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Yap S, Lamireau D, Feillet F, Ruiz Gomez A, Davison J, Tangeraas T, Giordano V. Real-World Experience of Carglumic Acid for Methylmalonic and Propionic Acidurias: An Interim Analysis of the Multicentre Observational PROTECT Study. Drugs R D 2024; 24:69-80. [PMID: 38198106 PMCID: PMC11035519 DOI: 10.1007/s40268-023-00449-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Methylmalonic aciduria (MMA) and propionic aciduria (PA) are organic acidurias characterised by the accumulation of toxic metabolites and hyperammonaemia related to secondary N-acetylglutamate deficiency. Carglumic acid, a synthetic analogue of N-acetylglutamate, decreases ammonia levels by restoring the functioning of the urea cycle. However, there are limited data available on the long-term safety and effectiveness of carglumic acid. Here, we present an interim analysis of the ongoing, long-term, prospective, observational PROTECT study (NCT04176523), which is investigating the long-term use of carglumic acid in children and adults with MMA and PA. METHODS Individuals with MMA or PA from France, Germany, Italy, Norway, Spain, Sweden and the UK who have received at least 1 year of carglumic acid treatment as part of their usual care are eligible for inclusion. The primary objective is the number and duration of acute metabolic decompensation events with hyperammonaemia (ammonia level >159 µmol/L during a patient's first month of life or >60 µmol/L thereafter, with an increased lactate level [> 1.8 mmol/L] and/or acidosis [pH < 7.35]) before and after treatment with carglumic acid. Peak plasma ammonia levels during the last decompensation event before and the first decompensation event after carglumic acid initiation, and the annualised rate of decompensation events before and after treatment initiation are also being assessed. Secondary objectives include the duration of hospital stay associated with decompensation events. Data are being collected at approximately 12 months' and 18 months' follow-up. RESULTS Of the patients currently enrolled in the PROTECT study, data from ten available patients with MMA (n = 4) and PA (n = 6) were analysed. The patients had received carglumic acid for 14-77 (mean 36) months. Carglumic acid reduced the median peak ammonia level of the total patient population from 250 µmol/L (range 97-2569) before treatment to 103 µmol/L (range 97-171) after treatment. The annualised rate of acute metabolic decompensations with hyperammonaemia was reduced by a median of - 41% (range - 100% to + 60%) after treatment with carglumic acid. Of the five patients who experienced a decompensation event before treatment and for whom a post-treatment rate could be calculated, the annualised decompensation event rate was lower after carglumic acid treatment in four patients. The mean duration of hospital inpatient stay during decompensation events was shorter after than before carglumic acid treatment initiation in four of five patients for whom length of stay could be calculated. CONCLUSIONS In this group of patients with MMA and PA, treatment with carglumic acid for at least 1 year reduced peak plasma ammonia levels in the total patient population and reduced the frequency of metabolic decompensation events, as well as the duration of inpatient stay due to metabolic decompensations in a subset of patients. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT04176523. Registered 25 November, 2019, retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04176523 .
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Affiliation(s)
- Sufin Yap
- Department of Inherited Metabolic Diseases, Sheffield Children's Hospital, Western Bank, Sheffield, S10 2TH, UK.
| | - Delphine Lamireau
- Hopital Des Enfants, CHU de Bordeaux-GH Pellegrin, Bordeaux Cedex, France
| | - Francois Feillet
- CHU de Nancy, Hopitaux de Brabois, Vandoeuvre-les-Nancy Cedex, France
| | | | | | - Trine Tangeraas
- Department of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
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Cholico GN, Fling RR, Sink WJ, Nault R, Zacharewski T. Inhibition of the urea cycle by the environmental contaminant 2,3,7,8-tetrachlorodibenzo-p-dioxin increases serum ammonia levels in mice. J Biol Chem 2024; 300:105500. [PMID: 38013089 PMCID: PMC10731612 DOI: 10.1016/j.jbc.2023.105500] [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: 08/29/2023] [Revised: 10/26/2023] [Accepted: 11/18/2023] [Indexed: 11/29/2023] Open
Abstract
The aryl hydrocarbon receptor is a ligand-activated transcription factor known for mediating the effects of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) and related compounds. TCDD induces nonalcoholic fatty liver disease (NAFLD)-like pathologies including simple steatosis that can progress to steatohepatitis with fibrosis and bile duct proliferation in male mice. Dose-dependent progression of steatosis to steatohepatitis with fibrosis by TCDD has been associated with metabolic reprogramming, including the disruption of amino acid metabolism. Here, we used targeted metabolomic analysis to reveal dose-dependent changes in the level of ten serum and eleven hepatic amino acids in mice upon treatment with TCDD. Bulk RNA-seq and protein analysis showed TCDD repressed CPS1, OTS, ASS1, ASL, and GLUL, all of which are associated with the urea cycle and glutamine biosynthesis. Urea and glutamine are end products of the detoxification and excretion of ammonia, a toxic byproduct of amino acid catabolism. Furthermore, we found that the catalytic activity of OTC, a rate-limiting step in the urea cycle was also dose dependently repressed. These results are consistent with an increase in circulating ammonia. Collectively, the repression of the urea and glutamate-glutamine cycles increased circulating ammonia levels and the toxicity of TCDD.
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Affiliation(s)
- Giovan N Cholico
- Biochemistry and Molecular Biology, Michigan State University, East Lansing, Michigan, USA; Institute for Integrative Toxicology, Michigan State University, East Lansing, Michigan, USA
| | - Russell R Fling
- Institute for Integrative Toxicology, Michigan State University, East Lansing, Michigan, USA; Microbiology & Molecular Genetics, Michigan State University, East Lansing, Michigan, USA
| | - Warren J Sink
- Biochemistry and Molecular Biology, Michigan State University, East Lansing, Michigan, USA; Institute for Integrative Toxicology, Michigan State University, East Lansing, Michigan, USA
| | - Rance Nault
- Biochemistry and Molecular Biology, Michigan State University, East Lansing, Michigan, USA; Institute for Integrative Toxicology, Michigan State University, East Lansing, Michigan, USA
| | - Tim Zacharewski
- Biochemistry and Molecular Biology, Michigan State University, East Lansing, Michigan, USA; Institute for Integrative Toxicology, Michigan State University, East Lansing, Michigan, USA.
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Zhao L, Hou S, Na R, Liu B, Wang Z, Li Y, Xie K. Prognostic role of serum ammonia in patients with sepsis-associated encephalopathy without hepatic failure. Front Public Health 2023; 10:1016931. [PMID: 36684934 PMCID: PMC9846324 DOI: 10.3389/fpubh.2022.1016931] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 11/30/2022] [Indexed: 01/05/2023] Open
Abstract
Objectives Our previous study shows that serum ammonia in sepsis patients without hepatic failure is associated with a poor prognosis. The relationship between serum ammonia level and the prognosis of sepsis-associated encephalopathy (SAE) patients without hepatic failure remains unclear. We aimed to explore the relationship between serum ammonia levels and the prognosis of patients with SAE. Materials and methods This study is a retrospective cohort study. We collected 465 patients with SAE admitted to the intensive care unit (ICU) from Medical Information Mart for Intensive Care IV (MIMIC IV) from 2008 to 2019. Patients with SAE were divided into a survival group (369 patients) and a non-survival group (96 patients). We used the Wilcoxon signed-rank test and the multivariate logistic regression analysis to analyze the relationship between serum ammonia levels and the prognosis of patients with SAE. R software was used to analyze the dataset. Results The primary outcome was the relationship between serum ammonia level and hospital mortality of SAE. The secondary outcomes were the relationship between serum ammonia level and hospital stays, simplified acute physiology score (SAPS II), Charlson, Glasgow coma scale (GCS), sequential organ failure assessment (SOFA), and lactate level of SAE. The mortality of patients with SAE was 20.6%. The serum ammonia level was not significantly associated with hospital mortality, longer hospital stays, higher SAPS II and Charlson scores, and lower GCS of patients with SAE. The serum ammonia level was associated with higher SOFA scores and lactate levels in patients with SAE. The SAPS II and Charlson scores were independent risk factors for death in patients with SAE. Conclusion Serum ammonia level was associated with higher SOFA scores and lactate levels in patients with SAE. In addition, the SAPS II and Charlson scores can be used to assess the prognosis of patients with SAE. Therefore, we should closely monitor serum ammonia, SAPS II, and Charlson levels in patients with SAE.
