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Sen K, Izem R, Long Y, Jiang J, Konczal LL, McCarter RJ, Gropman AL, Bedoyan JK. Are asymptomatic carriers of OTC deficiency always asymptomatic? A multicentric retrospective study of risk using the UCDC longitudinal study database. Mol Genet Genomic Med 2024; 12:e2443. [PMID: 38634223 PMCID: PMC11024633 DOI: 10.1002/mgg3.2443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 03/24/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Ornithine transcarbamylase deficiency (OTCD) due to an X-linked OTC mutation, is responsible for moderate to severe hyperammonemia (HA) with substantial morbidity and mortality. About 80% of females with OTCD remain apparently "asymptomatic" with limited studies of their clinical characteristics and long-term health vulnerabilities. Multimodal neuroimaging studies and executive function testing have shown that asymptomatic females exhibit limitations when stressed to perform at higher cognitive load and had reduced activation of the prefrontal cortex. This retrospective study aims to improve understanding of factors that might predict development of defined complications and serious illness in apparent asymptomatic females. A proband and her daughter are presented to highlight the utility of multimodal neuroimaging studies and to underscore that asymptomatic females with OTCD are not always asymptomatic. METHODS We review data from 302 heterozygote females with OTCD enrolled in the Urea Cycle Disorders Consortium (UCDC) longitudinal natural history database. We apply multiple neuroimaging modalities in the workup of a proband and her daughter. RESULTS Among the females in the database, 143 were noted as symptomatic at baseline (Sym). We focused on females who were asymptomatic (Asx, n = 111) and those who were asymptomatic initially upon enrollment in study but who later became symptomatic sometime during follow-up (Asx/Sym, n = 22). The majority of Asx (86%) and Asx/Sym (75%) subjects did not restrict protein at baseline, and ~38% of Asx and 33% of Asx/Sym subjects suffered from mild to severe neuropsychiatric conditions such as mood disorder and sleep problems. The risk of mild to severe HA sometime later in life for the Asx and Asx/Sym subjects as a combined group was ~4% (5/133), with ammonia ranging from 77 to 470 μM and at least half (2/4) of subjects requiring hospital admission and nitrogen scavenger therapy. For this combined group, the median age of first HA crisis was 50 years, whereas the median age of first symptom which included neuropsychiatric and/or behavioral symptoms was 17 years. The multimodal neuroimaging studies in female heterozygotes with OTCD also underscore that asymptomatic female heterozygotes with OTCD (e.g., proband) are not always asymptomatic. CONCLUSIONS Analysis of Asx and Asx/Sym females with OTCD in this study suggests that future evidence-based management guidelines and/or a clinical risk score calculator for this cohort could be useful management tools to reduce morbidity and improve long-term quality of life.
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Affiliation(s)
- Kuntal Sen
- Division of Neurogenetics and Neurodevelopmental PediatricsChildren's National Hospital, The George Washington School of MedicineWashingtonDCUSA
| | - Rima Izem
- Center for Translational Sciences, Children's National HospitalThe George Washington UniversityWashingtonDCUSA
- Children's National HospitalWashingtonDCUSA
| | - Yuelin Long
- Columbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | - Jiji Jiang
- Center for Translational Sciences, Children's National HospitalThe George Washington UniversityWashingtonDCUSA
- Children's National HospitalWashingtonDCUSA
| | - Laura L. Konczal
- Center for Human Genetics, University Hospitals Cleveland Medical Center, Department of Genetics and Genome SciencesCase Western Reserve University School of MedicineClevelandOhioUSA
| | - Robert J. McCarter
- Center for Translational Sciences, Children's National HospitalThe George Washington UniversityWashingtonDCUSA
- Children's National HospitalWashingtonDCUSA
| | - Andrea L. Gropman
- Division of Neurogenetics and Neurodevelopmental PediatricsChildren's National Hospital, The George Washington School of MedicineWashingtonDCUSA
- Center for Translational Sciences, Children's National HospitalThe George Washington UniversityWashingtonDCUSA
| | - Jirair K. Bedoyan
- Division of Genetic and Genomic Medicine, Department of PediatricsUPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
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Barati M, Mosharkesh E, Tahmassian AH, Khodaei M, Jabbari M, Kalhori A, Alipour M, Ghavidel AA, Khalili-Moghadam S, Fathollahi A, Davoodi SH. Engineered Probiotics for the Management of Congenital Metabolic Diseases: A Systematic Review. Prev Nutr Food Sci 2024; 29:1-7. [PMID: 38576877 PMCID: PMC10987387 DOI: 10.3746/pnf.2024.29.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/29/2023] [Accepted: 12/29/2023] [Indexed: 04/06/2024] Open
Abstract
Engineered probiotics (EPs) can be used to treat/manage chronic and congenital diseases. However, to the best of our knowledge, no systematic review has evaluated the effects of EPs on congenital metabolic disorders in murine models and human subjects. Thus, the present study systematically reviewed interventional studies that assessed the effects of EPs on congenital metabolic disorders. PubMed, Web of Science, and Scopus databases were searched up to February 2023 to retrieve related publications. Seventy-six articles were obtained in the primary step. After screening the titles/abstracts based on the inclusion and exclusion criteria, 11 papers were included. Finally, only seven articles were included after performing full-text evaluation. The included articles evaluated the effects of EPs on managing phenylketonuria (PKU, n=4) and hyperammonemia (n=3). Moreover, these studies examined mice and/or rats (n=6), monkeys (n=1), and humans (n=2). Studies on EPs and hyperammonemia revealed that some wild strains such as Lactobacillus plantarum have an innate ammonia-hyper-consuming potential; thus, there was no need to manipulate them. However, manipulation is needed to obtain a phenylalanine-metabolizing strain. In conclusion, EPs can be used to manage or treat congenital metabolic diseases including PKU.
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Affiliation(s)
- Meisam Barati
- Student Research Committee, Department of Clinical Nutrition, National Nutrition and Food Technology Research Institute, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran 1516745811, Iran
| | - Erfan Mosharkesh
- Faculty of Veterinary Medicine, University of Tabriz, Tabriz 5166616471, Iran
| | - Amir Hossein Tahmassian
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad 9138813944, Iran
| | - Maryam Khodaei
- Department of Clinical Biochemistry, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran 1516745811, Iran
| | - Masoumeh Jabbari
- Department of Community Nutrition, National Nutrition and Food Technology Research Institute, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran 151674581, Iran
| | - Ali Kalhori
- Department of Food Science and Technology, Nutritional Science, The Ohio State University, Columbus, OH 43210, USA
| | - Mohsen Alipour
- Cellular and Molecular Biology Research Center, Shahid Beheshti University of Medical Sciences, Tehran 1516745811, Iran
| | - Afshin Abdi Ghavidel
- Cellular and Molecular Biology Research Center, Shahid Beheshti University of Medical Sciences, Tehran 1516745811, Iran
| | - Sajad Khalili-Moghadam
- Student Research Committee, Department of Clinical Nutrition, National Nutrition and Food Technology Research Institute, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran 1516745811, Iran
| | - Anwar Fathollahi
- Saqqez School of Nursing, Kurdistan University of Medical Sciences, Sanandaj 66177-13446, Iran
| | - Sayed Hossein Davoodi
- Student Research Committee, Department of Clinical Nutrition, National Nutrition and Food Technology Research Institute, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran 1516745811, Iran
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran 1461965381, Iran
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Llansola M, Arenas YM, Sancho-Alonso M, Mincheva G, Palomares-Rodriguez A, Doverskog M, Izquierdo-Altarejos P, Felipo V. Neuroinflammation alters GABAergic neurotransmission in hyperammonemia and hepatic encephalopathy, leading to motor incoordination. Mechanisms and therapeutic implications. Front Pharmacol 2024; 15:1358323. [PMID: 38560359 PMCID: PMC10978603 DOI: 10.3389/fphar.2024.1358323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
Enhanced GABAergic neurotransmission contributes to impairment of motor coordination and gait and of cognitive function in different pathologies, including hyperammonemia and hepatic encephalopathy. Neuroinflammation is a main contributor to enhancement of GABAergic neurotransmission through increased activation of different pathways. For example, enhanced activation of the TNFα-TNFR1-NF-κB-glutaminase-GAT3 pathway and the TNFα-TNFR1-S1PR2-CCL2-BDNF-TrkB pathway in cerebellum of hyperammonemic rats enhances GABAergic neurotransmission. This is mediated by mechanisms affecting GABA synthesizing enzymes GAD67 and GAD65, total and extracellular GABA levels, membrane expression of GABAA receptor subunits, of GABA transporters GAT1 and GAT three and of chloride co-transporters. Reducing neuroinflammation reverses these changes, normalizes GABAergic neurotransmission and restores motor coordination. There is an interplay between GABAergic neurotransmission and neuroinflammation, which modulate each other and altogether modulate motor coordination and cognitive function. In this way, neuroinflammation may be also reduced by reducing GABAergic neurotransmission, which may also improve cognitive and motor function in pathologies associated to neuroinflammation and enhanced GABAergic neurotransmission such as hyperammonemia, hepatic encephalopathy or Parkinson's disease. This provides therapeutic targets that may be modulated to improve cognitive and motor function and other alterations such as fatigue in a wide range of pathologies. As a proof of concept it has been shown that antagonists of GABAA receptors such as bicuculline reduces neuroinflammation and improves cognitive and motor function impairment in rat models of hyperammonemia and hepatic encephalopathy. Antagonists of GABAA receptors are not ideal therapeutic tools because they can induce secondary effects. As a more effective treatment to reduce GABAergic neurotransmission new compounds modulating it by other mechanisms are being developed. Golexanolone reduces GABAergic neurotransmission by reducing the potentiation of GABAA receptor activation by neurosteroids such as allopregnanolone. Golexanolone reduces neuroinflammation and GABAergic neurotransmission in animal models of hyperammonemia, hepatic encephalopathy and cholestasis and this is associated with improvement of fatigue, cognitive impairment and motor incoordination. This type of compounds may be useful therapeutic tools to improve cognitive and motor function in different pathologies associated with neuroinflammation and increased GABAergic neurotransmission.
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Affiliation(s)
- Marta Llansola
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Yaiza M. Arenas
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - María Sancho-Alonso
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Gergana Mincheva
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | | | | | | | - Vicente Felipo
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
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Forsah SF, Ugwendum D, Arrey Agbor DB, Ndemazie NB, Kankeu Tonpouwo G, Ndema N, Taylor AA, Nfonoyim J. Severe Sepsis Associated With Multiorgan Failure and Precipitating Nonhepatic Hyperammonemia Crisis in Late-Onset Ornithine Transcarbamylase Deficiency: A Case Report and Literature Review. Cureus 2024; 16:e55711. [PMID: 38586796 PMCID: PMC10998436 DOI: 10.7759/cureus.55711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/09/2024] Open
Abstract
Sepsis is characterized by a dysregulated immune response to an infection. It is a major public health problem owing to its high mortality and morbidity. Sepsis is a medical emergency and requires aggressive and timely management. It can cause multiorgan failure, unmask an existing but undiagnosed disease such as ornithine transcarbamylase deficiency (OTCD), or make a known well-controlled disease worse. We present the case of a 52-year-old male who was brought to the emergency department unresponsive. He was diagnosed with severe sepsis which was associated with multiorgan failure and hyperammonemia crisis. Hyperammonemia was due to a newly diagnosed, late-onset OTCD which was unmasked by severe sepsis. This case will enable physicians to be aware and consider OTCD in a patient presenting with severe sepsis, altered mentation, and seizures, with no obvious cause of hyperammonemia.
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Affiliation(s)
- Sabastain F Forsah
- Internal Medicine, Richmond University Medical Center, Staten Island, USA
| | - Derek Ugwendum
- Internal Medicine, Richmond University Medical Center, Staten Island, USA
| | | | | | | | - Nancelle Ndema
- Internal Medicine, Richmond University Medical Center, Staten Island, USA
| | - Akua Aboah Taylor
- Internal Medicine, Richmond University Medical Center, Staten Island, USA
| | - Jay Nfonoyim
- Pulmonary and Critical Care, Richmond University Medical Center, Staten Island, USA
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Shetty SS, AnnajiGowda HH, Dahale AB. Valproate-induced hyperammonemia, neuroleptic sensitivity, and cerebellar atrophy-A clinical conundrum in the management of bipolar disorder. Bipolar Disord 2024; 26:200-203. [PMID: 38253983 DOI: 10.1111/bdi.13403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
OBJECTIVE Treatment of bipolar disorder (BD) involves complexities especially when patients come with significant sensitivity to various psychotropic medications and comorbidities. The following cases aim to recapitulate and discuss some of such situations. CASES Case 1: A 36-year-old man with intellectual development disorder and BD experienced catatonia, seizures, and hyperammonemia following valproate administration. Treatment involved electroconvulsive therapy (ECT) and a tailored medication regimen, ultimately leading to stability. Case 2: A 63-year-old man with long-standing BD exhibited resistance to lithium and valproate of late, having co-existing essential tremors and cerebellar atrophy. Multiple medication trials led to side effects, requiring ECT for symptom improvement, followed by a carefully adjusted maintenance regimen. CONCLUSION Medication side effects can pose major challenges in treatment of BD. Comprehensive evaluation and monitoring are essential. ECT can prove valuable in such cases. There is pressing need to develop more safer treatment alternatives, especially considering the progressively ageing society.
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Affiliation(s)
- Samarth S Shetty
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India
| | - Harshitha H AnnajiGowda
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India
| | - Ajit Bhalchandra Dahale
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India
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Kirchberg I, Lainka E, Gangfuß A, Kuechler A, Baertling F, Schlieben LD, Lenz D, Tschiedel E. Distinct neonatal hyperammonemia and liver synthesis dysfunction: case report of a severe MEGDHEL syndrome. Front Pediatr 2024; 12:1278047. [PMID: 38445077 PMCID: PMC10912554 DOI: 10.3389/fped.2024.1278047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 02/05/2024] [Indexed: 03/07/2024] Open
Abstract
Background/purpose MEGDHEL syndrome is a rare autosomal recessive metabolic disorder, which is characterized by 3-methylglutaconic aciduria with deafness-dystonia, hepatopathy, encephalopathy and Leigh-like syndrome. It is caused by biallelic pathogenic variants in the SERAC1 gene. Due to the unspecific symptoms and the diverse manifestations of the clinical phenotype, the diagnosis is challenging. Infantile MEGDHEL syndrome often has a severe disease course with acute liver failure. Differentiation from other metabolic disorders is difficult and requires a multidisciplinary approach. Case presentation A two-day-old small for gestational age neonate was admitted to our pediatric intensive care unit (PICU) due to severe liver failure with distinct hyperammonemia and hypoglycemia without elevation of transaminases or cholestasis. Due to high ammonia level, continuous hemodialysis was established immediately after admission. In addition, protein intake was stopped, and the patient anabolized with intravenous glucose. Temporary stabilization could be achieved after four days. In the further course, severe neurological and cardiocirculatory complications occurred, which ultimately led to the infant's death. In the metabolic diagnostics, a pronounced lactate acidosis and in urine an increased excretion of 3-methylglutaconic acid as well as other metabolites of mitochondrial energy metabolism has been the leading findings besides the hyperammonemia. Post-mortem trio whole genome analysis detected a homozygous pathogenic variant in SERAC1 with evidence of SERAC1 deficiency leading to the diagnosis of infantile MEGDHEL syndrome. Conclusion When pediatricians are faced with hepatopathy or even acute liver failure without elevation of transaminases or cholestasis in newborns, SERAC1 deficiency should be considered as a potential differential diagnosis. The initial treatment is based on the recommended management of suspected metabolic disorders. Even while no cure is available yet, patients should be offered proper supportive management through a multidisciplinary team. In addition, genetic confirmation of the diagnosis is important for the families, especially regarding further family planning.If a newborn presents with hyperammonemia, hypoglycemia and impaired liver synthesis function without elevation of transaminases or cholestasis, the possible presence of MEGDHEL syndrome due to a SERAC1 mutation should be considered.
