempenhaeghe & Maastricht UMC+, Heeze, The Netherlands; Research School of Mental Health & Neuroscience, Maastricht University, The Netherlands; Department of Neurology, Maastricht University Medical Centre, The Netherlands
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The Short-Term Effects of Ketogenic Diet on Cardiac Ventricular Functions in Epileptic Children. Pediatr Neurol 2015; 53:233-237.e1. [PMID: 26302701 DOI: 10.1016/j.pediatrneurol.2015.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 05/15/2015] [Accepted: 06/11/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Our primary aim was to determine the short-term effects of a ketogenic diet on cardiac ventricular function in patients with refractory epilepsy. METHODS Thirty-eight drug-resistant epileptic patients who were treated with a ketogenic diet were enrolled in this prospective study. Echocardiography was performed on all patients before beginning the ketogenic diet and after the sixth month of therapy. Two-dimensional, M-mode, color flow, spectral Doppler, and pulsed-wave tissue Doppler imaging measurements were performed on all patients. RESULTS The median age of the 32 patients was 45.5 months, and 22 (57.8%) of them were male. Body weight, height, and body mass index increased significantly at the sixth month of therapy when compared with baseline values (P < 0.05). Baseline variables assessed by conventional M-mode echocardiography showed no significant difference at month 6 (P > 0.05). Doppler flow indices of mitral annulus and tricuspid annulus velocity of patients at baseline and month 6 showed no significant differences (P > 0.05). Tricuspid annular E/A ratio was lower at month 6 (P < 0.05). Although mitral annulus tissue Doppler imaging studies showed no significant difference (P > 0.05), there was a decrease in Ea velocity and Ea/Aa ratio gathered from tricuspid annulus at month 6 compared with baseline (P < 0.05). CONCLUSION A 6-month duration ketogenic diet does not impair left ventricular functions in children with refractory epilepsy; however, it may be associated with a right ventricular diastolic dysfunction.
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Pascual JM, Liu P, Mao D, Kelly DI, Hernandez A, Sheng M, Good LB, Ma Q, Marin-Valencia I, Zhang X, Park JY, Hynan LS, Stavinoha P, Roe CR, Lu H. Triheptanoin for glucose transporter type I deficiency (G1D): modulation of human ictogenesis, cerebral metabolic rate, and cognitive indices by a food supplement. JAMA Neurol 2015; 71:1255-65. [PMID: 25110966 DOI: 10.1001/jamaneurol.2014.1584] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Disorders of brain metabolism are multiform in their mechanisms and manifestations, many of which remain insufficiently understood and are thus similarly treated. Glucose transporter type I deficiency (G1D) is commonly associated with seizures and with electrographic spike-waves. The G1D syndrome has long been attributed to energy (ie, adenosine triphosphate synthetic) failure such as that consequent to tricarboxylic acid (TCA) cycle intermediate depletion. Indeed, glucose and other substrates generate TCAs via anaplerosis. However, TCAs are preserved in murine G1D, rendering energy-failure inferences premature and suggesting a different hypothesis, also grounded on our work, that consumption of alternate TCA precursors is stimulated and may be detrimental. Second, common ketogenic diets lead to a therapeutically counterintuitive reduction in blood glucose available to the G1D brain and prove ineffective in one-third of patients. OBJECTIVE To identify the most helpful outcomes for treatment evaluation and to uphold (rather than diminish) blood glucose concentration and stimulate the TCA cycle, including anaplerosis, in G1D using the medium-chain, food-grade triglyceride triheptanoin. DESIGN, SETTING, AND PARTICIPANTS Unsponsored, open-label cases series conducted in an academic setting. Fourteen children and adults with G1D who were not receiving a ketogenic diet were selected on a first-come, first-enrolled basis. INTERVENTION Supplementation of the regular diet with food-grade triheptanoin. MAIN OUTCOMES AND MEASURES First, we show that, regardless of electroencephalographic spike-waves, most seizures are rarely visible, such that perceptions by patients or others are inadequate for treatment evaluation. Thus, we used quantitative electroencephalographic, neuropsychological, blood analytical, and magnetic resonance imaging cerebral metabolic rate measurements. RESULTS One participant (7%) did not manifest spike-waves; however, spike-waves promptly decreased by 70% (P = .001) in the other participants after consumption of triheptanoin. In addition, the neuropsychological performance and cerebral metabolic rate increased in most patients. Eleven patients (78%) had no adverse effects after prolonged use of triheptanoin. Three patients (21%) experienced gastrointestinal symptoms, and 1 (7%) discontinued the use of triheptanoin. CONCLUSIONS AND RELEVANCE Triheptanoin can favorably influence cardinal aspects of neural function in G1D. In addition, our outcome measures constitute an important framework for the evaluation of therapies for encephalopathies associated with impaired intermediary metabolism.