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Affiliation(s)
- Lina Zhao
- Department of Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Shaowei Hou
- School of Biomedical Engineering and Technology, Tianjin Medical University, Tianjin, China
| | - Risu Na
- Department of Science and Education Department, Chifeng Municipal Hospital, Chifeng Clinical Medical College of Inner Mongolia Medical University, Chifeng, China
| | - Bin Liu
- Department of Emergency Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, China
| | - Zhiwei Wang
- Department of Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Yun Li
- Department of Anesthesiology, Tianjin Institute of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Keliang Xie
- Department of Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin, China
- Department of Anesthesiology, Tianjin Institute of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, China
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Kim K, Jung SM. Desflurane and remifentanil anesthesia in a child with citrin deficiency: A case report. Medicine (Baltimore) 2022; 101:e28954. [PMID: 35244055 PMCID: PMC8896430 DOI: 10.1097/md.0000000000028954] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/11/2022] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Hyperammonemia, metabolic derangement, and/or the prolonged effects of anesthetics may lead to delayed emergence from general anesthesia as well as the onset of type 2 citrullinemia, even in compensated patients with citrin deficiency. PATIENT CONCERN A 5-year-old girl with citrin deficiency was scheduled for blepharoplasty under general anesthesia. She developed hyperammonemia with temporary interruption of medication for a few days before surgery. DIAGNOSIS The patient was genetically diagnosed as citrin deficiency with a mutation in the SLC25A13 gene via newborn screening for metabolic disorders. Her citrulline and ammonia levels were well-controlled with arginine medication and protein-rich diet. Her elevated ammonia level by temporary interruption of medication was corrected with resumption of arginine medication and protein-rich diet before surgery. INTERVENTIONS We used desflurane and remifentanil for general anesthesia to avoid hyperammonemia and delayed emergence. End-tidal desflurane concentration and anesthetic depth were carefully monitored to avoid excessive anesthesia. OUTCOMES She recovered consciousness with slightly increased ammonia level immediately after anesthesia. LESSIONS General anesthesia of the shortest duration with the least metabolized drugs using desflurane and remifentanil, would be beneficial for rapid emergence in surgical patients with citrin deficiency. Maintenance of nitrogen scavenging medication, a protein-rich diet, and serial measurement of ammonia levels in the perioperative period are also important for avoiding hyperammonemia-related neurological dysfunction.
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Affiliation(s)
- Kanghui Kim
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Sung Mee Jung
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
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Solipuram V, Baretti M, Kim AY, Chen LX, Fahrner JA, Gunay-Aygun M, Peng XP, Hardenbergh D, Ferguson A, Griffith P, Wang Y, Brancati M, Gopalakrishna H, Kato T, Shubert C, Laheru D, Yarchoan M. Surgical Debulking for Refractory Hyperammonemic Encephalopathy in Fibrolamellar Hepatocellular Carcinoma. Hepatology 2021; 74:2899-2901. [PMID: 34105830 PMCID: PMC9472764 DOI: 10.1002/hep.31998] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/03/2021] [Accepted: 06/04/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Vinod Solipuram
- Department of Internal Medicine, Saint Agnes Hospital, Baltimore, MD
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Marina Baretti
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Alexander Y. Kim
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lucy X. Chen
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jill A. Fahrner
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Meral Gunay-Aygun
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Xiao P. Peng
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dylan Hardenbergh
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Anna Ferguson
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Paige Griffith
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Yuxuan Wang
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Madelena Brancati
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Harish Gopalakrishna
- Department of Internal Medicine, Saint Agnes Hospital, Baltimore, MD
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Tomoaki Kato
- Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Chris Shubert
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Daniel Laheru
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Mark Yarchoan
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
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Li Y, Ju S, Li X, Zhou YL, Qiang JW. Prediction of minimal hepatic encephalopathy by using an radiomics nomogram in chronic hepatic schistosomiasis patients. PLoS Negl Trop Dis 2021; 15:e0009834. [PMID: 34653175 PMCID: PMC8550421 DOI: 10.1371/journal.pntd.0009834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 10/27/2021] [Accepted: 09/23/2021] [Indexed: 01/04/2023] Open
Abstract
Objective To construct an MR-radiomics nomogram to predict minimal hepatic encephalopathy (MHE) in patients with chronic hepatic schistosomiasis (CHS). Methods From July 2017 to July 2020, 236 CHS patients with non-HE (n = 140) and MHE (n = 96) were retrospective collected and randomly divided into training group and testing group. Radiomics features were extracted from substantia nigra-striatum system of a brain diffusion weighted images (DWI) and combined with clinical predictors to build a radiomics nomogram for predicting MHE in CHS patients. The ROC curve was used to evaluate the predicting performance in training group and testing group. The clinical decisive curve (CDC) was used to assess the clinical net benefit of using radiomics nomogram in predicting MHE. Results Low seralbumin (P < 0.05), low platelet count (P < 0.05) and high plasma ammonia (P < 0.05) was the significant clinical predictors for MHE in CHS patients. The AUC, specificity and sensitivity of the radiomics nomogram were 0.89, 0.90 and 0.86 in the training group, and were 0.83, 0.85 and 0.75 in the training group. The CDC analysis showed clinical net benefits for the radiomics nomogram in predicting MHE. Conclusions The radiomics nomogram combining DWI radiomics features and clinical predictors could be useful tool to predict MHE in CHS patients. Minimal hepatic encephalopathy (MHE) is usually neglected clinically in chronic hepatic schistosomiasis (CHS) patients. The diffusion change in substantia nigra-striatum system of MHE patients has been reported. We hypothesized that the change could be better detected by DWI-based radiomics. A radiomics nomogram combining radiomics and clinical predictors of MHE was built to predict MHE in CHS patients. The results demonstrate that the radiomics nomogram would be useful for predicting MHE in CHS patients.
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Affiliation(s)
- Ying Li
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Shuai Ju
- Department of Intervention Radiology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Xin Li
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Yan Li Zhou
- Department of Nuclear medicine, Jinshan Hospital, Fudan University, Shanghai, China
| | - Jin Wei Qiang
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China
- * E-mail:
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Eloot S, De Rudder J, Verloo P, Dhont E, Raes A, Van Biesen W, Snauwaert E. Towards an Algorithm-Based Tailored Treatment of Acute Neonatal Hyperammonemia. Toxins (Basel) 2021; 13:484. [PMID: 34357956 PMCID: PMC8309957 DOI: 10.3390/toxins13070484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 12/30/2022] Open
Abstract
Acute neonatal hyperammonemia is associated with poor neurological outcomes and high mortality. We developed, based on kinetic modeling, a user-friendly and widely applicable algorithm to tailor the treatment of acute neonatal hyperammonemia. A single compartmental model was calibrated assuming a distribution volume equal to the patient's total body water (V), as calculated using Wells' formula, and dialyzer clearance as derived from the measured ammonia time-concentration curves during 11 dialysis sessions in four patients (3.2 ± 0.4 kg). Based on these kinetic simulations, dialysis protocols could be derived for clinical use with different body weights, start concentrations, dialysis machines/dialyzers and dialysis settings (e.g., blood flow QB). By a single measurement of ammonia concentration at the dialyzer inlet and outlet, dialyzer clearance (K) can be calculated as K = QB∙[(Cinlet - Coutlet)/Cinlet]. The time (T) needed to decrease the ammonia concentration from a predialysis start concentration Cstart to a desired target concentration Ctarget is then equal to T = (-V/K)∙LN(Ctarget/Cstart). By implementing these formulae in a simple spreadsheet, medical staff can draw an institution-specific flowchart for patient-tailored treatment of hyperammonemia.
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Affiliation(s)
- Sunny Eloot
- Department of Nephrology, Ghent University Hospital, 9000 Ghent, Belgium; (J.D.R.); (W.V.B.)
| | - Jonathan De Rudder
- Department of Nephrology, Ghent University Hospital, 9000 Ghent, Belgium; (J.D.R.); (W.V.B.)
| | - Patrick Verloo
- Department of Pediatric Metabolic Disease, Ghent University Hospital, 9000 Ghent, Belgium;
| | - Evelyn Dhont
- Department of Pediatric Intensive Care, Ghent University Hospital, 9000 Ghent, Belgium;
| | - Ann Raes
- Department of Pediatric Nephrology, Ghent University Hospital, 9000 Ghent, Belgium; (A.R.); (E.S.)
| | - Wim Van Biesen
- Department of Nephrology, Ghent University Hospital, 9000 Ghent, Belgium; (J.D.R.); (W.V.B.)
| | - Evelien Snauwaert
- Department of Pediatric Nephrology, Ghent University Hospital, 9000 Ghent, Belgium; (A.R.); (E.S.)
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Kido J, Matsumoto S, Häberle J, Nakajima Y, Wada Y, Mochizuki N, Murayama K, Lee T, Mochizuki H, Watanabe Y, Horikawa R, Kasahara M, Nakamura K. Long-term outcome of urea cycle disorders: Report from a nationwide study in Japan. J Inherit Metab Dis 2021; 44:826-837. [PMID: 33840128 DOI: 10.1002/jimd.12384] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 11/25/2020] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 12/20/2022]
Abstract
Urea cycle disorders (UCDs) are inherited metabolic disorders with impaired nitrogen detoxification caused by defects in urea cycle enzymes. They often manifest with hyperammonemic attacks resulting in significant morbidity or death. We performed a nationwide questionnaire-based study between January 2000 and March 2018 to document all UCDs in Japan, including diagnoses, treatments, and outcomes. A total of 229 patients with UCDs were enrolled in this study: 73 males and 53 females with ornithine transcarbamylase deficiency (OTCD), 33 patients with carbamoylphosphate synthetase 1 deficiency, 48 with argininosuccinate synthetase deficiency, 14 with argininosuccinate lyase deficiency, and 8 with arginase deficiency. Survival rates at 20 years of age of male and female patients with late-onset OTCD were 100% and 97.7%, respectively. Blood ammonia levels and time of onset had a significant impact on the neurodevelopmental outcome (P < .001 and P = .028, respectively). Hemodialysis and liver transplantation did not prevent poor neurodevelopmental outcomes. While treatment including medication, hemodialysis, and liver transplantation may aid in decreasing blood ammonia and/or preventing severe hyperammonemia, a blood ammonia level ≥ 360 μmol/L was found to be a significant indicator for a poor neurodevelopmental outcome. In conclusion, although current therapy for UCDs has advanced and helped saving lives, patients with blood ammonia levels ≥ 360 μmol/L at onset often have impaired neurodevelopmental outcomes. Novel neuroprotective measures should therefore be developed to achieve better neurodevelopmental outcomes in these patients.