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Affiliation(s)
- Ina Kirchberg
- Department of Pediatric Intensive Care, Children’s Hospital, University of Duisburg-Essen, Essen, Germany
| | - Elke Lainka
- Department of Pediatric Gastroenterology, Hepatology, and Transplant Medicine, Children’s Hospital, University Duisburg-Essen, Essen, Germany
| | - Andrea Gangfuß
- Department of Paediatric Neurology, Centre for Neuromuscular Disorders, Centre for Translational Neuro- and Behavioural Sciences, University Duisburg-Essen, Essen, Germany
| | - Alma Kuechler
- Institute of Human Genetics, University Hospital Essen, Essen, Germany
| | - Fabian Baertling
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children’s Hospital Duesseldorf, Heinrich Heine University, Dusseldorf, Germany
| | - Lea D. Schlieben
- School of Medicine, Institute of Human Genetics, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Institute of Neurogenomics, Computational Health Centre, Helmholtz Zentrum Muenchen, Neuherberg, Germany
| | - Dominic Lenz
- Division of Pediatric Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, Heidelberg University, Medical Faculty, University Hospital Heidelberg, Heidelberg, Germany
| | - Eva Tschiedel
- Department of Pediatric Intensive Care, Children’s Hospital, University of Duisburg-Essen, Essen, Germany
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Lyon AC, Lippa CF, Eiser AR. Metabolic and Environmental Biomarkers in Mild Cognitive Impairment and Dementia: An Exploratory Study. J Integr Complement Med 2024. [PMID: 38330435 DOI: 10.1089/jicm.2023.0583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
Objective: To determine the frequency with which suspected pathogenic factors, including metals and metabolites that might contribute to Alzheimer's disease (AD), may be found in patients with cognitive impairment through commonly available blood tests. Methods: A variety of serum studies, including metals, ammonia, homocysteine, vitamin B12, folate, thyroid tests, metabolic products, and inflammatory markers, were measured in two cohorts: one meeting mild cognitive impairment (MCI) criteria and the other meeting mild-to-moderate dementia (DE) criteria. Medications these patients received were reviewed. Results: Metal abnormalities were detected in over half the subjects, including evidence of mercury, lead, and arsenic elevation as well as instances of excessive essential metals, iron (Fe), and copper. Some metal aberration was detected in 64% of the DE group and 66% of the MCI group. Females were more likely to have elevated copper, consistent with hormonal effects on copper excretion. Homocysteinemia was the most common abnormality, detected in 71% with DE and 67% with MCI, while methylmalonic acid was not elevated. Slight hyperammonemia was moderately common (38%) suggesting a hepatic factor in this subset. Findings of moderate insulin resistance were present in nearly half (44% DE, 52% MCI). Sixty of 65 (92%) had at least one abnormal biomarker and 60% had two or more. The most common drug taken by the total cohort was proton pump inhibitors at 22% DE and 38% MCI. Conclusions: This study suggests that both toxic metals and excessive vital metals such as copper and iron, as well as common metabolic and hepatic factors are detectable at both stages of MCI and DE. There appears to be a multiplicity of provocative factors leading to DE. Individualized interventions based on these parameters may be a means to reduce cognitive decline leading to DE. A more comprehensive prospective study of these environmental and metabolic factors with corrective early interventions appears warranted.
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Affiliation(s)
- Abigail C Lyon
- Department of Neurology, Cognitive Disorders & Comprehensive Alzheimer's Disease Center, Vickie & Jack Farber Institute for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Carol F Lippa
- Department of Neurology, Cognitive Disorders & Comprehensive Alzheimer's Disease Center, Vickie & Jack Farber Institute for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Arnold R Eiser
- Senior Scholar, Penn Center for Public Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Santangeli E, Abbati C, Chen R, Di Carlo A, Leoni S, Piscaglia F, Ferri S. Pathophysiological-Based Nutritional Interventions in Cirrhotic Patients with Sarcopenic Obesity: A State-of-the-Art Narrative Review. Nutrients 2024; 16:427. [PMID: 38337711 PMCID: PMC10857546 DOI: 10.3390/nu16030427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/23/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
In recent decades, following the spread of obesity, metabolic dysfunction has come to represent the leading cause of liver disease. The classical clinical presentation of the cirrhotic patient has, therefore, greatly changed, with a dramatic increase in subjects who appear overweight or obese. Due to an obesogenic lifestyle (lack of physical activity and overall malnutrition, with an excess of caloric intake together with a deficit of proteins and micronutrients), these patients frequently develop a complex clinical condition defined as sarcopenic obesity (SO). The interplay between cirrhosis and SO lies in the sharing of multiple pathogenetic mechanisms, including malnutrition/malabsorption, chronic inflammation, hyperammonemia and insulin resistance. The presence of SO worsens the outcome of cirrhotic patients, affecting overall morbidity and mortality. International nutrition and liver diseases societies strongly agree on recommending the use of food as an integral part of the healing process in the comprehensive management of these patients, including a reduction in caloric intake, protein and micronutrient supplementation and sodium restriction. Based on the pathophysiological paths shared by cirrhosis and SO, this narrative review aims to highlight the nutritional interventions currently advocated by international guidelines, as well as to provide hints on the possible role of micronutrients and nutraceuticals in the treatment of this multifaceted clinical condition.
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Affiliation(s)
- Ernestina Santangeli
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (E.S.); (C.A.); (R.C.); (F.P.)
| | - Chiara Abbati
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (E.S.); (C.A.); (R.C.); (F.P.)
| | - Rusi Chen
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (E.S.); (C.A.); (R.C.); (F.P.)
| | - Alma Di Carlo
- Division of Internal Medicine, Hepatobiliary and Immunoallergologic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.D.C.); (S.L.)
| | - Simona Leoni
- Division of Internal Medicine, Hepatobiliary and Immunoallergologic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.D.C.); (S.L.)
| | - Fabio Piscaglia
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (E.S.); (C.A.); (R.C.); (F.P.)
- Division of Internal Medicine, Hepatobiliary and Immunoallergologic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.D.C.); (S.L.)
| | - Silvia Ferri
- Division of Internal Medicine, Hepatobiliary and Immunoallergologic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.D.C.); (S.L.)
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Kakiuchi T, Nosho T, Oka M, Tashiro K. Hyperammonemia in a carbamoyl-phosphate synthetase 1 deficiency recipient after living-donor liver transplantation from a carrier donor: a case report. Front Med (Lausanne) 2024; 10:1327854. [PMID: 38235270 PMCID: PMC10792046 DOI: 10.3389/fmed.2023.1327854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 12/13/2023] [Indexed: 01/19/2024] Open
Abstract
Carbamoyl-phosphate synthetase 1 (CPS1) deficiency is an autosomal recessive congenital urea cycle disorder (UCD) characterized by hyperammonemia. The recipients of liver transplantation (LT) for UCD are often children, and the potential donors are often the parents. Hereditary congenital diseases involving UCD entail the possibility of both parents being genetically heterozygous. Herein, we describe the case of a 12-year-old girl with CPS1 deficiency receiving a liver transplant (soon after birth) from her father, who had a heterozygous CPS1 mutation. She was referred to our hospital with respiratory distress after contracting two infections (respiratory syncytial virus and human metapneumovirus) within a short period, both of which presented with hyperammonemia. Medication for hyperammonemia quickly lowered the ammonia levels. The hyperammonemia was thought to be caused by the heterozygous mutation in the donor liver; moreover, it is likely that the low enzyme activity in the patient's liver was increased due to the infections. This is the first study to report hyperammonemia in a CPS1 deficiency patient due to an infection after LT. Thus, patients with CPS1 deficiency should be aware of the development of hyperammonemia after LT.
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Affiliation(s)
- Toshihiko Kakiuchi
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | - Tetsuya Nosho
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | - Masafumi Oka
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | - Katsuya Tashiro
- Department of Pediatrics, Karatsu Red Cross Hospital, Karatsu, Japan
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Kumar A, Bellar A, Mishra S, Sekar J, Welch N, Dasarathy S. L-Isoleucine reverses hyperammonemia-induced myotube mitochondrial dysfunction and post-mitotic senescence. J Nutr Biochem 2024; 123:109498. [PMID: 37871767 PMCID: PMC10841977 DOI: 10.1016/j.jnutbio.2023.109498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 10/25/2023]
Abstract
Perturbations in the metabolism of ammonia, a cytotoxic endogenous metabolite, occur in a number of chronic diseases, with consequent hyperammonemia. Increased skeletal muscle ammonia uptake causes metabolic, molecular, and phenotype alterations including cataplerosis of (loss of tricarboxylic acid cycle (TCA) cycle intermediate) α-ketoglutarate (αKG), mitochondrial oxidative dysfunction, and senescence-associated molecular phenotype (SAMP). L-Isoleucine (Ile) is an essential, branched-chain amino acid (BCAA) that simultaneously provides acetyl-CoA as an oxidative substrate and succinyl-CoA for anaplerosis (providing TCA cycle intermediates). Our multiomics analyses in myotubes and skeletal muscle from hyperammonemic mice and human patients with cirrhosis showed perturbations in BCAA transporters and catabolism. We, therefore, determined if Ile reverses hyperammonemia-induced impaired mitochondrial oxidative function and SAMP. Studies were performed in differentiated murine C2C12 myotubes that were early passage, late passage (senescent), or those depleted of LAT1/SLC7A5 and human induced pluripotent stem cell-derived myotubes (hiPSCM). Ile reverses hyperammonemia-induced reduction in the maximum respiratory capacity, complex I, II, and III functions in early passage murine myotubes and hiPSCM. Consistently, low ATP content and impaired global protein synthesis (high energy requiring cellular process) during hyperammonemia are reversed by Ile in murine myotubes and hiPSCM. Lower abundance of critical regulators of protein synthesis in mTORC1 signaling, and increased phosphorylation of eukaryotic initiation factor 2α are also reversed by Ile. Genetic depletion studies showed that Ile responses are independent of the amino acid transporter LAT1/SLC7A5. Our studies show that Ile reverses the hyperammonemia-induced impaired mitochondrial oxidative function, cataplerosis, and SAMP in a LAT1/SLC7A5 transporter-independent manner.
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Affiliation(s)
- Avinash Kumar
- Department of Gastroenterology, Hepatology and Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Annette Bellar
- Department of Inflammation and Immunity, Lerner Research Institute, Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Saurabh Mishra
- Department of Inflammation and Immunity, Lerner Research Institute, Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jinendiran Sekar
- Department of Inflammation and Immunity, Lerner Research Institute, Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nicole Welch
- Department of Inflammation and Immunity, Lerner Research Institute, Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Srinivasan Dasarathy
- Department of Inflammation and Immunity, Lerner Research Institute, Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA.
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Tsykunova G, Kristensen E, Stray-Pedersen A, Bruserud Ø, Sørensen IW, Bruserud Ø, Tvedt THA. Adult presentation of ornithine transcarbamylase deficiency: a possible cause of hyperammonemia after high-dose chemotherapy and stem cell transplantation. Hematology 2023; 28:2265187. [PMID: 38078487 DOI: 10.1080/16078454.2023.2265187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 09/26/2023] [Indexed: 12/18/2023] Open
Abstract
Hyperammonemia is a rare and often fatal complication following the conditioning therapy in autologous and allogeneic stem cell transplant recipients. It is characterized by anorexia, vomiting, lethargy and coma without any other apparent cause. The diagnosis is often delayed because symptoms can be subtle and ammonia is usually not included among the routine analyzes. Previous reports have not identified the molecular mechanisms behind hyperammonemia in stem cell transplant recipients. Urea cycle disorders (UCDs) are inborn errors of metabolism leading to hyperammonemia that usually presents in early childhood, whereas first presentation in adults is less common. Here we describe an adult woman with hyperammonemia following autologous stem cell transplantation for multiple myeloma. No apparent cause of hyperammonemia was identified, including portosystemic shunting, liver dysfunction or recent hyperammonemia-inducing chemotherapy. Hyperammonemia, normal blood glucose as well as anion gap and a previous history of two male newborns that died early after birth, prompted biochemical and genetic investigations for a UCD. A heterozygous variant in the X-linked gene encoding ornithine transcarbamylase (OTC) was identified and was regarded as a cause of UCD. The patient improved after treatment with nitrogen scavengers and high caloric intake according to a UCD protocol. This case report suggests that UCD should be considered as a possible cause of hyperammonemia following stem cell transplantation.