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Affiliation(s)
- Juan M Pascual
- Rare Brain Disorders Program, Department of Neurology and Neurotherapeutics, The University of Texas Southwestern Medical Center, Dallas2Department of Physiology, The University of Texas Southwestern Medical Center, Dallas3Department of Pediatrics, The Un
| | - Peiying Liu
- Advanced Imaging Research Center, The University of Texas Southwestern Medical Center, Dallas
| | - Deng Mao
- Advanced Imaging Research Center, The University of Texas Southwestern Medical Center, Dallas
| | - Dorothy I Kelly
- Rare Brain Disorders Program, Department of Neurology and Neurotherapeutics, The University of Texas Southwestern Medical Center, Dallas
| | - Ana Hernandez
- Department of Psychology, Children's Medical Center Dallas, Dallas, Texas
| | - Min Sheng
- Advanced Imaging Research Center, The University of Texas Southwestern Medical Center, Dallas
| | - Levi B Good
- Rare Brain Disorders Program, Department of Neurology and Neurotherapeutics, The University of Texas Southwestern Medical Center, Dallas
| | - Qian Ma
- Rare Brain Disorders Program, Department of Neurology and Neurotherapeutics, The University of Texas Southwestern Medical Center, Dallas
| | - Isaac Marin-Valencia
- Rare Brain Disorders Program, Department of Neurology and Neurotherapeutics, The University of Texas Southwestern Medical Center, Dallas3Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas
| | - Xuchen Zhang
- Rare Brain Disorders Program, Department of Neurology and Neurotherapeutics, The University of Texas Southwestern Medical Center, Dallas
| | - Jason Y Park
- Eugene McDermott Center for Human Growth and Development/Center for Human Genetics, The University of Texas Southwestern Medical Center, Dallas7Advanced Diagnostics Laboratory, Children's Medical Center, Dallas, Texas8Department of Pathology, The Universi
| | - Linda S Hynan
- Department of Clinical Sciences (Biostatistics), The University of Texas Southwestern Medical Center, Dallas10Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas
| | - Peter Stavinoha
- Department of Psychology, Children's Medical Center Dallas, Dallas, Texas10Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas
| | - Charles R Roe
- Rare Brain Disorders Program, Department of Neurology and Neurotherapeutics, The University of Texas Southwestern Medical Center, Dallas
| | - Hanzhang Lu
- Advanced Imaging Research Center, The University of Texas Southwestern Medical Center, Dallas10Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas
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Pascual JM. Glut1 Deficiency (G1D). Mov Disord 2015. [DOI: 10.1016/b978-0-12-405195-9.00050-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Sharma S, Jain P. The ketogenic diet and other dietary treatments for refractory epilepsy in children. Ann Indian Acad Neurol 2014; 17:253-8. [PMID: 25221391 PMCID: PMC4162008 DOI: 10.4103/0972-2327.138471] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 04/19/2014] [Accepted: 04/29/2014] [Indexed: 01/01/2023] Open
Abstract
The ketogenic diet is a high-fat, low-carbohydrate, and restricted protein diet that is useful in patients with refractory epilepsy. The efficacy of the ketogenic diet is better than most of the new antiepileptic drugs. Other modifications of the diet are also beneficial, such as the modified Atkins diet and the low glycemic index treatment. There is a lack of awareness of the ketogenic diet as a treatment modality for epilepsy amongst pediatricians and neurologists. In this review, the use of the ketogenic diet and other dietary treatments in refractory epilepsy is discussed. The Indian experience with the use of these dietary treatments is also briefly reviewed.