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Affiliation(s)
- Jun Kido
- Department of Pediatrics, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Shirou Matsumoto
- Department of Pediatrics, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Johannes Häberle
- University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
| | - Yoko Nakajima
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yoichi Wada
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
| | - Narutaka Mochizuki
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Kei Murayama
- Department of Metabolism, Center for Medical Genetics, Chiba Children's Hospital, Chiba, Japan
| | - Tomoko Lee
- Department of Pediatrics, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroshi Mochizuki
- Division of Endocrinology and Metabolism, Saitama Children's Medical Center, Saitama, Japan
| | - Yoriko Watanabe
- Research Institute of Medical Mass Spectrometry, Kurume University School of Medicine, Kurume, Japan
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
| | - Reiko Horikawa
- Division of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kimitoshi Nakamura
- Department of Pediatrics, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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Zhang Y, Tan SL, Du J, Chen Y, Jia J, Feng JG, Liu KX, Zhou J. Dexmedetomidine alleviates neuroinflammation, restores sleep disorders and neurobehavioral abnormalities in rats with minimal hepatic encephalopathy. Int Immunopharmacol 2021; 96:107795. [PMID: 34162157 DOI: 10.1016/j.intimp.2021.107795] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 02/17/2021] [Revised: 05/05/2021] [Accepted: 05/16/2021] [Indexed: 10/21/2022]
Abstract
The occurrence and progress of minimal hepatic encephalopathy (MHE) is closely related to the inflammatory response; however, inflammation contributes to behavioral abnormalities and sleep disorders. Dexmedetomidine has anti-inflammatory effects against various diseases. Whether dexmedetomidine improves MHE and the underlying mechanism is yet unclear. The present study aimed to explore the effects of dexmedetomidine on sleep structure, neurobehavior, and brain morphology of MHE rats and investigate its underlying mechanism. A rat MHE model was established by intraperitoneal injection of thioacetamide (TAA). Dexmedetomidine or yohimbine was administered intraperitoneally to investigate the role of α2 adrenoreceptor in the protection conferred by dexmedetomidine. The 24-h sleep, neurobehavioral changes, the liver function, blood ammonia and morphological changes of the liver and brain were assessed. Also, the microglia, astrocytes, neurons, the expression of pro-inflammatory factors (IL-1β, TNF-α, IL-18), and NLRP3 inflammasomes were detected. The results showed that marked sleep disorders, cognitive impairment, anxiety, abnormal liver function and pathological damage of liver and brain were detected in the MHE rats. The microglia in the prefrontal cortex was highly activated along with the increased expression of pro-inflammatory factors and NLRP3 inflammasomes. Interestingly, dexmedetomidine improved above indicators, however, yohimbine significantly abolished the protection of dexmedetomidine. These findings showed that dexmedetomidine restored the changes in the sleep disorders and neurobehavior in rats and reduced brain damage. The mechanism might be partially related to the activation of α2 adrenergic receptors, reduction of neuroinflammatory response, and inhibition of the activation of microglia and NLRP3/Caspase1 signaling pathway.
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Affiliation(s)
- Yu Zhang
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, PR China
| | - Su-Lan Tan
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, PR China
| | - Juan Du
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, PR China
| | - Ye Chen
- Department of Traditional Chinese Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, PR China
| | - Jing Jia
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, PR China
| | - Jian-Guo Feng
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, PR China
| | - Ke-Xuan Liu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Jun Zhou
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, PR China.
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Sugahara G, Yamasaki C, Yanagi A, Furukawa S, Ogawa Y, Fukuda A, Enosawa S, Umezawa A, Ishida Y, Tateno C. Humanized liver mouse model with transplanted human hepatocytes from patients with ornithine transcarbamylase deficiency. J Inherit Metab Dis 2021; 44:618-628. [PMID: 33336822 PMCID: PMC8247293 DOI: 10.1002/jimd.12347] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 12/10/2020] [Accepted: 12/16/2020] [Indexed: 12/20/2022]
Abstract
Ornithine transcarbamylase deficiency (OTCD) is a metabolic and genetic disease caused by dysfunction of the hepatocytic urea cycle. To develop new drugs or therapies for OTCD, it is ideal to use models that are more closely related to human metabolism and pathology. Primary human hepatocytes (HHs) isolated from two patients (a 6-month-old boy and a 5-year-old girl) and a healthy donor were transplanted into host mice (hemi-, hetero-OTCD mice, and control mice, respectively). HHs were isolated from these mice and used for serial transplantation into the next host mouse or for in vitro experiments. Histological, biochemical, and enzyme activity analyses were performed. Cultured HHs were treated with ammonium chloride or therapeutic drugs. Replacement rates exceeded 80% after serial transplantation in both OTCD mice. These highly humanized OTCD mice showed characteristics similar to OTCD patients that included increased blood ammonia levels and urine orotic acid levels enhanced by allopurinol. Hemi-OTCD mice showed defects in OTC expression and significantly low enzymatic activities, while hetero-OTCD mice showed residual OTC expression and activities. A reduction in ammonium metabolism was observed in cultured HHs from OTCD mice, and treatment with the therapeutic drug reduced the ammonia levels in the culture medium. In conclusion, we established in vivo OTC mouse models with hemi- and hetero-patient HHs. HHs isolated from the mice were useful as an in vitro model of OTCD. These OTC models could be a source of valuable patient-derived hepatocytes that would enable large scale and reproducible experiments using the same donor.
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Affiliation(s)
- Go Sugahara
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
| | - Chihiro Yamasaki
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
| | - Ami Yanagi
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
| | - Suzue Furukawa
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
| | - Yuko Ogawa
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
| | - Akinari Fukuda
- National Center for Child Health and DevelopmentTokyoJapan
| | - Shin Enosawa
- Division for Advanced Medical SciencesNational Center for Child Health and DevelopmentTokyoJapan
| | - Akihiro Umezawa
- Regenerative MedicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Yuji Ishida
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
- Research Center for Hepatology and GastroenterologyHiroshima UniversityHiroshimaJapan
| | - Chise Tateno
- Research and Development DepartmentPhoenixBio Co., LtdHigashi‐HiroshimaJapan
- Research Center for Hepatology and GastroenterologyHiroshima UniversityHiroshimaJapan
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11
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Mikkelsen ACD, Thomsen KL, Vilstrup H, Aamann L, Jones H, Mookerjee RP, Hamilton-Dutoit S, Frystyk J, Aagaard NK. Potassium deficiency decreases the capacity for urea synthesis and markedly increases ammonia in rats. Am J Physiol Gastrointest Liver Physiol 2021; 320:G474-G483. [PMID: 33404376 DOI: 10.1152/ajpgi.00136.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 04/21/2020] [Accepted: 12/07/2020] [Indexed: 01/31/2023]
Abstract
Our study provides novel findings of experimental hypokalemia reducing urea cycle functionality and thereby severely increasing plasma ammonia. This is pathophysiologically interesting because plasma ammonia increases during hypokalemia by a hitherto unknown mechanism, which may be particular important in relation to the unexplained link between hypokalemia and hepatic encephalopathy. Potassium deficiency decreases gene expression, protein synthesis, and growth. The urea cycle maintains body nitrogen homeostasis including removal of toxic ammonia. Hyperammonemia is an obligatory trait of liver failure, increasing the risk for hepatic encephalopathy, and hypokalemia is reported to increase ammonia. We aimed to clarify the effects of experimental hypokalemia on the in vivo capacity of the urea cycle, on the genes of the enzymes involved, and on ammonia concentrations. Female Wistar rats were fed a potassium-free diet for 13 days. Half of the rats were then potassium repleted. Both groups were compared with pair- and free-fed controls. The following were measured: in vivo capacity of urea-nitrogen synthesis (CUNS); gene expression (mRNA) of urea cycle enzymes; plasma potassium, sodium, and ammonia; intracellular potassium, sodium, and magnesium in liver, kidney, and muscle tissues; and liver sodium/potassium pumps. Liver histology was assessed. The diet induced hypokalemia of 1.9 ± 0.4 mmol/L. Compared with pair-fed controls, the in vivo CUNS was reduced by 34% (P < 0.01), gene expression of argininosuccinate synthetase 1 (ASS1) was decreased by 33% (P < 0.05), and plasma ammonia concentrations were eightfold elevated (P < 0.001). Kidney and muscle tissue potassium contents were markedly decreased but unchanged in liver tissue. Protein expressions of liver sodium/potassium pumps were unchanged. Repletion of potassium reverted all the changes. Hypokalemia decreased the capacity for urea synthesis via gene effects. The intervention led to marked hyperammonemia, quantitatively explainable by the compromised urea cycle. Our findings motivate clinical studies of patients with liver disease.