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Affiliation(s)
- Galina Tsykunova
- Department of Medicine Haukeland University Hospital, Bergen, Norway
| | - Erle Kristensen
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Asbjørg Stray-Pedersen
- The National Unit for Newborn Screening, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Øyvind Bruserud
- Department of Anesthesiology and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Ida Wiig Sørensen
- Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway
| | - Øystein Bruserud
- Department of Medicine Haukeland University Hospital, Bergen, Norway
- Section for Hematology, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Tor Henrik Anderson Tvedt
- Department of Medicine Haukeland University Hospital, Bergen, Norway
- Department of Haematology, Oslo University Hospital, Oslo, Norway
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12
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Li Y, Yao Z, Li Y, Yang Z, Li M, Chen Z, Liu S, Gong J, Huang L, Xu P, Li Y, Li H, Liu X, Zhang L, Zhang G, Wang H. Prognostic value of serum ammonia in critical patients with non-hepatic disease: A prospective, observational, multicenter study. J Transl Int Med 2023; 11:401-409. [PMID: 38130646 PMCID: PMC10732347 DOI: 10.2478/jtim-2022-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background and Objectives Non-hepatic hyperammonemia can damage the central nervous system (CNS), and possible prognostic factors are lacking. This study aimed to investigate the prognostic and risk factors for patients admitted to the intensive care unit (ICU). Materials and Methods This prospective, observational, multicenter study was conducted between November and December 2019 at 11 ICUs in the Chinese Heilongjiang province. Changes in blood ammonia level during and after ICU admission were continuously monitored and expressed as the high level (H-), mean level (M-), and initial level (I-) of ammonia. The risk factors of poor prognosis were investigated by conducting univariate and multivariate logistic regression analyses. Receiver operating characteristic (ROC) curve analysis was conducted to compare the predictive ability of Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE-II) score, lactic acid, total bilirubin (TBil), and M-ammonia. Results A total of 1060 patients were included in this study, of which 707 (67%) had a favorable prognosis and 353 (33%) had a poor prognosis. As shown by univariate models, a poor prognosis was associated with elevated serum levels of lactic acid, TBil, and ammonia (P < 0.05) and pathologic scores from three assessments: APACHE-II, Glasgow Coma Scale (GCS), and Sequential Organ Failure Assessment (SOFA). Multivariate analysis revealed that circulating mean ammonia levels in ICU patients were independently associated with a poor prognosis (odds ratio [OR] = 1.73, 95% confidence interval [CI]: 1.07-2.80, P = 0.02). However, the APACHE-II score (area under the curve [AUC]: 0.714, sensitivity: 0.86, specificity: 0.68, P < 0.001) remained the most predictive factor for patient prognosis by ROC analysis. Conclusion Elevated serum levels of ammonia in the blood were independently prognostic for ICU patients without liver disease.
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Affiliation(s)
- Yue Li
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin150086, Heilongjiang Province, China
| | - Zhipeng Yao
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin150086, Heilongjiang Province, China
| | - Yunlong Li
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin150086, Heilongjiang Province, China
| | - Zhenyu Yang
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin150086, Heilongjiang Province, China
| | - Ming Li
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin150086, Heilongjiang Province, China
| | - Zhendong Chen
- Department of Intensive Care Medicine, The First Affiliated Hospital of Jiamusi University, Jiamusi154004, Heilongjiang Province, China
| | - Shujie Liu
- Department of Intensive Care Medicine, Mudanjiang City Second People’s Hospital, Mudanjiang157199, Heilongjiang Province, China
| | - Jianguo Gong
- Department of Intensive Care Medicine, The Fifth Affiliated Hospital of Harbin Medical University, Daqing163711, Heilongjiang Province, China
| | - Libin Huang
- Department of Intensive Care Medicine, Harbin Fifth Hospital, Harbin150001, Heilongjiang Province, China
| | - Ping Xu
- Department of Intensive Care Medicine, General Hospital of Heilongjiang Province Land Reclamation Bureau, Harbin150001, Heilongjiang Province, China
| | - Yan Li
- Department of Intensive Care Medicine, The First Hospital of Harbin, Harbin150001, Heilongjiang Province, China
| | - Haihong Li
- Department of Intensive Care Medicine, Hongqi Hospital Affiliated to Mudanjiang Medical University, Mudanjiang157000, Heilongjiang Province, China
| | - Xuan Liu
- Department of Intensive Care Medicine, Jiamusi Central Hospital, Jiamusi154003, Heilongjiang Province, China
| | - Li Zhang
- Department of Intensive Care Medicine, Daqing Oilfield General Hospital, Daqing163001, Heilongjiang Province, China
| | - Guixia Zhang
- Department of Intensive Care Medicine, The Longnan Hospital of Daqing, Daqing163458, Heilongjiang Province, China
| | - Hongliang Wang
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin150086, Heilongjiang Province, China
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13
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Yun S, Scalia C, Farghaly S. Treatment of Hyperammonemia Syndrome in Lung Transplant Recipients. J Clin Med 2023; 12:6975. [PMID: 38002590 PMCID: PMC10672283 DOI: 10.3390/jcm12226975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/27/2023] [Accepted: 11/02/2023] [Indexed: 11/26/2023] Open
Abstract
Hyperammonemia syndrome is a complication that has been reported to occur in 1-4% of lung transplant patients with mortality rates as high as 60-80%, making detection and management crucial components of post-transplant care. Patients are treated with a multimodal strategy that may include renal replacement therapy, bowel decontamination, supplementation of urea cycle intermediates, nitrogen scavengers, antibiotics against Mollicutes, protein restriction, and restriction of parenteral nutrition. In this review we provide a framework of pharmacologic mechanisms, medication doses, adverse effects, and available evidence for commonly used treatments to consider when initiating therapy. In the absence of evidence for individual strategies and conclusive knowledge of the causes of hyperammonemia syndrome, clinicians should continue to design multimodal regimens based on suspected etiologies, institutional drug availability, patient ability to tolerate enteral medications and nutrition, and availability of intravenous access.
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Affiliation(s)
- Sarah Yun
- The Mount Sinai Hospital, New York, NY 10029, USA;
| | - Ciana Scalia
- The Mount Sinai Hospital, New York, NY 10029, USA;
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14
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Inoue S, Yasuda H, Yoshida K, Mori K, Ogawa K, Yokotsuka Y, Okamoto H. A Diabetic Patient with Prolonged Hyperammonemia Due to Urinary Tract Infection Caused by Urease-producing Bacteria. Intern Med 2023:2817-23. [PMID: 37926530 DOI: 10.2169/internalmedicine.2817-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Obstructive tract infection caused by urease-producing bacteria can lead to hyperammonemia. We herein report a 73-year-old woman with diabetes and compensated liver cirrhosis who developed obstructive pyelonephritis. Her consciousness level declined on day 3 of hospitalization. Blood tests revealed an elevated ammonia level of 140 μg/dL. Urine and blood cultures identified Proteus mirabilis as a urease-producing bacterium. The treatment included double J (WJ) catheter insertion and administration of antimicrobial agents. On day 7 of hospitalization, the ammonia level gradually decreased, and the patient's consciousness improved. However, despite these interventions, perinephric overflow of urine persisted, necessitating nephrectomy.
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15
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Abou Haidar L, Pachnis P, Gotway GK, Ni M, DeBerardinis RJ, McNutt MC. Partial N-acetyl glutamate synthase deficiency presenting as postpartum hyperammonemia: Diagnosis and subsequent pregnancy management. JIMD Rep 2023; 64:403-409. [PMID: 37927481 PMCID: PMC10623101 DOI: 10.1002/jmd2.12388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 07/28/2023] [Accepted: 08/01/2023] [Indexed: 11/07/2023] Open
Abstract
N-acetyl glutamate synthase (NAGS) deficiency (OMIM #: 237310) is a rare urea cycle disorder that usually presents early in life with hyperammonemia. NAGS catalyzes the synthesis of N-acetyl glutamate (NAG) which functions as an activator of the carbamoyl phosphate synthetase-1 mediated conversion of ammonia to carbamoyl phosphate. The absence of NAG results in a proximal urea cycle disorder which can result in severe neurologic sequelae secondary to hyperammonemia and even death. Unlike the other urea cycle disorders, a specific pharmacological treatment for NAGS deficiency exists in the form of carglumic acid, an analog of NAG. Here we present a 29-year-old previously healthy female who presented with hyperammonemia and obtundation just after the birth of her first child. Exome sequencing revealed two novel variants in the NAGS gene, and plasma metabolomics revealed extremely low levels of NAG. Carglumic acid treatment led to prompt resolution of her biochemical abnormalities and symptoms. She tolerated two subsequent pregnancies, 2 years and 6 years after her initial presentation, while taking carglumic acid, and breastfed her third child, all without complications in the mother or children. This case report emphasizes the importance of considering urea cycle disorders in previously-healthy adults presenting with neurological symptoms during periods of metabolic stress, including the postpartum period. It also highlights the efficacious and safe use of carglumic acid during pregnancy and while breastfeeding.
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Affiliation(s)
- Lea Abou Haidar
- Children's Medical Center Research InstituteThe University of Texas Southwestern Medical CenterDallasTexasUSA
- Howard Hughes Medical InstituteThe University of Texas Southwestern Medical CenterDallasTexasUSA
| | - Panayotis Pachnis
- Children's Medical Center Research InstituteThe University of Texas Southwestern Medical CenterDallasTexasUSA
- Department of PediatricsThe University of Texas Southwestern Medical CenterDallasTexasUSA
| | - Garrett K. Gotway
- Department of PediatricsThe University of Texas Southwestern Medical CenterDallasTexasUSA
- Eugene McDermott Center for Human Growth and DevelopmentThe University of Texas Southwestern Medical CenterDallasTexasUSA
- Department of Internal MedicineThe University of Texas Southwestern Medical CenterDallasTexasUSA
| | - Min Ni
- Children's Medical Center Research InstituteThe University of Texas Southwestern Medical CenterDallasTexasUSA
- Department of PediatricsThe University of Texas Southwestern Medical CenterDallasTexasUSA
| | - Ralph J. DeBerardinis
- Children's Medical Center Research InstituteThe University of Texas Southwestern Medical CenterDallasTexasUSA
- Howard Hughes Medical InstituteThe University of Texas Southwestern Medical CenterDallasTexasUSA
- Department of PediatricsThe University of Texas Southwestern Medical CenterDallasTexasUSA
- Eugene McDermott Center for Human Growth and DevelopmentThe University of Texas Southwestern Medical CenterDallasTexasUSA
| | - Markey C. McNutt
- Department of PediatricsThe University of Texas Southwestern Medical CenterDallasTexasUSA
- Eugene McDermott Center for Human Growth and DevelopmentThe University of Texas Southwestern Medical CenterDallasTexasUSA
- Department of Internal MedicineThe University of Texas Southwestern Medical CenterDallasTexasUSA
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16
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Ocaña-Sánchez MF, Soto-Ojeda GA, Cocotle-Ronzón Y, Soria-Fregozo C, Sánchez-Medina A, García-Rodríguez RV, Rodríguez-Landa JF, Corro-Méndez EJ, Hernández-Lozano M. Flaxseed Oil ( Linum usitatissimum) Prevents Cognitive and Motor Damage in Rats with Hyperammonemia. Nutrients 2023; 15:4550. [PMID: 37960203 PMCID: PMC10647672 DOI: 10.3390/nu15214550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/25/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Hyperammonemia is characterized by the excessive accumulation of ammonia in the body as a result of the loss of liver detoxification, leading to the development of hepatic encephalopathy (HE). These metabolic alterations carry cognitive and motor deficits and cause neuronal damage, with no effective treatment at present. In this study, we aimed to evaluate the effect of two subacute oral administrations of flaxseed oil (0.26 and 0.52 mL/kg) on short- and long-term memory, visuospatial memory, locomotor activity, motor coordination, and the neuronal morphology of the prefrontal cortex (PFC) via tests on Wistar rats with hyperammonemia. The goal was to identify its role in the regulation of cerebral edema, without liver damage causing cerebral failure. In contrast with an ammonium-rich diet, flaxseed oil and normal foods did not cause cognitive impairment or motor alterations, as evidenced in the short-term and visuospatial memory tests. Furthermore, the flaxseed oil treatment maintained a regular neuronal morphology of the prefrontal cortex, which represents a neuroprotective effect. We conclude that the oral administration of flaxseed oil prevents cognitive and motor impairments as well as neuronal alterations in rats with hyperammonemia, which supports the potential use of this oil to ameliorate the changes that occur in hepatic encephalopathy.
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Affiliation(s)
- Marcos F. Ocaña-Sánchez
- Programa de Doctorado en Ciencias Biomédicas, Centro de Investigaciones Biomédicas, Universidad Veracruzana, Xalapa 91190, Mexico
- Facultad de Química Farmacéutica Biológica, Universidad Veracruzana, Xalapa 91090, Mexico; (G.A.S.-O.); (Y.C.-R.)
| | - Gabriel A. Soto-Ojeda
- Facultad de Química Farmacéutica Biológica, Universidad Veracruzana, Xalapa 91090, Mexico; (G.A.S.-O.); (Y.C.-R.)
| | - Yolanda Cocotle-Ronzón
- Facultad de Química Farmacéutica Biológica, Universidad Veracruzana, Xalapa 91090, Mexico; (G.A.S.-O.); (Y.C.-R.)
| | - Cesar Soria-Fregozo
- Laboratorio Ciencias Biomédicas/área Histología y Psicobiología, Departamento de Ciencias de la Tierra y de la Vida, Centro Universitario de los Lagos, Universidad de Guadalajara, Lagos de Moreno 47460, Mexico;
| | - Alberto Sánchez-Medina
- Instituto de Química Aplicada, Universidad Veracruzana, Xalapa 91190, Mexico; (A.S.-M.); (R.V.G.-R.)
| | - Rosa V. García-Rodríguez
- Instituto de Química Aplicada, Universidad Veracruzana, Xalapa 91190, Mexico; (A.S.-M.); (R.V.G.-R.)
| | | | - Erick J. Corro-Méndez
- Facultad de Ciencias Biológicas y Agropecuarias, Universidad Veracruzana, Amatlán 94945, Mexico;
| | - Minerva Hernández-Lozano
- Facultad de Química Farmacéutica Biológica, Universidad Veracruzana, Xalapa 91090, Mexico; (G.A.S.-O.); (Y.C.-R.)
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17
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Ivchenko GS, Lobzhanidze NN, Rusina DS, Denisova EV, Ivchenko AA. [Mild post-COVID syndrome in young patients]. TERAPEVT ARKH 2023; 95:674-678. [PMID: 38158904 DOI: 10.26442/00403660.2023.08.202349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 10/10/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Many COVID-19 survivors suffer from post-COVID syndrome, which significantly worsens the quality of life. Its presentation is quite diverse, with cognitive disorders being of particular importance. Liver injury due to the direct virus action and the treatment of the new coronavirus infection can persist for a long time during the recovery period and lead to hyperammonemia, which can cause cognitive disorders, including minimal hepatic encephalopathy. AIM To study cognitive disorders in post-COVID syndrome and the possibility of their treatment with L-ornithine-L-aspartate. MATERIALS AND METHODS The study included 30 students from 18 to 24 years old who had COVID-19 and decreased attention, memory impairment, and other cognitive disorders inherent in hepatic encephalopathy of latent (grade 0) or mild (grade 1) severity, without pronounced impairment of intelligence, memory, speech, and learning ability. Hyperammonemia, elevated alanine aminotransferase, aspartate aminotransferase, and ã-glutamyl transpeptidase, signs of hepatic encephalopathy according to psychometric tests, were reported in young people. All patients in the study were treated with L-ornithine-L-aspartate to correct the ammonia blood level and improve signs of hepatic encephalopathy and the general condition. RESULTS AND CONCLUSION An improvement in the objective findings, liver enzymes, a decrease in ammonia level, and an improvement in testing results for changes in cognitive functions were reported.