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Affiliation(s)
- Suvasini Sharma
- Department of Pediatrics, Division of Pediatric Neurology, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India
| | - Puneet Jain
- Consultant, Department of Pediatrics, Division of Pediatric Neurology, BLK Super Speciality Hospital, Pusa Road, New Delhi, India
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Dedkova EN, Blatter LA. Role of β-hydroxybutyrate, its polymer poly-β-hydroxybutyrate and inorganic polyphosphate in mammalian health and disease. Front Physiol 2014; 5:260. [PMID: 25101001 PMCID: PMC4102118 DOI: 10.3389/fphys.2014.00260] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 06/19/2014] [Indexed: 12/14/2022] Open
Abstract
We provide a comprehensive review of the role of β-hydroxybutyrate (β-OHB), its linear polymer poly-β-hydroxybutyrate (PHB), and inorganic polyphosphate (polyP) in mammalian health and disease. β-OHB is a metabolic intermediate that constitutes 70% of ketone bodies produced during ketosis. Although ketosis has been generally considered as an unfavorable pathological state (e.g., diabetic ketoacidosis in type-1 diabetes mellitus), it has been suggested that induction of mild hyperketonemia may have certain therapeutic benefits. β-OHB is synthesized in the liver from acetyl-CoA by β-OHB dehydrogenase and can be used as alternative energy source. Elevated levels of PHB are associated with pathological states. In humans, short-chain, complexed PHB (cPHB) is found in a wide variety of tissues and in atherosclerotic plaques. Plasma cPHB concentrations correlate strongly with atherogenic lipid profiles, and PHB tissue levels are elevated in type-1 diabetic animals. However, little is known about mechanisms of PHB action especially in the heart. In contrast to β-OHB, PHB is a water-insoluble, amphiphilic polymer that has high intrinsic viscosity and salt-solvating properties. cPHB can form non-specific ion channels in planar lipid bilayers and liposomes. PHB can form complexes with polyP and Ca(2+) which increases membrane permeability. The biological roles played by polyP, a ubiquitous phosphate polymer with ATP-like bonds, have been most extensively studied in prokaryotes, however polyP has recently been linked to a variety of functions in mammalian cells, including blood coagulation, regulation of enzyme activity in cancer cells, cell proliferation, apoptosis and mitochondrial ion transport and energy metabolism. Recent evidence suggests that polyP is a potent activator of the mitochondrial permeability transition pore in cardiomyocytes and may represent a hitherto unrecognized key structural and functional component of the mitochondrial membrane system.
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Affiliation(s)
- Elena N Dedkova
- Department of Molecular Biophysics and Physiology, Rush University Medical Center Chicago, IL, USA
| | - Lothar A Blatter
- Department of Molecular Biophysics and Physiology, Rush University Medical Center Chicago, IL, USA
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The impact of the ketogenic diet on arterial morphology and endothelial function in children and young adults with epilepsy: A case–control study. Seizure 2014; 23:260-5. [DOI: 10.1016/j.seizure.2013.12.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 12/03/2013] [Accepted: 12/04/2013] [Indexed: 12/21/2022] Open
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Doksöz Ö, Güzel O, Yılmaz Ü, Işgüder R, Çeleğen K, Meşe T. Dispersion durations of P-wave and QT interval in children treated with a ketogenic diet. Pediatr Neurol 2014; 50:343-6. [PMID: 24485016 DOI: 10.1016/j.pediatrneurol.2013.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 12/02/2013] [Accepted: 12/03/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Limited data are available on the effects of a ketogenic diet on dispersion duration of P-wave and QT-interval measures in children. We searched for the changes in these measures with serial electrocardiograms in patients treated with a ketogenic diet. METHODS Twenty-five drug-resistant patients with epilepsy treated with a ketogenic diet were enrolled in this study. Electrocardiography was performed in all patients before the beginning and at the sixth month after implementation of the ketogenic diet. Heart rate, maximum and minimum P-wave duration, P-wave dispersion, and maximum and minimum corrected QT interval and QT dispersion were manually measured from the 12-lead surface electrocardiogram. RESULTS Minimum and maximum corrected QT and QT dispersion measurements showed nonsignificant increase at month 6 compared with baseline values. Other previously mentioned electrocardiogram parameters also showed no significant changes. CONCLUSIONS A ketogenic diet of 6 months' duration has no significant effect on electrocardiogram parameters in children. Further studies with larger samples and longer duration of follow-up are needed to clarify the effects of ketogenic diet on P-wave dispersion and corrected QT and QT dispersion.
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Affiliation(s)
- Önder Doksöz
- Department of Pediatric Cardiology, Izmir Dr. Behcet Uz Children's Hospital, Izmir, Turkey.