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Affiliation(s)
| | - Karen Louise Thomsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
- UCL Institute of Liver and Digestive Health, University College London, London, United Kingdom
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Luise Aamann
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Helen Jones
- UCL Institute of Liver and Digestive Health, University College London, London, United Kingdom
| | - Rajeshwar P Mookerjee
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
- UCL Institute of Liver and Digestive Health, University College London, London, United Kingdom
| | | | - Jan Frystyk
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Kristian Aagaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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12
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Yan T, Li F, Xiong W, Wu B, Xiao F, He B, Jia Y. Nootkatone improves anxiety- and depression-like behavior by targeting hyperammonemia-induced oxidative stress in D-galactosamine model of liver injury. Environ Toxicol 2021; 36:694-706. [PMID: 33270352 DOI: 10.1002/tox.23073] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [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: 08/13/2020] [Accepted: 11/20/2020] [Indexed: 06/12/2023]
Abstract
Acute or chronic liver injury is closely related to hyperammonemia, which will result in oxidative stress and damage to nerve cells, and these factors are vital to the development of anxiety and depression. In this study, the effect of Nootkatone (NKT) on the anxiety- and depression-like behavioral changes in mice induced by liver injury was investigated. Liver injury was induced by D-galactosamine (D-GalN; 350 mg/kg) three times a week for 4 weeks. NKT (5 mg/kg or 10 mg/kg) was given as co-treatment daily for 4 weeks. NKT (5 mg/kg) co-treatment remarkably ameliorates D-GalN-induced anxiety- and depression-like behaviors as evident from the results of sucrose preference test, forced swimming test, tail suspension test, and novelty suppressed feeding test. Results showed that NKT could induce an elevation in serum alanine transaminase and aspartate transaminase level, alleviate the oxidative stress induced by hyperammonemia through activating Keap1/Nrf2/HO-1 antioxidant pathways, decrease the expression of inducible nitric oxide synthase and NOX2 in hippocampus and prefrontal cortex, enhance the vitality of superoxide dismutase, catalase, and glutathione levels in serum, liver, and brain, and significantly reduce the generation of malondialdehyde. At the same time, NKT also reduces the level of ammonia in serum and brain and upgrades the activity of glutamine synthetase in the hippocampus and prefrontal cortex. Taken together, the present results suggested that NKT has a significant antidepressant effect through modulation of oxidative stress induced by D-GalN administration.
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Affiliation(s)
- Tingxu Yan
- School of Functional Food and Wine, Shenyang Pharmaceutical University, Shenyang, China
| | - Fuyuan Li
- School of Traditional Chinese Materia Medica, Shenyang Pharmaceutical University, Shenyang, China
| | - Weilin Xiong
- School of Traditional Chinese Materia Medica, Shenyang Pharmaceutical University, Shenyang, China
| | - Bo Wu
- School of Functional Food and Wine, Shenyang Pharmaceutical University, Shenyang, China
| | - Feng Xiao
- School of Functional Food and Wine, Shenyang Pharmaceutical University, Shenyang, China
| | - Bosai He
- School of Functional Food and Wine, Shenyang Pharmaceutical University, Shenyang, China
| | - Ying Jia
- School of Functional Food and Wine, Shenyang Pharmaceutical University, Shenyang, China
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13
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El-Baz FK, Elgohary R, Salama A. Amelioration of Hepatic Encephalopathy Using Dunaliella salina Microalgae in Rats: Modulation of Hyperammonemia/TLR4. Biomed Res Int 2021; 2021:8843218. [PMID: 33855084 PMCID: PMC8021475 DOI: 10.1155/2021/8843218] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 02/27/2021] [Accepted: 03/19/2021] [Indexed: 12/28/2022]
Abstract
Hepatic encephalopathy (HE) is a neuropsychiatric disease that is developed as a complication of both acute and chronic liver failure affecting psychomotor dysfunction, memory, and concentration. This study is aimed at evaluating the therapeutic effects of Dunaliella salina (D. salina) microalgae in thioacetamide- (TAA-) induced HE in rats. HE was induced by TAA (200 mg/kg; i.p.) for three successive days. Forty male Wister albino rats were divided into 4 groups; the first group was served as a normal, and the second group was injected with TAA and served as TAA control. The third and fourth groups were administered D. salina (100 and 200 mg/kg; p.o.), respectively, after TAA injection for 7 days. The behavioral and biochemical markers as well as histological aspects of HE were estimated. This study revealed that TAA caused behavioral changes, oxidative stress, neuroinflammation, nuclear pyknosis, and neurons degeneration. D. salina improved liver function and decreased oxidative stress and inflammatory mediator as TLR4 protein expression. Also, D. salina elevated HSP-25 and IGF-1 as well as improved brain histopathological alterations. In conclusion, D. salina exerted a therapeutic potential against HE via its antioxidant, antiinflammatory and cytoprotective effects.
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Affiliation(s)
- Farouk K. El-Baz
- Plant Biochemistry Department, National Research Centre (NRC), 33 El Buhouth St., Dokki, Cairo 12622, Egypt
| | - Rania Elgohary
- Narcotics, Ergogenics and Poisons Department, National Research Centre (NRC), 33 El Buhouth St., Dokki, Cairo 12622, Egypt
| | - Abeer Salama
- Pharmacology Department, National Research Centre (NRC), 33 El Buhouth St., Dokki, Cairo 12622, Egypt
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14
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Abstract
The aim of this study was to evaluate the association of non-hepatic hyperammonemia (NHH) with the prognosis of critically ill patients with NHH.According to the serum ammonia level, the patients with NHH (n = 498) were retrieved by us. The risk factors of the mortality with NHH patients were investigated by conducting univariate and multivariate logistic regression analyses. A nomogram to predict the risk of hospital mortality was constructed. Receiver operating characteristic curve (ROC) analysis was conducted to compare nomogram (ammonia into a prognostic model, P1) with the simplified acute physiology II (SAPSII) and quick sequential organ failure assessment (qSOFA).Five independent factors for the mortality in patients with NHH were identified, including age, platelets, bun, hemoglobin, and ammonia. Models P1 using ammonia showed good prediction power. The AUROC of P1 (AUROC, 0.755 [95% CI, 0.713-0.796]) was higher than that of qSOFA (AUROC, 0.500 [95% CI, 0.449-0.551]), and SAPS II (AUROC, 0.703[95% CI, 0.658-0.748]).Ammonia was an independent prognostic predictor of mortality for NHH patients. We developed a nomogram that can predict hospital mortality with patients. Nomogram had superior discriminative power to qSOFA and SAPS II, indicating that the nomogram may have clinical utility.
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Affiliation(s)
- Yun Li
- Department of Anesthesiology, Chifeng Municipal Hospital, Chifeng Clinical Medical College of Inner Mongolia Medical University, Chifeng
| | - Qi Zhou
- Department of Anesthesiology, Chifeng Municipal Hospital, Chifeng Clinical Medical College of Inner Mongolia Medical University, Chifeng
| | - Jian-Nan Song
- Department of Anesthesiology, Chifeng Municipal Hospital, Chifeng Clinical Medical College of Inner Mongolia Medical University, Chifeng
| | - Xue-Zhao Chen
- Second Medical College of Shanxi Medical University, Taiyuan, China
| | - Xi-Zhe Zhang
- Department of Anesthesiology, Chifeng Municipal Hospital, Chifeng Clinical Medical College of Inner Mongolia Medical University, Chifeng
| | - Yi Sun
- Department of Anesthesiology, Chifeng Municipal Hospital, Chifeng Clinical Medical College of Inner Mongolia Medical University, Chifeng
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15
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Longo N, Diaz GA, Lichter-Konecki U, Schulze A, Inbar-Feigenberg M, Conway RL, Bannick AA, McCandless SE, Zori R, Hainline B, Ah Mew N, Canavan C, Vescio T, Kok T, Porter MH, Berry SA. Glycerol phenylbutyrate efficacy and safety from an open label study in pediatric patients under 2 months of age with urea cycle disorders. Mol Genet Metab 2021; 132:19-26. [PMID: 33388234 PMCID: PMC8655853 DOI: 10.1016/j.ymgme.2020.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/08/2020] [Accepted: 12/09/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND/AIMS Neonatal onset Urea cycle disorders (UCDs) can be life threatening with severe hyperammonemia and poor neurological outcomes. Glycerol phenylbutyrate (GPB) is safe and effective in reducing ammonia levels in patients with UCD above 2 months of age. This study assesses safety, ammonia control and pharmacokinetics (PK) of GPB in UCD patients below 2 months of age. METHODS This was an open-label study in UCD patients aged 0 - 2 months, consisting of an initiation/transition period (1 - 4 days) to GPB, followed by a safety extension period (6 months to 2 years). Patients presenting with a hyperammonemic crisis (HAC) did not initiate GPB until blood ammonia levels decreased to below 100 µmol/L while receiving sodium phenylacetate/sodium benzoate and/or hemodialysis. Ammonia levels, PK analytes and safety were evaluated during transition and monthly during the safety extension for 6 months and every 3 months thereafter. RESULTS All 16 patients with UCD (median age 0.48 months, range 0.1 to 2.0 months) successfully transitioned to GPB within 3 days. Average plasma ammonia level excluding HAC was 94.3 µmol/L at baseline and 50.4 µmol/L at the end of the transition period (p = 0.21). No patient had a HAC during the transition period. During the safety extension, the majority of patients had controlled ammonia levels, with mean plasma ammonia levels lower during GPB treatment than baseline. Mean glutamine levels remained within normal limits throughout the study. PK analyses indicate that UCD patients <2 months are able to hydrolyze GPB with subsequent absorption of phenylbutyric acid (PBA), metabolism to phenylacetic acid (PAA) and conjugation with glutamine. Plasma concentrations of PBA, PAA, and phenylacetylglutamine (PAGN) were stable during the safety extension phase and mean plasma phenylacetic acid: phenylacetylglutamine ratio remained below 2.5 suggesting no accumulation of GPB. All patients reported at least 1 treatment emergent adverse event with gastroesophageal reflux disease, vomiting, hyperammonemia, diaper dermatitis (37.5% each), diarrhea, upper respiratory tract infection and rash (31.3% each) being the most frequently reported. CONCLUSIONS This study supports safety and efficacy of GPB in UCD patients aged 0 -2 months who cannot be managed by dietary protein restriction and/or amino acid supplementation alone. GPB undergoes intestinal hydrolysis with no accumulation in this population.