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18
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Pané A, Milad C, Santana-Domínguez M, Baños N, Borras-Novell C, Espinosa G, Magnano L, Nomdedeu M, Moreno-Lozano PJ, Cofan F, Placeres M, Fernández RM, García-Villoria J, Garrabou G, Vinagre I, Tanner LM, Montserrat-Carbonell C, Forga-Visa MDT. Lysinuric Protein Intolerance and Its Nutritional and Multisystemic Challenges in Pregnancy: A Case Report and Literature Review. J Clin Med 2023; 12:6405. [PMID: 37835050 PMCID: PMC10573933 DOI: 10.3390/jcm12196405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/01/2023] [Accepted: 10/07/2023] [Indexed: 10/15/2023] Open
Abstract
Lysinuric protein intolerance (LPI) is a rare inborn error of metabolism (IEM), classified as an inherited aminoaciduria, caused by mutations in the SLC7A7 gene, leading to a defective cationic amino acid transport. The metabolic adaptations to the demands of pregnancy and delivery cause significant physiological stress, so those patients affected by IEM are at greater risk of decompensation. A 28-year-old woman with LPI had experienced 3 early miscarriages. While pregnancy was finally achieved, diverse nutritional and medical challenges emerged (food aversion, intrauterine growth restriction, bleeding risk, and preeclampsia suspicion), which put both the mother and the fetus at risk. Moreover, the patient requested a natural childbirth (epidural-free, delayed cord clamping). Although the existence of multiple safety concerns rejected this approach at first, the application of novel strategies made a successful delivery possible. This case reinforces that the woman's wish for a non-medicated, low-intervention natural birth should not be automatically discouraged because of an underlying complex metabolic condition. Achieving a successful pregnancy is conceivable thanks to the cooperation of interdisciplinary teams, but it is still important to consider the risks beforehand in order to be prepared for possible additional complications.
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Affiliation(s)
- Adriana Pané
- Endocrinology and Nutrition Department, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Adult Inborn Errors of Metabolism Unit, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red de la Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain
| | - Camila Milad
- Endocrinology and Nutrition Department, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
| | - Marta Santana-Domínguez
- Neonatology Department, BCNatal (Barcelona Center for Fetal and Neonatal Medicine), Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
| | - Núria Baños
- Neonatology Department, BCNatal (Barcelona Center for Fetal and Neonatal Medicine), Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Fundació Clínic per la Recerca Biomèdica (FCR), Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Cristina Borras-Novell
- Neonatology Department, BCNatal (Barcelona Center for Fetal and Neonatal Medicine), Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
| | - Gerard Espinosa
- Fundació Clínic per la Recerca Biomèdica (FCR), Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Autoimmune Diseases Unit, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
| | - Laura Magnano
- Fundació Clínic per la Recerca Biomèdica (FCR), Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Department of Hematology, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
| | - Meritxell Nomdedeu
- Department of Hematology, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
| | - Pedro Juan Moreno-Lozano
- Adult Inborn Errors of Metabolism Unit, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Internal Medicine Department, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Asociación Española para el Estudio de los Errores Congénitos del Metabolismo (AECOM), 28221 Majadahonda, Spain
| | - Frederic Cofan
- Renal Transplantation and Nephrology Department, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
| | - Mercè Placeres
- Adult Inborn Errors of Metabolism Unit, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Pharmacy Department, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
| | - Rosa Maria Fernández
- Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
| | - Judit García-Villoria
- Adult Inborn Errors of Metabolism Unit, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Asociación Española para el Estudio de los Errores Congénitos del Metabolismo (AECOM), 28221 Majadahonda, Spain
- Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain
| | - Glòria Garrabou
- Adult Inborn Errors of Metabolism Unit, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain
- Inherited Metabolic Diseases and Muscle Disorders Laboratory, FCRB-IDIBAPS and Faculty of Medicine and Heath Sciences, University of Barcelona, 08036 Barcelona, Spain
| | - Irene Vinagre
- Endocrinology and Nutrition Department, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Fundació Clínic per la Recerca Biomèdica (FCR), Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Laura M. Tanner
- Fetomaternal Medical Center and Department of Clinical Genetics, Helsinki University Hospital, Department of Medical and Clinical Genetics, University of Helsinki, 00251 Helsinki, Finland
| | - Cristina Montserrat-Carbonell
- Endocrinology and Nutrition Department, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Adult Inborn Errors of Metabolism Unit, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Asociación Española para el Estudio de los Errores Congénitos del Metabolismo (AECOM), 28221 Majadahonda, Spain
| | - Maria de Talló Forga-Visa
- Endocrinology and Nutrition Department, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Adult Inborn Errors of Metabolism Unit, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
- Asociación Española para el Estudio de los Errores Congénitos del Metabolismo (AECOM), 28221 Majadahonda, Spain
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Sammar A, Tawfik M, Fatima F, Butler A, Aylor-Lee K. Valproate-Induced Hyperammonemic Encephalopathy Causing New-Onset Seizures. Cureus 2023; 15:e47288. [PMID: 38021840 PMCID: PMC10656206 DOI: 10.7759/cureus.47288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Valproate-induced hyperammonemic encephalopathy (VHE) is a rare and severe side effect that can occur with valproic acid (VPA) therapy, despite therapeutic doses and normal serum levels of valproate. The typical signs of this condition include a sudden onset of impaired consciousness, focal neurologic symptoms, and an increase in seizure frequency. The exact cause of VHE is unknown, but it is believed to be related to the accumulation of toxic VPA metabolites and increased levels of ammonia that can cause swelling of the astrocytes and cerebral edema. We present a case of a 19-year-old male patient with a history of bipolar disorder on valproic acid 250 mg daily, admitted to the hospital after a new-onset seizure. He was found to have elevated levels of ammonia in his blood, despite having therapeutic levels of valproate and no liver dysfunction. His symptoms improved with discontinuation of the medication and his ammonia levels decreased. We discuss possible mechanisms and risk factors leading to encephalopathy while on valproate therapy. VHE should be considered a possibility when patients treated with valproate show signs of impaired consciousness.
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Affiliation(s)
- Aleena Sammar
- Internal Medicine, Parkview Medical Center, Pueblo, USA
| | - Mena Tawfik
- Internal Medicine/Gastroenterology, Parkview Medical Center, Pueblo, USA
| | - Fareha Fatima
- Internal Medicine, Parkview Medical Center, Pueblo, USA
| | - Adam Butler
- Internal Medicine, Parkview Medical Center, Pueblo, USA
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20
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Kosenko EA, Alilova GA, Tikhonova LA. Impaired Enzymatic Antioxidant Defense in Erythrocytes of Rats with Ammonia-Induced Encephalopathy: Role of NMDA Receptors. Biochemistry (Mosc) 2023; 88:1404-1415. [PMID: 37770406 DOI: 10.1134/s0006297923090195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 09/30/2023]
Abstract
Hepatic encephalopathy (HE), a neuropsychiatric disorder developing in patients with severe hepatic dysfunction, has been known for more than a century. However, pathogenetic mechanisms of cerebral dysfunction associated with liver disease are still poorly understood. There is a consensus that the primary cause of HE is accumulation of ammonia in the brain as a result of impaired liver detoxification capacity or the portosystemic shunt. Current evidence suggests that ammonia toxicity is mediated by hyperactivation of glutamate receptors, mainly N-methyl-D-aspartate receptors (NMDARs), and affects brain aerobic metabolism, which provides energy for multiple specific functions and neuronal viability. Recent reports on the presence of functional NMDARs in erythrocytes and the data on the deviations of blood parameters from their normal ranges indicate impaired hemodynamics and reduced oxygen-carrying capacity of erythrocytes in most patients with HE, thus suggesting a relationship between erythrocyte damage and cerebral dysfunction. In order to understand how hyperammonemia (HA)-induced disturbances in the energy metabolism in the brain (which needs a constant supply of large amounts of oxygen in the blood) lead to encephalopathy, it is necessary to reveal ammonia-induced impairments in the energy metabolism and antioxidant defense system of erythrocytes and to explore a potential role of ammonia in reduced brain oxygenation. To identify the said missing link, the activities of antioxidant enzymes and concentrations of reduced glutathione (GSH), oxidized glutathione (GSSG), and H2O2 were measured in the erythrocytes of rats with HA that were injected with the noncompetitive NMDAR antagonist MK-801. We found that in rats with HA, ammonia was accumulated in erythrocytes (cells lacking ammonia removal enzymes), which made them more susceptible to the prooxidant environment created during oxidative stress. This effect was completely or partially inhibited by MK-801. The data obtained might help to identify the risk factors in cognitive disorders and facilitate prediction of unfavorable outcomes of hypoperfusion in patients with a blood elevated ammonia concentration.
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Affiliation(s)
- Elena A Kosenko
- Institute of Theoretical and Experimental Biophysics of the Russian Academy of Sciences, Pushchino, Moscow Region, 142290, Russia.
| | - Gubidat A Alilova
- Institute of Theoretical and Experimental Biophysics of the Russian Academy of Sciences, Pushchino, Moscow Region, 142290, Russia
| | - Lyudmila A Tikhonova
- Institute of Theoretical and Experimental Biophysics of the Russian Academy of Sciences, Pushchino, Moscow Region, 142290, Russia
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21
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Wada H, Goto M, Misonou M. Hyperammonemia Due to Empyema. Intern Med 2023; 62:2527-2529. [PMID: 36725045 PMCID: PMC10518550 DOI: 10.2169/internalmedicine.0922-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/06/2022] [Indexed: 02/03/2023] Open
Abstract
A 91-year-old woman was brought to our hospital with altered consciousness. Blood tests showed an increased ammonia level of 468 μg/dL and a normal liver function. Chest computed tomography showed massive right pleural effusion with loculation. We immediately performed chest drainage using two drainage tubes. The pleural effusate pH was 8.5. We diagnosed her with right empyema leading to hyperammonemia and initiated ampicillin/sulbactam therapy. However, she developed progressive renal failure and died on the third day. Empyema caused by urease-producing bacteria can lead to hyperammonemia. This is the first report of hyperammonemia due to empyema in the English literature.
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Affiliation(s)
- Hiroshi Wada
- Department of Respiratory Medicine, National Hospital Organization Higashi-ohmi General Medical Center, Japan
| | - Miyuki Goto
- Department of Respiratory Medicine, National Hospital Organization Higashi-ohmi General Medical Center, Japan
| | - Masashi Misonou
- Department of Respiratory Medicine, National Hospital Organization Higashi-ohmi General Medical Center, Japan
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22
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Baba C, Yukimasa S, Yasuno R, Ichiyanagi H, Ninagawa J, Kasuya S, Kasahara M, Horikawa R, Nagasaka Y, Suzuki Y. Anesthesia management protocol for liver transplantation as treatment for ornithine transcarbamylase deficiency. Paediatr Anaesth 2023; 33:620-630. [PMID: 37401903 DOI: 10.1111/pan.14691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/18/2023] [Accepted: 04/20/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Ornithine transcarbamylase deficiency is an X-linked genetic disorder that induces accumulation of ammonia in the liver and is the most common urea cycle disorder. The clinical manifestation of ornithine transcarbamylase deficiency is hyperammonemia that causes irreversible neurological damage. Liver transplantation is a curative therapy for ornithine transcarbamylase deficiency. The aim of this study is to suggest, from our previous experience, an anesthesia management protocol of liver transplantation for ornithine transcarbamylase deficiency, particularly focused on liver transplantation for cases with uncontrolled hyperammonemia. METHOD We retrospectively reviewed our anesthesia-related experience in all cases of liver transplantation for ornithine transcarbamylase deficiency in our center. RESULTS Twenty-nine liver transplantation cases for ornithine transcarbamylase deficiency were found between November 2005 and March 2021 in our center. Of these, 25 cases were stable through the perioperative period. However, 2 cases with carrier donor graft had hyperammonemia after liver transplantation. Another two cases had uncontrolled hyperammonemia before liver transplantation, even with continuous hemodialysis. They underwent life-saving liver transplantation. Their metabolic status stabilized after the anhepatic phase. CONCLUSION Liver transplantation for cases with uncontrolled hyperammonemia can be performed with proper management. Second, liver transplantation with carrier donors should be avoided because of the risk of postoperative recurrence.
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Affiliation(s)
- Chiaki Baba
- Division of Anesthesia, Department of Critical Care and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
| | - Sho Yukimasa
- Division of Anesthesia, Department of Critical Care and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
| | - Risa Yasuno
- Department of Anesthesiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hiroki Ichiyanagi
- Division of Anesthesia, Department of Critical Care and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
| | - Jun Ninagawa
- Division of Anesthesia, Department of Critical Care and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
| | - Shugo Kasuya
- Division of Anesthesia, Department of Critical Care and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Center for Organ Transplantation, National Center for Child Health and Development, Tokyo, Japan
| | - Reiko Horikawa
- Division of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | - Yasuko Nagasaka
- Department of Anesthesiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yasuyuki Suzuki
- Division of Anesthesia, Department of Critical Care and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
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Balzano T, Llansola M, Arenas YM, Izquierdo-Altarejos P, Felipo V. Hepatic encephalopathy: investigational drugs in preclinical and early phase development. Expert Opin Investig Drugs 2023; 32:1055-1069. [PMID: 37902074 DOI: 10.1080/13543784.2023.2277386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 10/26/2023] [Indexed: 10/31/2023]
Abstract
INTRODUCTION Hepatic encephalopathy (HE) is a neuropsychiatric syndrome, in patients with liver disease, which affects life quality and span. Current treatments are lactulose or rifaximin, acting on gut microbiota. Treatments aiming ammonia levels reduction have been tested with little success. AREAS COVERED Pre-clinical research shows that the process inducing HE involves sequentially: liver failure, altered microbiome, hyperammonemia, peripheral inflammation, changes in immunophenotype and extracellular vesicles and neuroinflammation, which alters neurotransmission impairing cognitive and motor function. HE may be reversed using drugs acting at any step: modulating microbiota with probiotics or fecal transplantation; reducing peripheral inflammation with anti-TNFα, autotaxin inhibitors or silymarin; reducing neuroinflammation with sulforaphane, p38 MAP kinase or phosphodiesteras 5 inhibitors, antagonists of sphingosine-1-phosphate receptor 2, enhancing meningeal lymphatic drainage or with extracellular vesicles from mesenchymal stem cells; reducing GABAergic neurotransmission with indomethacin or golexanolone. EXPERT OPINION A factor limiting the progress of HE treatment is the lack of translation of research advances into clinical trials. Only drugs acting on microbiota or ammonia reduction have been tested in patients. It is urgent to change the mentality on how to approach HE treatment to develop clinical trials to assess drugs acting on the immune system/peripheral inflammation, neuroinflammation or neurotransmission to improve HE.