| | - Orkide Güzel
- Department of Pediatric Neurology, Izmir Dr. Behcet Uz Children's Hospital, Izmir, Turkey
| | - Ünsal Yılmaz
- Department of Pediatric Neurology, Izmir Dr. Behcet Uz Children's Hospital, Izmir, Turkey
| | - Rana Işgüder
- Pediatric Intensive Care Unit, Izmir Dr. Behcet Uz Children's Hospital, Izmir, Turkey
| | - Kübra Çeleğen
- Department of Pediatrics, Izmir Dr. Behcet Uz Children's Hospital, Izmir, Turkey
| | - Timur Meşe
- Department of Pediatric Cardiology, Izmir Dr. Behcet Uz Children's Hospital, Izmir, Turkey
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Hu T, Bazzano LA. The low-carbohydrate diet and cardiovascular risk factors: evidence from epidemiologic studies. Nutr Metab Cardiovasc Dis 2014; 24:337-43. [PMID: 24613757 PMCID: PMC4351995 DOI: 10.1016/j.numecd.2013.12.008] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 11/22/2013] [Accepted: 12/22/2013] [Indexed: 12/15/2022]
Abstract
AIMS Obesity is an important public health issue because of its high prevalence and concomitant increase in risk of cardiovascular diseases. Low carbohydrate diets are popular for weight loss and weight management but are not recommended in leading guidelines due to the perception that increases in dietary fat intake may lead to an adverse cardiovascular risk profile. To clarify the effects of a low-carbohydrate diet for weight loss on cardiovascular disease risk factors as compared to a low fat diet for weight loss, we systematically reviewed data from randomized controlled clinical trials and large observational studies. DATA SYNTHESIS We searched the MEDLINE database (Jan 1966-Nov 2013) to identify studies that examined a low-carbohydrate diet as compared to a low-fat diet for weight loss or the improvement of cardiovascular disease risk factors. CONCLUSIONS Recent randomized controlled trials document that low-carbohydrate diets not only decrease body weight but also improve cardiovascular risk factors. In light of this evidence from randomized controlled trials, dietary guidelines should be re-visited advocating a healthy low carbohydrate dietary pattern as an alternative dietary strategy for the prevention of obesity and cardiovascular disease risk factors.
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Affiliation(s)
- T Hu
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112, USA
| | - L A Bazzano
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112, USA.
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Galli-Tsinopoulou A, Chatzidimitriou A, Kyrgios I, Rousso I, Varlamis G, Karavanaki K. Children and adolescents with type 1 diabetes mellitus have a sixfold greater risk for prolonged QTc interval. J Pediatr Endocrinol Metab 2014; 27:237-43. [PMID: 24127534 DOI: 10.1515/jpem-2013-0193] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Accepted: 09/11/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND QT-wave abnormalities have been detected in type 1 diabetes mellitus (T1DM). Prolongation of the heart rate corrected QT interval (QTc) has been associated with cardiovascular mortality. We evaluated how often QT/QTc abnormalities are present in youth with T1DM and if they are associated with disease parameters. METHODS Sixty-two T1DM youngsters and equal age- and gender-matched controls were studied. Demographic, anthropometric, and laboratory data were determined. QT was measured on a 12-lead resting electrocardiogram. QTc was calculated using Bazett's formula. RESULTS T1DM patients had significantly longer QT/QTc than controls, but significance disappeared after adjustment for confounders. Abnormally prolonged QTc≥440 ms was observed six times more frequently in those with T1DM. QT was correlated with age, age at disease onset, but not with glycated hemoglobin or diabetes duration; QTc was only correlated with pubertal stage. CONCLUSIONS T1DM youths have a sixfold increased risk for QT/QTc prolongation and should have regular follow-up for cardiac autonomic dysfunction.
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50
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Tilton RK, Wilkens A, Krantz ID, Izumi K. Cardiac manifestations of Pallister-Killian syndrome. Am J Med Genet A 2014; 164A:1130-5. [PMID: 24504854 DOI: 10.1002/ajmg.a.36413] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 12/07/2013] [Indexed: 11/10/2022]
Abstract
Pallister-Killian syndrome (PKS) is a sporadic multisystem genetic diagnosis characterized by facial dysmorphia, variable developmental delay and intellectual impairment, hypotonia, hearing loss, seizures, differences in skin pigmentation, temporal alopecia, diaphragmatic hernia, congenital heart defects, and other systemic abnormalities. Although congenital heart defects have been described in association with PKS, the full spectrum of heart disease is still not entirely known. Here, we describe the pattern of cardiac findings of 81 probands with PKS who have had at least one cardiac evaluation, demonstrating structural heart difference in 37% of our cohort (n = 30). Septal defects such as atrial or ventricular septal defects (n = 12) were the most commonly seen congenital heart differences. Additional findings included the occasional occurrence of bicuspid aortic valve, aortic dilatation, and cardiac hypertrophy/cardiomyopathy. We suggest cardiac evaluation for all individuals with PKS at the time of diagnosis as well as subsequent longitudinal follow-up to monitor for the development of cardiomyopathy and aortic dilatation.
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Affiliation(s)
- Richard K Tilton
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Temple University School of Medicine, Philadelphia, Pennsylvania
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