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Affiliation(s)
| | - George A Diaz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Andreas Schulze
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Shawn E McCandless
- University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
| | | | - Bryan Hainline
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | | | - Teresa Kok
- Horizon Therapeutics plc, Deerfield, IL, USA.
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16
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Cavino K, Sung B, Su Q, Na E, Kim J, Cheng X, Gromada J, Okamoto H. Glucagon Receptor Inhibition Reduces Hyperammonemia and Lethality in Male Mice with Urea Cycle Disorder. Endocrinology 2021; 162:5988952. [PMID: 33206168 DOI: 10.1210/endocr/bqaa211] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 08/07/2020] [Indexed: 12/14/2022]
Abstract
The liver plays a critical role in maintaining ammonia homeostasis. Urea cycle defects, liver injury, or failure and glutamine synthetase (GS) deficiency result in hyperammonemia, serious clinical conditions, and lethality. In this study we used a mouse model with a defect in the urea cycle enzyme ornithine transcarbamylase (Otcspf-ash) to test the hypothesis that glucagon receptor inhibition using a monoclonal blocking antibody will reduce the hyperammonemia and associated lethality induced by a high-protein diet, which exacerbates disease. We found reduced expression of glutaminase, which degrades glutamine and increased expression of GS in livers of Otcspf-ash mice treated with the glucagon receptor blocking antibody. The gene expression changes favor ammonia consumption and were accompanied by increased circulating glutamine levels and diminished hyperammonemia. Otcspf-ash mice treated with the glucagon receptor-blocking antibody gained lean and body mass and had increased survival. These data suggest that glucagon receptor inhibition using a monoclonal antibody could reduce the risk for hyperammonemia and other clinical manifestations of patients suffering from defects in the urea cycle, liver injury, or failure and GS deficiency.
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Affiliation(s)
- Katie Cavino
- Regeneron Pharmaceuticals, Tarrytown, New York USA
| | - Biin Sung
- Regeneron Pharmaceuticals, Tarrytown, New York USA
| | - Qi Su
- Regeneron Pharmaceuticals, Tarrytown, New York USA
| | - Erqian Na
- Regeneron Pharmaceuticals, Tarrytown, New York USA
| | - Jinrang Kim
- Regeneron Pharmaceuticals, Tarrytown, New York USA
| | - Xiping Cheng
- Regeneron Pharmaceuticals, Tarrytown, New York USA
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17
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Liang L, Huang Z, Li N, Wang D, Ding L, Shi H, Hong M. Effects of ammonia exposure on antioxidant function, immune response and NF-κB pathway in Chinese Strip-necked Turtle (Mauremys sinensis). Aquat Toxicol 2020; 229:105621. [PMID: 33129562 DOI: 10.1016/j.aquatox.2020.105621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 06/29/2020] [Revised: 08/29/2020] [Accepted: 08/31/2020] [Indexed: 06/11/2023]
Abstract
As one of the main toxic substances in aquaculture water, ammonia causes seriously physiological harm to aquatic animals. In order to investigate the effects of ammonia exposure on the antioxidant defense, immune response, and NF-κB signaling pathway in Chinese Strip-necked Turtle (Mauremys sinensis), we designed two experimental groups (control and 6.45 mM ammonia), and sampled at 6 h, 24 h, 48 h, re 24 h (recover 24 h), and re 48 h. The results showed that the blood ammonia (BA) content was significantly increased when the turtles were subjected to ammonia, and the activities of cholinesterase (CHE) and aspartate aminotransferase (AST) in the serum also showed a significant upward trend. The malondialdehyde (MDA) content continuously increased during ammonia exposure, and more than doubled at 48 h compared with the control group. The activities of superoxide dismutase (SOD), glutathione peroxidase (GSH-PX), catalase (CAT) and their corresponding relative mRNA expression levels in the liver during ammonia exposure were obviously increased when compared to the control group, but most decreased to the normal levels at re 48 h. In addition, the relative mRNA and protein expression levels of NF-E2 related factor 2 (Nrf2) showed similar up-regulation patterns to antioxidase during ammonia exposed periods; whereas kelch-like ECH-binding protein 1 (Keap1), as Nrf2 negative regulator, showed opposite patterns. Moreover, the relative mRNA expression levels of heat shock proteins (HSP70, HSP90) significantly elevated upon the exposure of ammonia. Furthermore, ammonia increased the relative mRNA and protein expression levels of p50 and p65 at different exposed times. The reative mRNA expression levels of immune cytokines (BAFF and IL-6) were upregulated during ammonia exposured time, while there was a decline but did not return to normal levels, in the recovery periods. Taken together, these results indicated that antioxidation, immunity, and NF-κB signaling played a certain protective role for Mauremys sinensis under ammonia exposure. Our results will be helpful to understand the mechanism of aquatic toxicology induced by ammonia in turtles.
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Affiliation(s)
- Lingyue Liang
- Ministry of Education Key Laboratory for Ecology of Tropical Islands, Key Laboratory of Tropical Animal and Plant Ecology of Hainan Province, College of Life Sciences, Hainan Normal University, Haikou 571158, China
| | - Zubin Huang
- Ministry of Education Key Laboratory for Ecology of Tropical Islands, Key Laboratory of Tropical Animal and Plant Ecology of Hainan Province, College of Life Sciences, Hainan Normal University, Haikou 571158, China
| | - Na Li
- Ministry of Education Key Laboratory for Ecology of Tropical Islands, Key Laboratory of Tropical Animal and Plant Ecology of Hainan Province, College of Life Sciences, Hainan Normal University, Haikou 571158, China
| | - Dongmei Wang
- Tropical Biological Technology Research Institute, Chinese Academy of Tropical Agriculture Science, Haikou 571101, China
| | - Li Ding
- Ministry of Education Key Laboratory for Ecology of Tropical Islands, Key Laboratory of Tropical Animal and Plant Ecology of Hainan Province, College of Life Sciences, Hainan Normal University, Haikou 571158, China.
| | - Haitao Shi
- Ministry of Education Key Laboratory for Ecology of Tropical Islands, Key Laboratory of Tropical Animal and Plant Ecology of Hainan Province, College of Life Sciences, Hainan Normal University, Haikou 571158, China
| | - Meiling Hong
- Ministry of Education Key Laboratory for Ecology of Tropical Islands, Key Laboratory of Tropical Animal and Plant Ecology of Hainan Province, College of Life Sciences, Hainan Normal University, Haikou 571158, China.
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18
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Stergachis AB, Mogensen KM, Khoury CC, Lin AP, Peake RW, Baker JJ, Barkoudah E, Sahai I, Sweetser DA, Berry GT, Krier JB. A retrospective study of adult patients with noncirrhotic hyperammonemia. J Inherit Metab Dis 2020; 43:1165-1172. [PMID: 32713002 DOI: 10.1002/jimd.12292] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/03/2020] [Accepted: 07/22/2020] [Indexed: 12/13/2022]
Abstract
Adult-onset noncirrhotic hyperammonemia (NCH) is poorly understood and has a high morbidity and mortality. To elucidate the etiology and management of NCH, we performed a retrospective analysis of 23 adults (median age 51) with NCH treated between 2014 and 2020 at two academic medical centers. Hyperammonemia was diagnosed in all cases during the evaluation of altered mental status, with 22% presenting with seizures. Peak ammonia levels were >200 μmol/L in 70% of cases. Defects in ammonia metabolism were assessed using urea cycle biochemical testing, germline genetic testing, and testing for urease-producing infectious agents. Ammonia metabolism defects in these cases appear attributable to four major sources: (a) infection with urease-producing organism (n = 5); (b) previously undiagnosed inborn errors of metabolism (IEMs) (n = 4); (c) clinical exposures causing acquired urea cycle dysfunction (n = 6); and (d) unexplained acquired urea cycle dysfunction (uaUCD) (n = 8), as evidenced by biochemical signatures of urea cycle dysfunction without a genetic or clinical exposure. Severe protein malnutrition appeared to be a reversible risk factor for uaUCD. Overall, 13% of our cohort died prior to resolution of hyperammonemia, 26% died after hyperammonemia resolution, 57% survived after having reversible neurological changes, and 4% survived with irreversible neurological changes. Renal replacement therapy for ammonia clearance was often utilized for patients with an ammonia level above 250 μmol/L and patients were frequently empirically treated with antibiotics targeting urea-splitting organisms. Our study demonstrates that acquired urea cycle dysfunction, IEMs and urease-producing infections are major sources of adult-onset NCH and highlights successful management strategies for adult-onset NCH.