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Affiliation(s)
- Tiziano Balzano
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
- HM CINAC (Centro Integral de Neurociencias Abarca Campal), Hospital Universitario HM Puerta del Sur, HM Hospitales, Madrid, Spain
| | - Marta Llansola
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Yaiza M Arenas
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
- Departamento de Patología, Facultad de Medicina, Universidad Valencia, Valencia, Spain
| | | | - Vicente Felipo
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
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24
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Baskar D, Lakshmi V, Nalini A, Arunachal G, Bhat MD, Nanjaiah ND, Yadav R, Chowdary R, Raja P, Mounika A, Sharath PS, Vengalil S. Adult Onset Episodic Encephalopathy Due to Citrin Deficiency-A Case Report. Ann Indian Acad Neurol 2023; 26:553-555. [PMID: 37970284 PMCID: PMC10645226 DOI: 10.4103/aian.aian_175_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/18/2023] [Accepted: 04/08/2023] [Indexed: 11/17/2023] Open
Abstract
Hyperammonemia is a rare cause of adult episodic encephalopathy. Citrin deficiency resulting in citrullinemia type 2 (CTLN2) can lead to recurrent delirium in adults. Here we report a case of adult onset episodic encephalopathy due to citrin deficiency. A 40 years old male presented with one-year history of episodic encephalopathy triggered by high protein and fat diet. He also had chronic pancreatitis and subacute intestinal obstruction which is a novel manifestation of CTLN2. Evaluation showed elevated blood liver enzymes, ammonia, and citrulline. MRI brain showed frontal hyperintensities and bulky basal ganglia which have not been reported. Diagnosis was confirmed by next-generation sequencing which showed a novel variant c. 1591G > A in exon15 of SLC25A13. Hyperammonemic syndromes should be considered in differential diagnosis of episodic encephalopathy in adults. This report shows novel features of subacute intestinal obstruction and MRI findings in CTLN2 expanding spectrum of manifestation.
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Affiliation(s)
- Dipti Baskar
- Department of Neurology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Vathsala Lakshmi
- Department of Neurology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Atchayaram Nalini
- Department of Neurology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Gautham Arunachal
- Department of Human Genetics, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Maya Dhattatraya Bhat
- Department of Neuroradiology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | | | - Ravi Yadav
- Department of Neurology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Ravindranadh Chowdary
- Department of Neurology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Pritam Raja
- Department of Neurology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Ambati Mounika
- Department of Neurology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - PS Sharath
- Department of Neurology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Seena Vengalil
- Department of Neurology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
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25
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Kimura S, Fujisaki Y, Onizuka C, Hasuike S, Sato Y, Mukai S, Kamoto T. A case of hyperammonemia occurring during treatment of metastatic renal cell carcinoma with axitinib. IJU Case Rep 2023; 6:206-210. [PMID: 37405030 PMCID: PMC10315238 DOI: 10.1002/iju5.12586] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/15/2023] [Indexed: 07/06/2023] Open
Abstract
Introduction Although the incidence of hyperammonemia as an adverse event of tyrosine kinase inhibitors is quite low, several cases of tyrosine kinase inhibitor associated hyperammonemia have been reported. We report a case of hyperammonemia, that occurred during combined treatment with axitinib and pembrolizumab in a metastatic renal cell carcinoma patient without hepatic disorder or liver metastases. Case presentation A 77-year-old Japanese woman was diagnosed with metastatic renal cell carcinoma and was treated with pembrolizumab and axitinib. Both agents were subsequently discontinued due to hyperammonemia with hypothyroidism. After recovery, the patient resumed single-agent therapy with axitinib. However, hyperammonemia and hypothyroidism occurred again, suggesting axitinib-inducible adverse event. After nephrectomy, a lower dose of axitinib was restarted and continued safely for residual metastases under prophylactic treatment with aminoleban, lactulose, and levothyroxine. Conclusion The rare occurrence of hyperammonemia should be considered during treatment with VEGFR- targeted tyrosine kinase inhibitor including axitinib, and supportive prophylactic medication may be useful.
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Affiliation(s)
- Shoichi Kimura
- Department of Urology, Faculty of MedicineMiyazaki University HospitalMiyazakiJapan
| | - Yukiya Fujisaki
- Department of UrologyMiyazaki Prefectural Nichinan HospitalMiyazakiJapan
| | - Chie Onizuka
- Department of UrologyMiyazaki Prefectural Nichinan HospitalMiyazakiJapan
| | - Satoru Hasuike
- Department of Internal medicine, Gastroenterology and Hepatology, Faculty of MedicineMiyazaki University HospitalMiyazakiJapan
| | - Yuichiro Sato
- Department of Diagnostic Pathology, Faculty of MedicineMiyazaki University HospitalMiyazakiJapan
| | - Shoichiro Mukai
- Department of Urology, Faculty of MedicineMiyazaki University HospitalMiyazakiJapan
| | - Toshiyuki Kamoto
- Department of Urology, Faculty of MedicineMiyazaki University HospitalMiyazakiJapan
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26
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Kawakami T, Fukaguchi K, Isogai N, Koyama H. Severe Hyperammonemia Due to Fecal Bowel Obstruction With a Congenital Portosystemic Shunt Resulting in Refractory Status Epilepticus and Cerebral Edema. Cureus 2023; 15:e42452. [PMID: 37637566 PMCID: PMC10449597 DOI: 10.7759/cureus.42452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 08/29/2023] Open
Abstract
Hyperammonemic encephalopathy is a neurological emergency that can lead to seizures and cerebral edema. Although early interventions have been suggested, no clear criteria have been established. Herein, we report a case of severe non-hepatic hyperammonemia resulting in refractory status epilepticus within a day. A 79-year-old woman presented with acute altered mental status. Initial evaluation revealed septic shock and hyperammonemia due to fecal bowel obstruction with congenital portosystemic shunt. The patient was unresponsive to medical treatment and developed refractory status epilepticus. After surgical drainage with colostomy and a decrease in ammonia level, the patient developed cerebral edema and did not recover from the coma. Severe hyperammonemia warrants early intervention, especially in critically ill patients, with treatment of the cause and augmented removal of ammonia with renal replacement therapy.
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Affiliation(s)
- Tetsuro Kawakami
- Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, JPN
| | | | - Naoko Isogai
- Department of Surgery, Shonan Kamakura General Hospital, Kanagawa, JPN
| | - Hiroshi Koyama
- Division of Critical Care, Shonan Kamakura General Hospital, Kanagawa, JPN
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27
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Kuyama N, Nagaki S, Miyamoto A, Etou K, Maruyama H, Osawa M. Arginase deficiency with parotid gland swelling and hyperamylasemia: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231181836. [PMID: 37377459 PMCID: PMC10291395 DOI: 10.1177/2050313x231181836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/27/2023] [Indexed: 06/29/2023] Open
Abstract
Arginase deficiency is a progressive neurological disorder characterized by episodic hyperammonemia crises. Our patient had been diagnosed with cerebral palsy (spastic paraplegia) in childhood and received rehabilitation. She had suffered parotid swelling since the age of 5 years, prior to liver dysfunction becoming apparent, and then developed hyperamylasemia at 8 years of age. At age 25 years, she presented with hyperammonemia and elevations of aspartate aminotransferase and alanine aminotransferase. At age 27 years, she was diagnosed with arginase deficiency due to hyperargininemia and absent arginase activity in erythrocytes. Liver cirrhosis was also present. She was hospitalized several times for management of episodic hyperammonemia due to recurrent viral infections, an unbalanced diet, and poor compliance with medications.
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Affiliation(s)
- Noboru Kuyama
- Department of Pediatrics, Tokyo Women’s Medical University, Tokyo, Japan
- Kuyama Children’s Clinic, Chiba, Japan
| | - Shigeru Nagaki
- Department of Pediatrics, Tokyo Women’s Medical University, Tokyo, Japan
- Nagaki Children’s Clinic, Tokyo, Japan
| | - Akie Miyamoto
- Department of Pediatrics, Tokyo Women’s Medical University, Tokyo, Japan
| | - Kaoru Etou
- Department of Pediatrics, Tokyo Women’s Medical University, Tokyo, Japan
| | - Hiroshi Maruyama
- Department of Pediatrics, Tokyo Women’s Medical University, Tokyo, Japan
- Matudo Clinic, Chiba, Japan
| | - Makiko Osawa
- Department of Pediatrics, Tokyo Women’s Medical University, Tokyo, Japan
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28
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Wang ZX, Wang MY, Yang RX, Ren TY, Zhao ZH, Xin FZ, Fan JG. Limited role for hyperammonemia in the progression of diet-induced nonalcoholic steatohepatitis. J Dig Dis 2023; 24:408-418. [PMID: 37529891 DOI: 10.1111/1751-2980.13214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 07/10/2023] [Accepted: 07/31/2023] [Indexed: 08/03/2023]
Abstract
OBJECTIVES To determine whether hyperammonemia has a direct impact on steatohepatitis in mice fed with a high-fat diet (HFD). METHODS Male C57BL/6 mice were divided into two groups receiving either chow diet or HFD. After 12-week NASH modeling, hyperammonemia was induced by intragastric administration of ammonium chloride solution (NH4 Cl) or liver-specific carbamoyl phosphate synthetase 1 (Cps1) knockdown. In vitro experiments were performed in HepG2 cells induced by free fatty acid (FFA) and NH4 Cl. RESULTS NH4 Cl administration led to increased levels of plasma and hepatic ammonia in NASH mice. NH4 Cl-induced hyperammonemia did not influence liver histological changes in mice fed with HFD; however, elevated plasma cholesterol level, and an increasing trend of liver lipid content were observed. No significant effect of hyperammonemia on hepatic inflammation and fibrosis in NASH mice was found. In vitro cell experiments showed that NH4 Cl treatment failed to increase the lipid droplet content and the expressions of de novo lipogenesis genes in HepG2 cells induced by FFA. The knockdown of Cps1 in HFD-fed mice resulted in elevated plasma ammonia levels but did not cause histological change in the liver. CONCLUSIONS Our study revealed a limited role of ammonia in aggravating the progression of NASH. Further studies are needed to clarify the role and mechanism of ammonia in NASH development.
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Affiliation(s)
- Zi Xuan Wang
- Department of Gastroenterology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Meng Yu Wang
- Department of Gastroenterology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rui Xu Yang
- Department of Gastroenterology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tian Yi Ren
- Department of Gastroenterology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ze Hua Zhao
- Department of Gastroenterology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Hepatology, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
| | - Feng Zhi Xin
- Department of Gastroenterology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian Gao Fan
- Department of Gastroenterology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Lab of Pediatric Gastroenterology and Nutrition, Shanghai, China
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29
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Wigston C, Lavender M, Long R, Sankhesara D, Ching D, Weaire-Buchanan G, Mowlaboccus S, Coombs GW, Lam K, Wrobel J, Yaw MC, Musk M, Boan P. Mycoplasma and Ureaplasma Donor-Derived Infection and Hyperammonemia Syndrome in 4 Solid Organ Transplant Recipients From a Single Donor. Open Forum Infect Dis 2023; 10:ofad263. [PMID: 37323424 PMCID: PMC10264062 DOI: 10.1093/ofid/ofad263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 05/17/2023] [Indexed: 06/17/2023] Open
Abstract
Hyperammonemia syndrome (HS) is a life-threatening condition occurring in solid organ transplant patients, affecting primarily lung recipients, and is associated with Mycoplasma hominis and/or Ureaplasma spp infection. The organ donor was a young man who died of hypoxic brain injury and had urethral discharge antemortem. The donor and 4 solid organ transplant recipients had infection with M hominis and/or Ureaplasma spp. The lung and heart recipients both developed altered conscious state and HS associated with M hominis and Ureaplasma spp infections. Despite treatment with antibiotics and ammonia scavengers, both the lung and heart recipients died at day +102 and day +254, respectively. After diagnosis in the thoracic recipients, screening samples from the liver recipient and 1 kidney recipient were culture positive for M hominis with or without Ureaplasma spp. Neither the liver nor kidney recipients developed HS. Our case series demonstrates the unique finding of M hominis and Ureaplasma spp dissemination from an immunocompetent donor across 4 different organ recipients. Phylogenetic whole genome sequencing analysis demonstrated that M hominis samples from recipients and donor were closely related, suggesting donor-derived infection. Screening of lung donors and/or recipients for Mycoplasma and Ureaplasma spp is recommended, as well as prompt treatment with antimicrobials to prevent morbidity.
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Affiliation(s)
- Charlotte Wigston
- Correspondence: Charlotte Wigston, MBBCh, PGCertHPE, MRCP, Department of Respiratory Medicine, Fiona Stanley Hospital, Murdoch, Perth, WA 6150, Australia (); Peter Boan, MBBS, FRACP, FRCPA, Department of Microbiology, PathWest Laboratory Medicine Western Australia, Fiona Stanley Hospital, Murdoch, Perth, WA 6150, Australia ()
| | - Melanie Lavender
- Advanced Lung Disease Unit, Fiona Stanley Hospital,Murdoch, Western Australia, Australia
| | - Rebecca Long
- Advanced Lung Disease Unit, Fiona Stanley Hospital,Murdoch, Western Australia, Australia
| | - Dipen Sankhesara
- Advanced Heart Failure Unit, Fiona Stanley Hospital,Murdoch, Western Australia, Australia
| | - David Ching
- Advanced Lung Disease Unit, Fiona Stanley Hospital,Murdoch, Western Australia, Australia
| | - Graham Weaire-Buchanan
- Department of Microbiology, PathWest Laboratory Medicine Western Australia, Fiona Stanley Hospital,Murdoch, Western Australia, Australia
| | - Shakeel Mowlaboccus
- Department of Microbiology, PathWest Laboratory Medicine Western Australia, Fiona Stanley Hospital,Murdoch, Western Australia, Australia
- College of Science, Health, Engineering and Education, Murdoch University, Perth, Western Australia, Australia
| | - Geoffrey W Coombs
- Department of Microbiology, PathWest Laboratory Medicine Western Australia, Fiona Stanley Hospital,Murdoch, Western Australia, Australia
- College of Science, Health, Engineering and Education, Murdoch University, Perth, Western Australia, Australia
| | - Kaitlyn Lam
- Advanced Heart Failure Unit, Fiona Stanley Hospital,Murdoch, Western Australia, Australia
| | - Jeremy Wrobel
- Advanced Lung Disease Unit, Fiona Stanley Hospital,Murdoch, Western Australia, Australia
- Department of Medicine, University of Notre Dame, Perth, Western Australia, Australia
| | - Meow Cheong Yaw
- Advanced Lung Disease Unit, Fiona Stanley Hospital,Murdoch, Western Australia, Australia
| | - Michael Musk
- Advanced Lung Disease Unit, Fiona Stanley Hospital,Murdoch, Western Australia, Australia
| | - Peter Boan
- Correspondence: Charlotte Wigston, MBBCh, PGCertHPE, MRCP, Department of Respiratory Medicine, Fiona Stanley Hospital, Murdoch, Perth, WA 6150, Australia (); Peter Boan, MBBS, FRACP, FRCPA, Department of Microbiology, PathWest Laboratory Medicine Western Australia, Fiona Stanley Hospital, Murdoch, Perth, WA 6150, Australia ()
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30
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Li M, Chen X, Chen H, Hu L, Cao Y, Cheng G, Wang L, Wu B, Lu W, Yang L, Zhou W. Genetic background and clinical characteristics of infantile hyperammonemia. Transl Pediatr 2023; 12:882-889. [PMID: 37305718 PMCID: PMC10248927 DOI: 10.21037/tp-22-359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 03/15/2023] [Indexed: 06/13/2023] Open
Abstract
Background This study was conducted to analyze the genetic spectrum and clinical characteristics of infantile hyperammonemia. Methods Between January 2016 and June 2020, we retrospectively enrolled infantile hyperammonemia patients with definitive genetic diagnosis at the Children's Hospital of Fudan University. Based on the age of hyperammonemia onset, patients were grouped into neonatal and post-neonatal subgroups to compare their genetic and clinical features. Results Collectively, 136 pathogenic or likely pathogenic variants of the 33 genes were identified. Fourteen genes were reported with hyperammonemia (42%, 14/33), with SLC25A13 and MUT being the top two detected genes. In contrast, 19 genes, which have not been previously reported with hyperammonemia, were detected (58%, 19/33), in which JAG1 and ABCC8 were the most frequently mutated genes. Compared with post-neonatal hyperammonemia, neonatal patients with hyperammonemia presented with higher rates of organic acidemia (P=0.001) and fatty acid oxidation disorder (P=0.006), but a lower rate of cholestasis (P<0.001). Patients with neonatal hyperammonemia had a higher ratio of peak plasma ammonia level ≥500 µmol/L (P=0.003) and were more likely to receive precision medicine (P=0.027); however, they had a refractory clinical course (P=0.001) and poorer prognosis than the infantile group. Conclusions There were significant differences in the genetic spectrum, clinical features, clinical course, and outcomes between infants with different hyperammonemia onset ages.
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Affiliation(s)
- Mengyao Li
- Department of Neonatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Xiang Chen
- Department of Neonatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Huiyao Chen
- Clinical Genetic Center, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Liyuan Hu
- Department of Neonatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Yun Cao
- Department of Neonatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Guoqiang Cheng
- Department of Neonatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Laishuan Wang
- Department of Neonatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Bingbing Wu
- Clinical Genetic Center, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Wei Lu
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Lin Yang
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Wenhao Zhou
- Department of Neonatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
- Clinical Genetic Center, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
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31
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Kim JS, Lio KU, Henderson H, Pourshahid S. A Case of Acute Encephalopathy After the Initiation of FOLFOX Chemotherapy in a Patient With Colon Cancer. Cureus 2023; 15:e37237. [PMID: 37162780 PMCID: PMC10164293 DOI: 10.7759/cureus.37237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2023] [Indexed: 05/11/2023] Open
Abstract
Acute encephalopathy is a change in the level of consciousness where the underlying etiology can be difficult to diagnose, and thus, difficult to treat, especially in the context of multi-organ diseases. We report a case of acute encephalopathy in a patient with end-stage renal disease (ESRD) on hemodialysis, chronic hypotension, and a recent diagnosis of colon cancer who presented shortly after initiation of FOLFOX, a chemotherapy regimen for treatment of colorectal cancer comprised of folinic acid (leucovorin), fluorouracil (5-FU), and oxaliplatin (eloxatin). We present a systematic approach to elucidate ambiguous causes of toxic-metabolic encephalopathy.
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Affiliation(s)
- Jin S Kim
- Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, USA
| | - Ka U Lio
- Internal Medicine, Temple University Hospital, Philadelphia, USA
| | | | - Seyedmohammad Pourshahid
- Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, USA
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32
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Jeong ISD, Abiri P, Cai J, Yim C, Powell L. A Case of Non-cirrhotic Hyperammonemic Encephalopathy in a Patient With Metastatic Gastrointestinal Stromal Tumor. Cureus 2023; 15:e37541. [PMID: 37193452 PMCID: PMC10182871 DOI: 10.7759/cureus.37541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 05/18/2023] Open
Abstract
Acute toxic encephalopathy (ATE) is a widely recognized medical emergency with an expansive differential. One particular known etiology for ATE is elevated ammonia, a powerful neurotoxin that often presents with clinical findings of confusion, disorientation, tremors, and in severe cases, coma and death. Hyperammonemia is most commonly associated with liver disease and presents as hepatic encephalopathy in the setting of decompensated cirrhosis; however, in rare cases, a patient may suffer from non-cirrhotic hyperammonemic encephalopathy. We describe the case of a 61-year-old male with metastatic gastrointestinal stromal tumor who was diagnosed with non-cirrhotic hyperammonemic encephalopathy, and briefly explore the literature describing its mechanisms.
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Affiliation(s)
- Il Seok D Jeong
- Internal Medicine, Olive View - University of California, Los Angeles (UCLA) Medical Center, Sylmar, USA
| | - Parinaz Abiri
- Internal Medicine, Olive View - University of California, Los Angeles (UCLA) Medical Center, Sylmar, USA
| | - Johnny Cai
- Hematology and Oncology, Olive View - University of California, Los Angeles (UCLA) Medical Center, Sylmar, USA
| | - Catherine Yim
- Neurology/Radiology, Olive View - University of California, Los Angeles (UCLA) Medical Center, Sylmar, USA
| | - Leland Powell
- Hematology and Oncology, Olive View - University of California, Los Angeles (UCLA) Medical Center, Sylmar, USA
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33
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Nakamura H, Takada K, Murase K, Ikeda H, Iyama S, Manabe T, Kobune M. Multiple Myeloma with Hyperammonemia Treated with Novel Agents: A Case Series of Three Patients. Intern Med 2023; 62:775-778. [PMID: 35871579 PMCID: PMC10037000 DOI: 10.2169/internalmedicine.0010-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Multiple myeloma (MM) is a cancer characterized by the expansion of plasma cells in the bone marrow. Survival times of patients with MM have increased due to the development of novel therapeutic agents. We herein highlight three MM cases that had a poor prognosis despite treatment with novel therapeutic agents. Of note, all patients presented with hyperammonemia that led to a consciousness disorder. The outcome for patients with MM showing high levels of serum ammonia continues to be poor, even with the use of novel therapies. For such patients showing a consciousness disorder, hyperammonemia should be considered as a possible cause.
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Affiliation(s)
- Hajime Nakamura
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Japan
| | - Kohichi Takada
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Japan
| | - Kazuyuki Murase
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Japan
| | - Hiroshi Ikeda
- Department of Hematology, Sapporo Medical University School of Medicine, Japan
| | - Satoshi Iyama
- Department of Hematology, Sapporo Medical University School of Medicine, Japan
| | - Tatsuo Manabe
- Department of Neurology, Sapporo Medical University School of Medicine, Japan
| | - Masayoshi Kobune
- Department of Hematology, Sapporo Medical University School of Medicine, Japan
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34
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Molla GK, Kağnıcı M, Günlemez A, Yeni Y, Ünal Uzun Ö. Two cases of MEGDHEL syndrome diagnosed with hyperammonemia. J Pediatr Endocrinol Metab 2023; 36:203-206. [PMID: 36517456 DOI: 10.1515/jpem-2022-0418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/13/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES MEGDHEL [3-methylglutaconic aciduria (MEG), deafness (D), hepatopathy (H), encephalopathy (E), and Leigh-like disease (L)] syndrome is an autosomal recessive disorder caused by mutations in the serine active site-containing protein 1 (SERAC1) gene. MEGDHEL syndrome is clinically characterized by sensorineural hearing loss, encephalopathy, hepatopathy, 3-methylglutaconic aciduria, and Leigh-like lesions on cranial magnetic resonance imaging. During the neonatal period, it has been reported to present with hypoglycemia, hyperammonemia, impaired liver functions, cholestasis, metabolic acidosis, and sepsis-like clinical findings. However, clinical findings in the neonatal period were reported as a result of the retrospective evaluation of patients diagnosed at an older age. Herein we reported two cases diagnosed as MEGDHEL syndrome during neonatal period in two different clinics with sepsis-like findings, impaired liver functions, and ammonia levels high enough to require dialysis. CASE PRESENTATION One of the cases was born 37 weeks of gestation with a birth weight of 2,060 g and initially presented with respiratory distress and feeding difficulties. The other case admitted to the neonatal intensive care unit had fed problems together with respiratory distress and circulatory failure within the first 24 h after initiation of parenteral nutrition. CONCLUSIONS MEGDHEL syndrome should be suspected in patients with sepsis-like clinical features and hyperammonemia.
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Affiliation(s)
- Gülhan Karakaya Molla
- Division of Pediatric Metabolism, Faculty of Medicine, Kocaeli University, İzmit, Kocaeli, Türkiye
| | - Mehtap Kağnıcı
- Antalya Training and Research Hospital, Pediatric Metabolism Clinic, Antalya, Türkiye
| | - Ayla Günlemez
- Division of Neonatalogy, Faculty of Medicine, Kocaeli University, İzmit, Kocaeli, Türkiye
| | - Yaşar Yeni
- Antalya Training and Research Hospital, Neonatal İntensive Care, Antalya, Türkiye
| | - Özlem Ünal Uzun
- Division of Pediatric Metabolism, Faculty of Medicine, Kocaeli University, İzmit, Kocaeli, Türkiye
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35
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De Los Santos-La Torre MA, Del Águila-Villar CM, Lu-de Lama LR, Nuñez-Almache O, Chávez-Tejada EM, Espinoza-Robles OA, Pinto-Ibárcena PM, Calagua-Quispe MR, Azabache-Tafur PM, Tucto-Manchego RM. Hyperinsulinism- hyperammonemia syndrome in two Peruvian children with refractory epilepsy. J Pediatr Endocrinol Metab 2023; 36:207-211. [PMID: 36476334 DOI: 10.1515/jpem-2022-0490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Congenital hyperinsulinism (HI) is a heterogeneous clinical disorder with great variability in its clinical phenotype, and to date, pathogenic variants in 23 genes have been recognized. Hyperinsulinism-hyperammonemia syndrome (HI/HA) is the second most frequent cause of this disease that shows an autosomal dominant pattern and is caused by an activating mutation of the GLUD1 gene, which responds favorably to the use of diazoxide. HI/HA syndrome presents with fasting hypoglycemia; postprandial hypoglycemia, especially in those with a high protein content (leucine); and persistent mild hyperammonemia. Neurological abnormalities, in the form of epilepsy or neurodevelopmental delay, are observed in a high percentage of patients; therefore, timely diagnosis is crucial for proper management. CASE PRESENTATION We report the clinical presentation of two Peruvian children that presented with epilepsy whose genetic analysis revealed a missense mutation in the GLUD1 gene, one within exon 11, at 22% mosaicism; and another within exon 7, as well as their response to diazoxide therapy. To the best of our knowledge, these are the first two cases of HI/HA syndrome reported in Peru. CONCLUSIONS HI/HA syndrome went unnoticed, because hypoglycemia was missed and were considered partially controlled epilepsies. A failure to recognize hypoglycemic seizures will delay diagnosis and adequate treatment, so a proper investigation could avoid irreversible neurological damage.
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Affiliation(s)
| | - Carlos Manuel Del Águila-Villar
- Department of Endocrinology and Metabolism of The Child's Health National Institute, Instituto Nacional de Salud del Niño, Lima, Peru.,Faculty Member of the Medical School, Universidad Nacional Federico Villareal, Lima, Peru
| | - Luis Rómulo Lu-de Lama
- Department of Endocrinology and Metabolism of The Child's Health National Institute, Instituto Nacional de Salud del Niño, Lima, Peru
| | - Oswaldo Nuñez-Almache
- Department of Endocrinology and Metabolism of The Child's Health National Institute, Instituto Nacional de Salud del Niño, Lima, Peru.,Faculty Member of the Medical School, Universidad Nacional Federico Villareal, Lima, Peru
| | - Eliana Manuela Chávez-Tejada
- Department of Endocrinology and Metabolism of The Child's Health National Institute, Instituto Nacional de Salud del Niño, Lima, Peru
| | - Oscar Antonio Espinoza-Robles
- Department of Endocrinology and Metabolism of The Child's Health National Institute, Instituto Nacional de Salud del Niño, Lima, Peru
| | - Paola Marianella Pinto-Ibárcena
- Department of Endocrinology and Metabolism of The Child's Health National Institute, Instituto Nacional de Salud del Niño, Lima, Peru
| | - Martha Rosario Calagua-Quispe
- Department of Endocrinology and Metabolism of The Child's Health National Institute, Instituto Nacional de Salud del Niño, Lima, Peru
| | - Pamela Miluska Azabache-Tafur
- Department of Endocrinology and Metabolism of The Child's Health National Institute, Instituto Nacional de Salud del Niño, Lima, Peru.,Pediatric endocrinology fellow, Universidad Nacional Federico Villareal, Lima, Peru
| | - Rosa María Tucto-Manchego
- Department of Endocrinology and Metabolism of The Child's Health National Institute, Instituto Nacional de Salud del Niño, Lima, Peru.,Pediatric endocrinology fellow, Universidad Nacional Federico Villareal, Lima, Peru
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36
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Abstract
Hepatic encephalopathy (HE) is a neuropsychiatric syndrome derived from metabolic disorders due to various liver failures. Clinically, HE is characterized by hyperammonemia, EEG abnormalities, and different degrees of disturbance in sensory, motor, and cognitive functions. The molecular mechanism of HE has not been fully elucidated, although it is generally accepted that HE occurs under the influence of miscellaneous factors, especially the synergistic effect of toxin accumulation and severe metabolism disturbance. This review summarizes the recently discovered cellular mechanisms involved in the pathogenesis of HE. Among the existing hypotheses, ammonia poisoning and the subsequent oxidative/nitrosative stress remain the mainstream theories, and reducing blood ammonia is thus the main strategy for the treatment of HE. Other pathological mechanisms mainly include manganese toxicity, autophagy inhibition, mitochondrial damage, inflammation, and senescence, proposing new avenues for future therapeutic interventions.
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37
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Zorgdrager M, Cuperus FJC, de Haas RJ. Hyperammonemic Encephalopathy in a Patient with Pancreatic Neuroendocrine Tumor and Portosystemic Shunt. Diagnostics (Basel) 2023; 13:diagnostics13030572. [PMID: 36766677 PMCID: PMC9914007 DOI: 10.3390/diagnostics13030572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 01/29/2023] [Accepted: 02/01/2023] [Indexed: 02/08/2023] Open
Abstract
Hyperammonemia can lead to encephalopathy and may be accompanied by a diagnostic dilemma. Imaging as well as biochemical analyses are the cornerstone for identifying possible underlying causes such as severe liver disease or urea cycle defect. We report a case of a patient that presented with neurological deficits based on hyperammonemia in the presence of a large pancreatic neuroendocrine tumor (PNET) and portosystemic shunts in the liver. Prior cases are rather scarce, and the exact mechanism is not fully understood. The case illustrates the added value of a multimodality imaging approach in patients presenting with hyperammonemia-induced encephalopathy.