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Affiliation(s)
- Andrew B Stergachis
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kris M Mogensen
- Department of Nutrition, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Charbel C Khoury
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander P Lin
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Roy Wa Peake
- Department of Laboratory Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua J Baker
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ebrahim Barkoudah
- Hospital Medicine Unit, Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Inderneel Sahai
- Division of Medical Genetics and Metabolism, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David A Sweetser
- Division of Medical Genetics and Metabolism, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gerard T Berry
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joel B Krier
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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19
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Tang S, Xie J, Wu W, Yi B, Liu L, Zhang H. High ammonia exposure regulates lipid metabolism in the pig skeletal muscle via mTOR pathway. Sci Total Environ 2020; 740:139917. [PMID: 32563870 DOI: 10.1016/j.scitotenv.2020.139917] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [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: 12/10/2019] [Revised: 03/23/2020] [Accepted: 06/01/2020] [Indexed: 06/11/2023]
Abstract
Ambient ammonia exposure has been known to perturb lipid metabolism in farm animals, but the underlying mechanism is unclear. The current study was conducted to investigate how ambient ammonia exposure influences lipid metabolism in the pig model. Twelve pigs were randomly divided into two groups, either exposed to 0 or 35 mg/m3 atmospheric ammonia for 25 days. Serum ammonia remained unchanged (p > 0.05), but increased serum urea concentration was found (p < 0.05) after ammonia exposure. Ammonia exposure also caused an increased C18:0, C18:2n6c, C18:3n6, C18:3n3, C20:0, C20:2, C20:3n6, C20:3n3, C22:0 concentrations and fat content in the longissimus dorsi muscle (p < 0.05), and also serum total triglyceride (p = 0.0294) and ApoB (p = 0.0061) contents. Analysis of serum free amino acids profile revealed that concentrations of ornithine, tyrosine, asparagine, histidine, phenylalanine, leucine, isoleucine, glutamine and valine were significantly increased in the pigs exposed to 35 mg/m3 ammonia (p < 0.05). RNA-Seq analysis showed that genes encoding enzymes involved in lipid synthesis (FASN, SCD and FADS1) and uptake (LDLR) were up-regulated, whereas genes related to lipolysis (PNPLA4, ANGPTL4 and CEL), transport (CPT1A, CPT1B and CPT2) and β-oxidation (ACADL, ACADVL, UCP2 and UCP3) were down-regulated. Furthermore, exposure to 35 mg/m3 atmospheric ammonia increased expression of mTOR (p = 0.0377) and its downstream P70S6K (p = 0.0139) and p-P70S6K (p = 0.0431), but decreased AMPK (p < 0.0001) and p-AMPK (p = 0.0071) in the longissimus dorsi muscle. In conclusion, high concentration of atmospheric ammonia exposure greatly interferes with amino acid metabolism, resulting in increased BCAAs and aromatic amino acids. The increased BCAAs production can up-regulate lipid synthesis and down-regulate β-oxidation by activating mTOR signaling and inhibiting AMPK signaling.
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Affiliation(s)
- Shanlong Tang
- State Key Laboratory of Animal Nutrition, Institute of Animal Science, Chinese Academy of Agricultural Sciences, Beijing 100193, PR China
| | - Jingjing Xie
- State Key Laboratory of Animal Nutrition, Institute of Animal Science, Chinese Academy of Agricultural Sciences, Beijing 100193, PR China.
| | - Weida Wu
- State Key Laboratory of Animal Nutrition, Institute of Animal Science, Chinese Academy of Agricultural Sciences, Beijing 100193, PR China
| | - Bao Yi
- State Key Laboratory of Animal Nutrition, Institute of Animal Science, Chinese Academy of Agricultural Sciences, Beijing 100193, PR China
| | - Lei Liu
- State Key Laboratory of Animal Nutrition, Institute of Animal Science, Chinese Academy of Agricultural Sciences, Beijing 100193, PR China
| | - Hongfu Zhang
- State Key Laboratory of Animal Nutrition, Institute of Animal Science, Chinese Academy of Agricultural Sciences, Beijing 100193, PR China.
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20
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Ozaki Y, Imamaki H, Ikeda A, Oura M, Nakagawa S, Funakoshi T, Kataoka S, Nishikawa Y, Horimatsu T, Yonezawa A, Matsubara T, Yanagita M, Muto M, Watanabe N. Successful management of hyperammonemia with hemodialysis on day 2 during 5-fluorouracil treatment in a patient with gastric cancer: a case report with 5-fluorouracil metabolite analyses. Cancer Chemother Pharmacol 2020; 86:693-699. [PMID: 33011861 PMCID: PMC7595983 DOI: 10.1007/s00280-020-04158-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/24/2020] [Indexed: 12/01/2022]
Abstract
Purpose Hyperammonemia is an important adverse event associated with
5-fluorouracil (5FU) from 5FU metabolite accumulation. We present a case of an
advanced gastric cancer patient with chronic renal failure, who was treated with
5FU/leucovorin (LV) infusion chemotherapy (2-h infusion of LV and 5FU bolus followed
by 46-h 5FU continuous infusion on day 1; repeated every 2 weeks) and developed
hyperammonemia, with the aim of exploring an appropriate hemodialysis (HD) schedule
to resolve its symptoms. Methods The blood concentrations of 5FU and its metabolites, α-fluoro-β-alanine
(FBAL), and monofluoroacetate (FA) of a patient who had hyperammonemia from seven
courses of palliative 5FU/LV therapy for gastric cancer were measured by liquid
chromatography–mass spectrometry. Results On the third day of the first cycle, the patient presented with
symptomatic hyperammonemia relieved by emergency HD. Thereafter, the 5FU dose was
reduced; however, in cycles 2–4, the patient developed symptomatic hyperammonemia and
underwent HD on day 3 for hyperammonemia management. In cycles 5–7, the timing of
scheduled HD administration was changed from day 3 to day 2, preventing symptomatic
hyperammonemia. The maximum ammonia and 5FU metabolite levels were significantly
lower in cycles 5–7 than in cycles 2–4 (NH3 75 ± 38 vs 303 ± 119 μg/dL, FBAL
13.7 ± 2.5 vs 19.7 ± 2.0 μg/mL, FA 204.0 ± 91.6 vs 395.9 ± 12.6 ng/mL,
mean ± standard deviation, all p < 0.05). After
seven cycles, partial response was confirmed. Conclusion HD on day 2 instead of 3 may prevent hyperammonemia in 5FU/LV
therapy. Electronic supplementary material The online version of this article (10.1007/s00280-020-04158-1) contains supplementary material, which is available to authorized
users.
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Affiliation(s)
- Yoshinao Ozaki
- Department of Gastroenterology, Hirakata Kohsai Hospital, Osaka, Japan.
| | - Hirotaka Imamaki
- Department of Nephrology, Hirakata Kohsai Hospital, Osaka, Japan
| | - Aki Ikeda
- Department of Gastroenterology, Hirakata Kohsai Hospital, Osaka, Japan
| | - Mitsuaki Oura
- Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shunsaku Nakagawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Taro Funakoshi
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shigeki Kataoka
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshitaka Nishikawa
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Takahiro Horimatsu
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Atsushi Yonezawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Takeshi Matsubara
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Motoko Yanagita
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Manabu Muto
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Norihiko Watanabe
- Department of Gastroenterology, Hirakata Kohsai Hospital, Osaka, Japan
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21
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Cormack BE, Jiang Y, Harding JE, Crowther CA, Lynn A, Nair A, Hewson M, Meyer M, Broadbent R, Webster D, Glamuzina E, Ryder B, Bloomfield FH. Plasma ammonia concentrations in extremely low birthweight infants in the first week after birth: secondary analysis from the ProVIDe randomized clinical trial. Pediatr Res 2020; 88:250-256. [PMID: 31896121 PMCID: PMC7384986 DOI: 10.1038/s41390-019-0730-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/20/2019] [Accepted: 12/09/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND Little is known about normative ammonia concentrations in extremely low birthweight (ELBW) babies and whether these vary with birth characteristics. We aimed to determine ammonia concentrations in ELBW babies in the first week after birth and relationships with neonatal characteristics and protein intake. METHODS Arterial blood samples for the measurement of plasma ammonia concentration were collected within 7 days of birth from ProVIDe trial participants in six New Zealand neonatal intensive care units. RESULTS Three hundred and twenty-two babies were included. Median (range) gestational age was 25.7 (22.7-31.6) weeks. Median (interquartile range (IQR)) ammonia concentration was 102 (80-131) µg/dL. There were no statistically significant associations between ammonia concentrations and birthweight or sex. Ammonia concentrations were weakly correlated with mean total (Spearman's rs = 0.11, P = 0.047) and intravenous (rs = 0.13, P = 0.02) protein intake from birth, gestational age at birth (rs = -0.13, P = 0.02) and postnatal age (rs = -0.13, P = 0.02). CONCLUSIONS Plasma ammonia concentrations in ELBW babies are similar to those of larger and more mature babies and only weakly correlated with protein intake. Currently, recommended thresholds for investigation of hyperammonaemia are appropriate for ELBW babies. Protein intake should not be limited by concerns about potential hyperammonaemia.
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Affiliation(s)
- Barbara E Cormack
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Newborn Services, Auckland City Hospital, Auckland, New Zealand
| | - Yannan Jiang
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | | | - Adrienne Lynn
- Neonatal Intensive Care Unit, Christchurch Women's Hospital, Christchurch, New Zealand
| | - Arun Nair
- Newborn Intensive Care Unit, Waikato Hospital, Hamilton, New Zealand
| | - Michael Hewson
- Neonatal Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
| | - Mike Meyer
- Neonatal Unit, Middlemore Hospital, Auckland, New Zealand
| | - Roland Broadbent
- Neonatal Intensive Care Unit, Dunedin Hospital, Dunedin, New Zealand
| | - Dianne Webster
- LabPlus, Auckland District Health Board, Auckland, New Zealand
| | - Emma Glamuzina
- National Adult and Paediatric Metabolic Service, Auckland, New Zealand
| | - Bryony Ryder
- National Adult and Paediatric Metabolic Service, Auckland, New Zealand
| | - Frank H Bloomfield
- Liggins Institute, University of Auckland, Auckland, New Zealand.
- Newborn Services, Auckland City Hospital, Auckland, New Zealand.
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22
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Abstract
Sarcopenia has a negative impact on the prognosis of patients with liver cirrhosis (LC). We investigated the significance of skeletal muscle volume and its changes in LC patients taking levocarnitine (L-carnitine).We retrospectively analyzed 51 LC patients taking L-carnitine from December 2012 to March 2019. Skeletal mass index was calculated as the left-right sum of the major × minor axis of psoas muscle at the third lumbar vertebra, divided by height squared (psoas muscle index [PMI]). Patients were classified into 2 groups (low and normal PMI) depending on PMI < 6.0 and < 3.4 cm/m for men and women, respectively. Changes in PMI per month during L-carnitine administration (ΔPMI/m) were calculated, and we classified the patients into 2 groups (severe and mild muscle atrophy) depending on ΔPMI/m below the lower quartile. We assessed overall survival (OS).At the start of L-carnitine administration, there were no significant differences in OS between groups with low and normal PMI. Multivariate analysis showed that ΔPMI/m (hazard ratio [HR], 0.007; P = .005) and L-carnitine administration period (HR, 0.956; P = .021) were significantly associated with OS. Patients with severe muscle atrophy had a significantly lower OS than those with mild muscle atrophy. There was the positive correlation relationship between ΔPMI/m and L-carnitine administration period.Among LC patients taking L-carnitine, progressive muscle volume loss was a predictor of poor prognosis. L-carnitine administration for longer may be able to prevent muscle volume loss and lead to a better prognosis in LC patients.
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23
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Zapolnik P, Sykut-Cegielska J, Pyrkosz A. Coincidence of 3-methylglutaconic aciduria and duplication 5q - a case report and literature review. Acta Biochim Pol 2020; 67:263-266. [PMID: 32511901 DOI: 10.18388/abp.2020_5355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 05/11/2020] [Indexed: 11/10/2022]
Abstract
3-methylglutaconic aciduria includes a heterogeneous group of inborn errors of metabolism. The disease may have various clinical presentations, as can duplication 5q. We present the case of a 13-year-old boy with 3-methylglutaconic aciduria and duplication 5q. The main symptoms included myopathy, weakness, spastic paresis intensified mostly in the lower limbs, and intellectual disability. Additional studies showed elevated levels of 3-methylglutaconic acid in urine and ammonia in plasma. A duplication in region 5q23.3q31.1 was found in array-based comparative genomic hybridization. Next-generation sequencing did not reveal any pathological mutation. On the basis of the clinical picture and the results of biochemical and genetic tests 3-methylglutaconic aciduria type IV with duplication 5q was diagnosed.
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Affiliation(s)
- Paweł Zapolnik
- Students' Scientific Association of Clinical Genetics, Department of Clinical Genetics, Medical College, University of Rzeszów, Poland
| | - Jolanta Sykut-Cegielska
- Department of Inborn Errors of Metabolism and Paediatrics, Institute of Mother and Child, Warsaw, Poland
| | - Antoni Pyrkosz
- Department of Clinical Genetics, Medical College, University of Rzeszów, Rzeszów, Poland
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24
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Warrillow S, Fisher C, Tibballs H, Bailey M, McArthur C, Lawson-Smith P, Prasad B, Anstey M, Venkatesh B, Dashwood G, Walsham J, Holt A, Wiersema U, Gattas D, Zoeller M, García Álvarez M, Bellomo R. Continuous renal replacement therapy and its impact on hyperammonaemia in acute liver failure. CRIT CARE RESUSC 2020; 22:158-165. [PMID: 32389108 PMCID: PMC10692487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Hyperammonaemia contributes to complications in acute liver failure (ALF) and may be treated with continuous renal replacement therapy (CRRT), but current practice is poorly understood. DESIGN We retrospectively analysed data for baseline characteristics, ammonia concentration, CRRT use, and outcomes in a cohort of Australian and New Zealand patients with ALF. SETTING All liver transplant ICUs across Australia and New Zealand. PARTICIPANTS Sixty-two patients with ALF. MAIN OUTCOME MEASURES Impact of CRRT on hyperammonaemia and patient outcomes. RESULTS We studied 62 patients with ALF. The median initial (first 24 h) peak ammonia was 132 μmol/L (interquartile range [IQR], 91-172), median creatinine was 165 μmol/L (IQR, 92-263) and median urea was 6.9 mmol/L (IQR, 3.1-12.0). Most patients (43/62, 69%) received CRRT within a median of 6 hours (IQR, 2-12) of ICU admission. At CRRT commencement, three-quarters of such patients did not have Stage 3 acute kidney injury (AKI): ten patients (23%) had no KDIGO creatinine criteria for AKI, 12 (28%) only had Stage 1, and ten patients (23%) had Stage 2 AKI. Compared with non-CRRT patients, those treated with CRRT had higher ammonia concentrations (median, 141 μmol/L [IQR, 102-198] v 91 μmol/L [IQR, 54-115]; P = 0.02), but a nadir Day 1 pH of only 7.25 (standard deviation, 0.16). Prevention of extreme hyperammonaemia (> 140 μmol/L) after Day 1 was achieved in 36 of CRRT-treated patients (84%) and was associated with transplant-free survival (55% v 13%; P = 0.05). CONCLUSION In Australian and New Zealand patients with ALF, CRRT is typically started early, before Stage 3 AKI or severe acidaemia, and in the presence hyperammonaemia. In these more severely ill patients, CRRT use was associated with prevention of extreme hyperammonaemia, which in turn, was associated with increased transplant-free survival.
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Affiliation(s)
- Stephen Warrillow
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia.
| | - Caleb Fisher
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Heath Tibballs
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | | | - Colin McArthur
- Medical Research Institute of New Zealand, Auckland, New Zealand
| | - Pia Lawson-Smith
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | | | - Matthew Anstey
- Department of Intensive Care, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Bala Venkatesh
- Department of Intensive Care, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Gemma Dashwood
- Department of Intensive Care, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - James Walsham
- Department of Intensive Care, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Andrew Holt
- Department of Intensive Care, Flinders Medical Centre, Adelaide, SA, Australia
| | - Ubbo Wiersema
- Department of Intensive Care, Flinders Medical Centre, Adelaide, SA, Australia
| | - David Gattas
- Department of Intensive Care, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Matthew Zoeller
- Department of Intensive Care, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Mercedes García Álvarez
- Department of Anaesthesiology and Pain Medicine, Hospital de la Santa Creu i Sant Pau, University of Barcelona, Barcelona, Spain
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
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25
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Pontoizeau C, Roda C, Arnoux JB, Vignolo-Diard P, Brassier A, Habarou F, Barbier V, Grisel C, Abi-Warde MT, Boddaert N, Kuster A, Servais A, Kaminska A, Hennequin C, Dupic L, Lesage F, Touati G, Valayannopoulos V, Chadefaux-Vekemans B, Oualha M, Eisermann M, Ottolenghi C, de Lonlay P. Neonatal factors related to survival and intellectual and developmental outcome of patients with early-onset urea cycle disorders. Mol Genet Metab 2020; 130:110-117. [PMID: 32273051 DOI: 10.1016/j.ymgme.2020.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 02/15/2020] [Revised: 03/14/2020] [Accepted: 03/14/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE We aimed to identify prognostic factors for survival and long-term intellectual and developmental outcome in neonatal patients with early-onset urea cycle disorders (UCD) experiencing hyperammonaemic coma. METHODS We retrospectively analysed ammonia (NH3) and glutamine levels, electroencephalogram and brain images obtained during neonatal coma of UCD patients born between 1995 and 2011 and managed at a single centre and correlated them to survival and intellectual and developmental outcome. RESULTS We included 38 neonates suffering from deficiencies of argininosuccinate synthetase (ASSD, N = 12), ornithine transcarbamylase (OTCD, N = 10), carbamoylphosphate synthetase 1 (CPSD, N = 7), argininosuccinate lyase (ASLD, N = 7), N-acetylglutamate synthase (NAGS, N = 1) or arginase (ARGD, N = 1). Symptoms occurred earlier in mitochondrial than in cytosolic UCD. Sixty-eight percent of patients survived, with a mean (standard deviation-SD) follow-up of 10.4 (5.3) years. Mortality was mostly observed in OTCD (N = 7/10) and CPSD (N = 4/7) patients. Plasma NH3 level during the neonatal period, expressed as area under the curve, but not glutamine level was associated with mortality (p = .044 and p = .610). 62.1% of the patients had normal intellectual and developmental outcome. Intellectual and developmental outcome tended to correlate with UCD subtype (p = .052). No difference in plasma NH3 or glutamine level during the neonatal period among developmental outcomes was identified. EEG severity was linked to UCD subtypes (p = .004), ammonia levels (p = .037), duration of coma (p = .043), and mortality during the neonatal period (p = .020). Status epilepticus was recorded in 6 patients, 3 of whom died neonatally, 1 developed a severe intellectual disability while the 2 last patients had a normal development. CONCLUSION UCD subtypes differed by survival rate, intellectual and developmental outcome and EEG features in the neonatal period. Hyperammonaemia expressed as area under the curve was associated with survival but not with intellectual and developmental outcome whereas glutamine was not associated with one of these outcomes. Prognostic value of video-EEG monitoring and the association between status epilepticus and mortality should be assessed in neonatal hyperammonaemic coma in further studies.