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Affiliation(s)
- Marcel Zorgdrager
- Department of Radiology, University Medical Centre Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
- Correspondence:
| | - Frans J. C. Cuperus
- Department of Gastro-Enterology and Hepatology, University Medical Centre Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| | - Robbert J. de Haas
- Department of Radiology, University Medical Centre Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
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38
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Köhler JP, Merkel M. [When a mild alcohol intoxication leads to liver failure and coma. The danger of unrecognized urea cycle disorders]. MMW Fortschr Med 2023; 165:22-24. [PMID: 36849767 DOI: 10.1007/s15006-023-2337-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Affiliation(s)
- Jan Philipp Köhler
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Martin Merkel
- endokrinologikum Hamburg, Lornsenstr. 6, 22767, Hamburg, Deutschland.
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39
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Borsuk M, Saab M, Tobin M. Rare Adult-onset Citrullinemia Type 1 in the Postpartum Period: A Case Report. Clin Pract Cases Emerg Med 2023; 7:20-23. [PMID: 36859323 PMCID: PMC9983343 DOI: 10.5811/cpcem.2022.10.57277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 10/13/2022] [Indexed: 02/23/2023] Open
Abstract
INTRODUCTION Citrullinemia type 1 (CTLN1) is a urea cycle disorder caused by defective argininosuccinate synthetase leading to impaired ammonia elimination. Urea cycle disorders are typically diagnosed on neonatal screening but rarely can lie dormant until a metabolic stressor causes initial onset of symptoms in adulthood. CASE REPORT A 23-year-old female presented four days postpartum to the emergency department (ED) obtunded and declined to the point of requiring intubation. Labs revealed hyperammonemia, and she was subsequently found to have CTLN1. CONCLUSION Urea cycle disorders presenting in adulthood are a rare etiology for the common ED complaint of altered mental status. The low incidence makes these treatable disorders easy to overlook leading to potentially significant morbidity and mortality. Therefore, it is important to recognize the risk factors that can trigger an acute metabolic derangement. This case highlights common risk factors for metabolic stress, possible presenting symptoms, and the positive outcome achievable when recognized and treated in a timely fashion.
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Affiliation(s)
| | - Mathew Saab
- Madigan Army Medical Center, Department of Emergency Medicine, Tacoma, Washington
| | - Michael Tobin
- Madigan Army Medical Center, Department of Emergency Medicine, Tacoma, Washington
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40
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Thompson S, Hertzog A, Selvanathan A, Batten K, Lewis K, Nisbet J, Mitchell A, Dalkeith T, Billmore K, Moore F, Tolun AA, Devanapalli B, Bratkovic D, Hilditch C, Rahman Y, Tchan M, Bhattacharya K. Treatment of HMG-CoA Lyase Deficiency-Longitudinal Data on Clinical and Nutritional Management of 10 Australian Cases. Nutrients 2023; 15. [PMID: 36771238 DOI: 10.3390/nu15030531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
3-Hydroxy-3-Methylglutaryl-CoA Lyase (HMGCL) deficiency can be a very severe disorder that typically presents with acute metabolic decompensation with features of hypoketotic hypoglycemia, hyperammonemia, and metabolic acidosis. A retrospective chart and literature review of Australian patients over their lifespan, incorporating acute and long-term dietary management, was performed. Data from 10 patients contributed to this study. The index case of this disorder was lost to follow-up, but there is 100% survival in the remainder of the cases despite several having experienced life-threatening episodes. In the acute setting, five of nine patients have used 900 mg/kg/day of sodium D,L 3-hydroxybutyrate in combination with intravenous dextrose-containing fluids (delivering glucose above estimated basal utilization requirements). All patients have been on long-term protein restriction, and those diagnosed more recently have had additional fat restriction. Most patients take L-carnitine. Three children and none of the adults take nocturnal uncooked cornstarch. Of the cohort, there were two patients that presented atypically-one with fulminant liver failure and the other with isolated developmental delay. Dietary management in patients with HMGCL deficiency is well tolerated, and rapid institution of acute supportive metabolic treatment is imperative to optimizing survival and improve outcomes in this disorder.
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41
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MOHR MAGNI, ERMIDIS GEORGIOS, JAMURTAS ATHANASIOSZ, VIGH-LARSEN JF, POULIOS ATHANASIOS, DRAGANIDIS DIMITRIOS, PAPANIKOLAOU KONSTANTINOS, TSIMEAS PANAGIOTIS, BATSILAS DIMITRIOS, LOULES GEORGIOS, BATRAKOULIS ALEXIOS, SOVATZIDIS APOSTOLOS, NIELSEN JAKOBL, TZATZAKIS THEOFANIS, DELI CHARIKLEIAK, NYBO LARS, KRUSTRUP PETER, FATOUROS IOANNISG. Extended Match Time Exacerbates Fatigue and Impacts Physiological Responses in Male Soccer Players. Med Sci Sports Exerc 2023; 55:80-92. [PMID: 35977104 PMCID: PMC9770137 DOI: 10.1249/mss.0000000000003021] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE This study evaluated how extended match time (90 + 30 min) affected physiological responses and fatigue in male soccer players. METHODS Twenty competitive players (mean ± SD: age, 20 ± 1 yr; maximal oxygen uptake, 59 ± 4 mL·min -1 ·kg -1 ) completed an experimental match with their activity pattern and heart rate assessed throughout the game, whereas countermovement jump performance and repeated sprint ability were tested and quadriceps muscle biopsies and venous blood samples were taken at baseline and after 90 and 120 min of match play. RESULTS Less high-intensity running (12%) was performed in extra time in association with fewer intense accelerations and decelerations per minute compared with normal time. Peak sprint speed was 11% lower in extra time compared with normal time, and fatigue also manifested in impaired postmatch repeated sprint ability and countermovement jump performance (all P < 0.05). Muscle glycogen declined from 373 ± 59 mmol·kg -1 dry weight (dw) at baseline to 266 ± 64 mmol·kg -1 dw after 90 min, with a further decline to 186 ± 56 mmol·kg -1 dw after extra time ( P < 0.05) and with single-fiber analyses revealing depleted or very low glycogen levels in ~75% of both slow and fast twitch fibers. Blood glucose did not change during the first 90-min but declined ( P < 0.05) to 81 ± 8 mg·dL -1 after extra time. Plasma glycerol and ammonia peaked at 236 ± 33 mg·dL -1 and 75 ± 21 μmol·L -1 after the extra period. CONCLUSIONS These findings demonstrate exacerbated fatigue after extra time compared with normal time, which seems to be associated with muscle glycogen depletion, reductions in blood glucose levels, and hyperammonemia. Together, this points to metabolic disturbances being a major part of the integrated and multifaceted fatigue response during extended soccer match play.
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Affiliation(s)
- MAGNI MOHR
- Department of Sports Science and Clinical Biomechanics, SDU Sport and Health Sciences Cluster (SHSC), University of Southern Denmark, Odense, DENMARK,Centre of Health Science, Faculty of Health Sciences, University of the Faroe Islands, Tórshavn, FAROE ISLANDS
| | - GEORGIOS ERMIDIS
- Department of Sports Science and Clinical Biomechanics, SDU Sport and Health Sciences Cluster (SHSC), University of Southern Denmark, Odense, DENMARK
| | - ATHANASIOS Z. JAMURTAS
- Department of Physical Education and Sport Science, University of Thessaly, Karies, Trikala, GREECE
| | - Jeppe F. VIGH-LARSEN
- Department of Sports Science and Clinical Biomechanics, SDU Sport and Health Sciences Cluster (SHSC), University of Southern Denmark, Odense, DENMARK,Department of Public Health, Section of Sport Science, Aarhus University, Aarhus, DENMARK
| | - ATHANASIOS POULIOS
- Department of Physical Education and Sport Science, University of Thessaly, Karies, Trikala, GREECE
| | - DIMITRIOS DRAGANIDIS
- Department of Physical Education and Sport Science, University of Thessaly, Karies, Trikala, GREECE
| | | | - PANAGIOTIS TSIMEAS
- Department of Physical Education and Sport Science, University of Thessaly, Karies, Trikala, GREECE
| | - DIMITRIOS BATSILAS
- Department of Physical Education and Sport Science, University of Thessaly, Karies, Trikala, GREECE
| | - GEORGIOS LOULES
- Department of Physical Education and Sport Science, University of Thessaly, Karies, Trikala, GREECE
| | - ALEXIOS BATRAKOULIS
- Department of Physical Education and Sport Science, University of Thessaly, Karies, Trikala, GREECE
| | | | - JAKOB L. NIELSEN
- Department of Sports Science and Clinical Biomechanics, SDU Sport and Health Sciences Cluster (SHSC), University of Southern Denmark, Odense, DENMARK
| | - THEOFANIS TZATZAKIS
- Department of Physical Education and Sport Science, University of Thessaly, Karies, Trikala, GREECE
| | - CHARIKLEIA K. DELI
- Department of Physical Education and Sport Science, University of Thessaly, Karies, Trikala, GREECE
| | - LARS NYBO
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, DENMARK
| | - PETER KRUSTRUP
- Department of Sports Science and Clinical Biomechanics, SDU Sport and Health Sciences Cluster (SHSC), University of Southern Denmark, Odense, DENMARK,Danish Institute for Advanced Study (DIAS), University of Southern Denmark, Odense, DENMARK,Sport and Health Sciences, University of Exeter, Exeter, UNITED KINGDOM
| | - IOANNIS G. FATOUROS
- Department of Physical Education and Sport Science, University of Thessaly, Karies, Trikala, GREECE
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42
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Grazioli A, Podell JE, Iacono A, Krupnik AS, Madathil RJ, Shah SR. Treatment of hyperammonemia using in-line renal replacement and hyperosmolar therapies within an extracorporeal membrane oxygenation circuit. Perfusion 2023; 38:193-196. [PMID: 34320858 DOI: 10.1177/02676591211035939] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
After orthotopic lung transplantation, hyperammonemia can be a rare complication secondary to infection by organisms that produce urease or inhibit the urea cycle. This can cause neurotoxicity, cerebral edema, and seizures. Ammonia is unique in that it has a large volume of distribution. However, it is also readily dialyzable given its small molecular weight. As such, removal of ammonia requires renal replacement modalities that can both rapidly remove ammonia from the plasma space and allow for continuous removal to prevent rebound accumulation from intracellular stores. Prevention of iatrogenic osmotic lowering in this setting is required to prevent worsening of cerebral edema. Herein, we describe use of sequential in-line renal replacement therapy using both intermittent hemodialysis and continuous venovenous hemofiltration within an extracorporeal membrane oxygenation circuit in conjunction with higher sodium dialysate and 7.5% hypertonic saline to achieve these treatment goals.
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Affiliation(s)
- Alison Grazioli
- Department of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jamie E Podell
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Aldo Iacono
- Department of Medicine and Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Ronson J Madathil
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sanjeev R Shah
- Division of Renal Electrolyte and Hypertension, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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García Vega M, Andrade JD, Morais A, Frauca E, Muñoz Bartolo G, Lledín MD, Bergua A, Hierro L. Urea cycle disorders and indications for liver transplantation. Front Pediatr 2023; 11:1103757. [PMID: 36937980 PMCID: PMC10020209 DOI: 10.3389/fped.2023.1103757] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 02/01/2023] [Indexed: 03/06/2023] Open
Abstract
Urea cycle disorders (UCD) are inborn errors of metabolism caused by deficiency of enzymes required to convert nitrogen from ammonia into urea. Current paradigms of treatment focus on dietary manipulations, ammonia scavenger drugs, and liver transplantation. The aim of this study was to describe the characteristics and indication of liver transplantation in UCD in a tertiary hospital. We performed a retrospective study of children with UCD seen in the period 2000-2021. Data was collected on clinical onset, hyperammonemia severity, evolution and liver transplantation. There were 33 patients in the study period, whose diagnosis were: ornithine transcarbamylase (OTC, n = 20, 10 females), argininosuccinate synthetase (ASS, n = 6), carbamylphosphate synthetase 1 (CPS1, n = 4), argininosuccinate lyase (ASL, n = 2) and N-acetylglutamate synthetase (NAGS, n = 1) deficiency. Thirty one were detected because of clinical symptoms (45% with neonatal onset). The other 2 were diagnosed being presymptomatic, by neonatal/family screening. Neonatal forms (n = 14) were more severe, all of them presented during the first week of life as severe hyperammonemia (mean peak 1,152 µmol/L). Seven patients died (6 at debut) and all survivors received transplantation. There was no mortality among the late forms. Of the 27 patients who did not die in the neonatal period, 16 (59%) received liver transplantationwith 100% survival, normal protein tolerance and usual need of citrulline supplementation. The transplant's metabolic success was accompanied by neurologic sequelae in 69%, but there was no progression of brain damage. Decision of continuous medical treatment in 11 patients appeared to be related with preserved neurodevelopment and fewer metabolic crises.
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Affiliation(s)
- Marta García Vega
- Department of Pediatric Hepatology & Liver Transplant, Hospital Universitario La Paz & IdiPAZ, ERN Rare-Liver, ERN Trasplant Child, Madrid, Spain
- Correspondence: Marta García Vega
| | - José D. Andrade
- Department of Pediatric Nutrition and Metabolic Diseases, Hospital Universitario La Paz, Madrid, Spain
| | - Ana Morais
- Department of Pediatric Nutrition and Metabolic Diseases, Hospital Universitario La Paz, Madrid, Spain
| | - Esteban Frauca
- Department of Pediatric Hepatology & Liver Transplant, Hospital Universitario La Paz & IdiPAZ, ERN Rare-Liver, ERN Trasplant Child, Madrid, Spain
| | - Gema Muñoz Bartolo
- Department of Pediatric Hepatology & Liver Transplant, Hospital Universitario La Paz & IdiPAZ, ERN Rare-Liver, ERN Trasplant Child, Madrid, Spain
| | - María D. Lledín
- Department of Pediatric Hepatology & Liver Transplant, Hospital Universitario La Paz & IdiPAZ, ERN Rare-Liver, ERN Trasplant Child, Madrid, Spain
| | - Ana Bergua
- Department of Pediatric Nutrition and Metabolic Diseases, Hospital Universitario La Paz, Madrid, Spain
| | - Loreto Hierro
- Department of Pediatric Hepatology & Liver Transplant, Hospital Universitario La Paz & IdiPAZ, ERN Rare-Liver, ERN Trasplant Child, Madrid, Spain
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Margaryan SR, Razumovsky AY, Mitupov ZB, Gurevich AI, Titova EA. [Reconstruction of total portosystemic shunt into selective portosystemic shunt in a child]. Khirurgiia (Mosk) 2023:140-146. [PMID: 38088852 DOI: 10.17116/hirurgia2023121140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
To date, side-to-side splenorenal shunt (SRS) and its analogues (splenosuprarenal shunts (SSRS)) are mainly used for portal hypertension. These are total portosystemic shunts characterized by total blood shunt from portal vein into inferior vena cava. The latter is fraught with a significant risk of complications such as pulmonary hypertension, decreased portal liver perfusion, liver failure and hepatic encephalopathy. Prevention of these complications is still an urgent problem in modern surgery. However, we proposed a new method of treatment, i.e. reconstruction of SRS and SSRS into selective shunt. This procedure was performed in 37 patients after 2020. We present laparoscopic reconstruction in an 11-year-old girl with portal hypertension and signs of hepatic encephalopathy identified after previous SSRS.
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Affiliation(s)
- S R Margaryan
- Pirogov Russian National Research Medical University, Moscow, Russia
- Children's City Clinical Hospital named after N.F. Filatov, Moscow, Russia
| | - A Yu Razumovsky
- Pirogov Russian National Research Medical University, Moscow, Russia
- Children's City Clinical Hospital named after N.F. Filatov, Moscow, Russia
| | - Z B Mitupov
- Pirogov Russian National Research Medical University, Moscow, Russia
- Children's City Clinical Hospital named after N.F. Filatov, Moscow, Russia
| | - A I Gurevich
- Children's City Clinical Hospital named after N.F. Filatov, Moscow, Russia
| | - E A Titova
- Children's City Clinical Hospital named after N.F. Filatov, Moscow, Russia
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45
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Margaryan SR, Mitupov ZB, Razumovsky AY. [Hepatic encephalopathy after portosystemic bypass surgery]. Khirurgiia (Mosk) 2023:57-65. [PMID: 37379406 DOI: 10.17116/hirurgia202307157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
The most effective modern treatment for gastrointestinal bleeding following portal hypertension is portosystemic bypass surgery. Hepatic encephalopathy after these procedures is still an urgent problem in modern pediatric surgery, and radical treatment is unknown. To optimize treatment outcomes in children with hepatic encephalopathy, we should choose adequate treatment considering the risk of hepatic encephalopathy in the future. In this review, the authors discuss modern data on hepatic encephalopathy regarding symptoms, advantages and disadvantages of various treatment methods. Risk of hepatic encephalopathy with and without surgical treatment, as well as methods of diagnosis and treatment are particularly analyzed. Total portosystemic bypass surgery, especially portocaval shunt, is followed by higher risk of hepatic encephalopathy compared to selective shunts and physiological mesoportal bypass. The last two approaches are advisable to improve treatment outcomes in children with hepatic encephalopathy.
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Affiliation(s)
- S R Margaryan
- Pirogov Russian National Research Medical University, Moscow, Russia
- N.F. Filatov Children's City Clinical Hospital, Moscow, Russia
| | - Z B Mitupov
- Pirogov Russian National Research Medical University, Moscow, Russia
- N.F. Filatov Children's City Clinical Hospital, Moscow, Russia
| | - A Yu Razumovsky
- Pirogov Russian National Research Medical University, Moscow, Russia
- N.F. Filatov Children's City Clinical Hospital, Moscow, Russia
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Etemad L, Roohbakhsh A, Abbaspour A, Alizadeh Ghamsari A, Amin F, Moshiri M. The effect of sodium benzoate, L-carnitine, and phenylacetate on valproate-induced hyperammonemia in Male Wistar rats. Int J Physiol Pathophysiol Pharmacol 2022; 14:324-331. [PMID: 36741198 PMCID: PMC9890203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 06/28/2022] [Indexed: 02/07/2023]
Abstract
INTRODUCTION L-carnitine (LC) is commonly used in the treatment of valproate-induced hyperammonemia (VIHA). LC prevents the production of ammonia with no significant effect on renal ammonia excretion. This study was conducted to evaluate the effect of sodium benzoate (SB) and phenyl acetate (PA) on reducing VIHA. MATERIALS AND METHODS Eight groups treated with Sodium Valproate (SV) at 300 mg/kg and 15 minutes later with normal saline, SB (144 mg/kg), PA (0.3 g/kg), LC (2.5 g/kg), SB (144 mg/kg) plus PA (0.3 g/kg), or SB (144 mg/kg) plus PA (0.3 g/kg) plus LC (2.5 g/kg), intraperitoneally. Other groups were exposed to normal saline, SB, LC or PA alone. Animal's motor function and serum ammonia, lactate, and sodium levels were assessed at 0.5, 1, and 1.5 hours after the SV injection. RESULTS The results showed that LC reduced SV-induced hyperammonemia just at one and half-hour after treatment (P<0.001). PA, alone or in combination with other antidotes, reduced serum ammonia at all evaluated times (P<0.001). LC improved the impaired motor function of animals only at 1.5 hours, while PA, alone or in combination decreased the motor function scores at different times. However, SB administration alone did not change SV-induced hyperammonemia or motor function impairment. There was no significant difference in the level of serum aminotransferases, blood urea nitrogen, and creatinine between groups. CONCLUSION These findings define that PA had a better therapeutic effect on valproate-induced hyperammonemia in comparison with SB. Co-administration of LC with PA ameliorated the elevated levels of ammonia and may relieve potential therapeutic application against acute SV intoxication.
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Affiliation(s)
- Leila Etemad
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical SciencesMashhad, Iran
| | - Ali Roohbakhsh
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical SciencesMashhad, Iran,Department of Pharmacodynamics and Toxicology, School of Pharmacy, Mashhad University of Medical SciencesMashhad, Iran
| | - Abolfazl Abbaspour
- Department of Pharmacodynamics and Toxicology, School of Pharmacy, Mashhad University of Medical SciencesMashhad, Iran
| | - Anahita Alizadeh Ghamsari
- Medical Toxicology Research Center, School of Medicine, Mashhad University of Medical SciencesMashhad, Iran
| | - Fatemeh Amin
- Department of Physiology and Pharmacology, School of Medicine, Rafsanjan University of Medical SciencesRafsanjan, Iran
| | - Mohammad Moshiri
- Medical Toxicology Research Center, School of Medicine, Mashhad University of Medical SciencesMashhad, Iran,Department of Clinical Toxicology, Imam Reza Hospital, Mashhad University of Medical SciencesMashhad, Iran
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Ni B, Qin M, Zhao J, Guo Q. A glance at transient hyperammonemia of the newborn: Pathophysiology, diagnosis, and treatment: A review. Medicine (Baltimore) 2022; 101:e31796. [PMID: 36482558 PMCID: PMC9726343 DOI: 10.1097/md.0000000000031796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Hyperammonemia is the excessive accumulation of ammonia in the blood, and is usually defined as a plasma level above 100 µmol/L in neonates or above 50 µmol/L in term infants, children, and adolescents. Patients with hyperammonemia usually experience life-threatening neuropsychiatric symptoms, especially newborns. It is routinely caused by inherited metabolic diseases and also by acquired disorders, such as liver failure, portosystemic shunting, gastrointestinal hemorrhage, ureterosigmoidostomy, renal tubular acidosis, hypoxic ischemic encephalopathy, infections with urea-metabolizing organisms, and some drugs. Transient hyperammonemia of the newborn (THAN) is a special type of hyperammonemia acknowledged in the field of metabolic disease as an inwell-defined or well-understood entity, which can be diagnosed only after the exclusion of genetic and acquired causes of hyperammonemia. Although the prognosis for THAN is good, timely identification and treatment are essential. Currently, THAN is underdiagnosed and much less is mentioned for early diagnosis and vigorous treatment. Herein, we present common themes that emerge from the pathogenesis, diagnosis, and management of THAN, based on current evidence. When a newborn presents with sepsis, intracranial hemorrhage, or asphyxia that cannot explain coma and seizures, doctors should always keep this disease in mind.
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Affiliation(s)
- Beibei Ni
- Department of Clinical Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Miao Qin
- Department of Neonatology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jun Zhao
- Department of Clinical Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Qie Guo
- Department of Clinical Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao, China
- * Correspondence: Qie Guo, Department of Clinical Pharmacy, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, Shandong 266003, China (e-mail: )
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48
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Qiu H, Gao T, Qian T, Cao Y, Cheng G, Wang L. Factors associated with short-term survival in neonates with hyperammonemia. Transl Pediatr 2022; 11:1899-1907. [PMID: 36643675 PMCID: PMC9834949 DOI: 10.21037/tp-22-70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 10/31/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Hyperammonemia due to inherited metabolic disease can lead to neurological sequelae and death in neonates. Metabolite scavenger (MS) administration and dialysis can be helpful. We aim at analyzing the factors affecting short-term survival in neonates with hyperammonemia. METHODS We conducted a retrospective study including all neonates with hyperammonemia admitted to the neonatal intensive care unit (NICU) of the Children's Hospital of Fudan University between April 2013 and June 2020. RESULTS Sixty-two neonates were enrolled in the study. Of these, 32 neonates were included in the non-survival group, and 30 neonates in the survival group. Compared to the survival group, the non-survival group had a higher peak ammonia level (882.2 vs. 433.4 µmol/L) (P=0.002), a shorter length of stay (5.7 vs. 22.3 d) (P<0.000), and higher rates of acidosis (19 vs. 10) (P=0.047), electrolyte disturbance (15 vs. 6) (P=0.033), coma (12 vs. 2) (P=0.005), and invasive mechanical ventilation (28 vs. 8) (P=0.000). A longer length of stay was the most significant protective factors in the multivariate logistic regression analysis, followed by MS administration. Factors of invasive mechanical ventilation, Δ<0 (Δ= last ammonia level - first ammonia level), coma and electrolyte disturbance established a risk score model that performed well in survival analysis. Area under ROC curve for survival length of hyperammonemia combined with peak ammonia levels was 0.737 (95% CI: 0.603-0.870). CONCLUSIONS MS administration is an effective treatment method for hyperammonemia in neonates, and increasing the length of stay in the NICU could help improve short-term survival. Further intervention should be administered when peak ammonia levels >406.5 µmol/L.
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Affiliation(s)
- Han Qiu
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China.,Key Laboratory of Neonatal Disease, Ministry of Health, Shanghai, China
| | - Ting Gao
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China.,Key Laboratory of Neonatal Disease, Ministry of Health, Shanghai, China
| | - Tianyang Qian
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China.,Key Laboratory of Neonatal Disease, Ministry of Health, Shanghai, China
| | - Yun Cao
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China.,Key Laboratory of Neonatal Disease, Ministry of Health, Shanghai, China
| | - Guoqiang Cheng
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China.,Key Laboratory of Neonatal Disease, Ministry of Health, Shanghai, China
| | - Laishuan Wang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China.,Key Laboratory of Neonatal Disease, Ministry of Health, Shanghai, China
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Semenova N, Marakhonov A, Ampleeva M, Kurkina M, Baydakova G, Skoblov M, Taran N, Babak O, Shchukina E, Strokova T. Hyperammonemia in Russia Due to Carbonic Anhydrase VA Deficiency Caused by Homozygous Mutation p.Lys185Lys (c.555G>A) of the CA5A Gene. Int J Mol Sci 2022; 23. [PMID: 36499355 DOI: 10.3390/ijms232315026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 12/02/2022] Open
Abstract
Hyperammonemia due to carbonic anhydrase VA deficiency (OMIM# 615751) is a rare, life-threatening hereditary disease caused by biallelic mutations in the CA5A gene, presenting as encephalopathic hyperammonemia of unexplained origin during the neonatal period and infancy. Here, we present a detailed description of a 5-year-old patient with the homozygous mutation p.Lys185Lys (c.555G>A) in the CA5A gene. This variant was previously described by van Karnebeek et al. in 2014 in a boy of Russian origin. We found a high frequency of carriers of this mutation in Russia; 1:213, which is 7 times higher than the expected frequency calculated based on data on Western European populations. Thus, targeted testing for the mutation p.Lys185Lys (c.555G>A) in the CA5A gene should be useful for early detection by selective screening in neonatal intensive care units.
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Bazo A, Lantero A, Mauleón I, Neri L, Poms M, Häberle J, Ricobaraza A, Bénichou B, Combal JP, Gonzalez-Aseguinolaza G, Aldabe R. Gene Therapy in Combination with Nitrogen Scavenger Pretreatment Corrects Biochemical and Behavioral Abnormalities of Infant Citrullinemia Type 1 Mice. Int J Mol Sci 2022; 23:14940. [PMID: 36499263 PMCID: PMC9736988 DOI: 10.3390/ijms232314940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 12/02/2022] Open
Abstract
Citrullinemia type I (CTLN1) is a rare autosomal recessive disorder caused by mutations in the gene encoding argininosuccinate synthetase 1 (ASS1) that catalyzes the third step of the urea cycle. CTLN1 patients suffer from impaired elimination of nitrogen, which leads to neurotoxic levels of circulating ammonia and urea cycle byproducts that may cause severe metabolic encephalopathy, death or irreversible brain damage. Standard of care (SOC) of CTLN1 consists of daily nitrogen-scavenger administration, but patients remain at risk of life-threatening decompensations. We evaluated the therapeutic efficacy of a recombinant adeno-associated viral vector carrying the ASS1 gene under the control of a liver-specific promoter (VTX-804). When administered to three-week-old CTLN1 mice, all the animals receiving VTX-804 in combination with SOC gained body weight normally, presented with a normalization of ammonia and reduction of citrulline levels in circulation, and 100% survived for 7 months. Similar to what has been observed in CTLN1 patients, CTLN1 mice showed several behavioral abnormalities such as anxiety, reduced welfare and impairment of innate behavior. Importantly, all clinical alterations were notably improved after treatment with VTX-804. This study demonstrates the potential of VTX-804 gene therapy for future clinical translation to CTLN1 patients.
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Affiliation(s)
- Andrea Bazo
- Division of Gene Therapy and Regulation of Gene Expression, CIMA, University of Navarra, 31008 Pamplona, Spain
| | | | - Itsaso Mauleón
- Division of Gene Therapy and Regulation of Gene Expression, CIMA, University of Navarra, 31008 Pamplona, Spain
| | - Leire Neri
- Vivet Therapeutics, S.L., 31008 Pamplona, Spain
| | - Martin Poms
- Department of Clinical Chemistry and Biochemistry, University Children’s Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Johannes Häberle
- Division of Metabolism, Children’s Research Centre (CRC), University Children’s Hospital Zurich, 8091 Zurich, Switzerland
| | - Ana Ricobaraza
- Division of Gene Therapy and Regulation of Gene Expression, CIMA, University of Navarra, 31008 Pamplona, Spain
| | | | | | - Gloria Gonzalez-Aseguinolaza
- Division of Gene Therapy and Regulation of Gene Expression, CIMA, University of Navarra, 31008 Pamplona, Spain
- Vivet Therapeutics, S.L., 31008 Pamplona, Spain
| | - Rafael Aldabe
- Division of Gene Therapy and Regulation of Gene Expression, CIMA, University of Navarra, 31008 Pamplona, Spain
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