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Affiliation(s)
- Clément Pontoizeau
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France.
| | - Célina Roda
- Université de Paris, CRESS, INSERM, INRA, HERA team (Health Environmental Risk Assessment), F-75004 Paris, France
| | - Jean-Baptiste Arnoux
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | | | - Anais Brassier
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Florence Habarou
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Valérie Barbier
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Coraline Grisel
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Marie-Thérèse Abi-Warde
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Nathalie Boddaert
- Department of Pediatric Radiology, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, PRES Sorbonne Paris Cité, INSERM U1000, Institut Imagine, Paris, France
| | - Alice Kuster
- Pediatric Critical Care Unit, Femme-Enfants-Adolescents Hospital, Nantes University, Nantes, France
| | - Aude Servais
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Department of Nephrology, Transplantation, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Anna Kaminska
- Neurophysiology Unit, AP-HP, Necker Enfants Malades Hospital, Paris, France
| | - Carole Hennequin
- Biochemistry, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Laurent Dupic
- Pediatric Critical Care Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Fabrice Lesage
- Pediatric Critical Care Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Guy Touati
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Vassili Valayannopoulos
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Bernadette Chadefaux-Vekemans
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Mehdi Oualha
- Pediatric Critical Care Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Monika Eisermann
- Neurophysiology Unit, AP-HP, Necker Enfants Malades Hospital, Paris, France
| | - Chris Ottolenghi
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Pascale de Lonlay
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
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26
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Brandt A, Agarwal N, Giri D, Yung Z, Didi M, Senniappan S. Hyperinsulinism hyperammonaemia (HI/HA) syndrome due to GLUD1 mutation: phenotypic variations ranging from late presentation to spontaneous resolution. J Pediatr Endocrinol Metab 2020; 33:675-679. [PMID: 32229669 DOI: 10.1515/jpem-2019-0416] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 09/09/2019] [Accepted: 02/06/2020] [Indexed: 12/16/2022]
Abstract
Background The hyperinsulinism/hyperammonaemia (HI/HA) syndrome is the second most common cause of hyperinsulinaemic hypoglycaemia, caused by activating mutations in GLUD1. In this article, we report a series of three unrelated patients with HI/HA syndrome who demonstrated variable phenotypes, ranging from delayed presentation to spontaneous resolution of hypoglycaemia, thereby expanding the current knowledge and understanding of GLUD1 mutations. Case presentation This paper is a retrospective analysis of patients with HI/HA syndrome who demonstrated a variable disease course. Patient 1 presented with hypoglycaemic seizures at the age of 7 months and was diagnosed with HI/HA syndrome. Patient 2, a 5-year-old boy, on anti-convulsants since 8 months of age, was diagnosed with HI/HA at the age of 4 years. Patient 3, an 11-year-old girl with a history of transient neonatal hypoglycaemia, was diagnosed with HI/HA at the age of 12 months following evaluation for absence seizures. Patients 1 and 2 had raised ammonia levels, whilst patient 3 had normal ammonia level. The genetic analysis in all three patients confirmed GLUD1 mutation. Good glycaemic control was observed in all following diazoxide treatment. All patients have learning difficulties. Patient 1 demonstrated spontaneous resolution of hypoglycaemia at the age of 8 years, enabling discontinuation of diazoxide. Conclusions The cases highlight the diagnostic challenges in HI/HA syndrome due to a highly variable presentation. Knowledge of variable phenotypes would enable early diagnosis, thereby decreasing the risk of long-term neurological damage. Spontaneous resolution of hyperinsulinism could occur, and it is important to consider a trial off diazoxide therapy especially if the patients are on a small dose of diazoxide.
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Affiliation(s)
- Agnieszka Brandt
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Neha Agarwal
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Dinesh Giri
- Department of Paediatric Endocrinology, Bristol Royal Hospital for Children, Bristol, UK
| | - Zoe Yung
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Mohammad Didi
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Senthil Senniappan
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
- Consultant Paediatric Endocrinologist and Honorary Senior Lecturer, Alder Hey Children's NHS Foundation Trust, Liverpool L12 2AP, UK
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27
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Abstract
Hepatic encephalopathy (HE) is one of the major clinical decompensations of cirrhosis, with a high impact on health care resource utilization and cost. For an effective and comprehensive management of HE, the clinicians need to understand the pathophysiologic mechanisms of HE. This review describes the multiorgan processes involved in HE and how several HE precipitants and treatment strategies act on ammonia production, excretion, and neurotoxicity, including the impact of diabetes and use of cannabinoids. The authors also discuss the current and future role of gut microbiome, systemic/central inflammation, and various neurotransmitters for the pathogenesis and treatment of HE.
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Affiliation(s)
- Ariel Jaffe
- Section of Digestive Diseases, Yale Liver Center, Yale University School of Medicine, 333 Cedar Street, LMP 1080, New Haven, CT 06520-8019, USA
| | - Joseph K Lim
- Section of Digestive Diseases, Yale Liver Center, Yale University School of Medicine, 333 Cedar Street, LMP 1080, New Haven, CT 06520-8019, USA; VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Sofia Simona Jakab
- Section of Digestive Diseases, Yale Liver Center, Yale University School of Medicine, 333 Cedar Street, LMP 1080, New Haven, CT 06520-8019, USA; VA Connecticut Healthcare System, West Haven, Connecticut, USA.
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Sfarti C, Ciobica A, Balmus IM, Ilie OD, Trifan A, Petrea O, Cojocariu C, Gîrleanu I, Sîngeap AM, Stanciu C. Systemic Oxidative Stress Markers in Cirrhotic Patients with Hepatic Encephalopathy: Possible Connections with Systemic Ammoniemia. Medicina (Kaunas) 2020; 56:medicina56040196. [PMID: 32340177 PMCID: PMC7231105 DOI: 10.3390/medicina56040196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 04/08/2020] [Accepted: 04/18/2020] [Indexed: 02/05/2023]
Abstract
Background and objectives: Oxidative stress shows evidence of dysregulation in cirrhotic patients with hepatic encephalopathy (HE), although there are still controversies regarding the connections between oxidative stress and ammonia in these patients. The aim of this study was to evaluate the oxidative stress implication in overt HE pathogenesis of cirrhotic patients. Materials and Methods: We performed a prospective case-control study, which included 40 patients divided into two groups: group A consisted of 20 cirrhotic patients with HE and increased systemic ammoniemia, and group B consisted of 20 cirrhotic patients with HE and normal systemic ammoniemia. The control group consisted of 21 healthy subjects matched by age and sex. The activity of superoxide dismutase (SOD), glutathione peroxidase (GPx), malondialdehyde (MDA) levels (lipid peroxidation marker), and ammoniemia were evaluated. Results: We found a significant decrease in SOD and GPx activity and also a significant increase of MDA levels in cirrhotic patients with HE as compared to the healthy age-matched control group (1.35 ± 0.08 vs. 0.90 ± 0.08 U/mL, p = 0.002; 0.093 ± 0.06 vs. 0.006 ± 0.008 U/mL, p = 0.001; and 35.94 ± 1.37 vs. 68.90 ± 5.68 nmols/mL, p = 0.0001, respectively). Additionally, we found significant correlations between the main oxidative stress markers and the levels of systemic ammonia (r = 0.452, p = 0.005). Patients from group A had a significant increase of MDA as compared with those from group B (76.93 ± 5.48 vs. 50.06 ± 5.60 nmols/mL, p = 0.019). Also, there was a compensatory increase in the activity of both antioxidant enzymes (SOD and GPx) in patients with increased systemic ammoniemia (group A), as compared to HE patients from group B. Conclusions: Our results demonstrated a significant decrease in antioxidants enzymes activities (SOD and GPx), as well as a significant increase in MDA concentrations, adding new data regarding the influence of oxidative stress in HE pathogenesis in cirrhotic patients.
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Affiliation(s)
- Cătălin Sfarti
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, “St. Spiridon” University Hospital, Institute of Gastroenterology and Hepatology, Independence Avenue, no 1, 700111 Iași, Romania; (C.S.); (A.T.); (O.P.); (I.G.); (A.M.S.)
| | - Alin Ciobica
- Department of Research, Faculty of Biology, “Alexandru Ioan Cuza” University, Carol I Avenue, no 11, 700505 Iasi, Romania; (I.-M.B.); (O.-D.I.)
- Correspondence: (A.C.); (C.C.)
| | - Ioana-Miruna Balmus
- Department of Research, Faculty of Biology, “Alexandru Ioan Cuza” University, Carol I Avenue, no 11, 700505 Iasi, Romania; (I.-M.B.); (O.-D.I.)
- Department of Interdisciplinary Research in Science, Alexandru Ioan Cuza University of Iasi, Carol I Avenue, no. 11, 700506 Iasi, Romania
| | - Ovidiu-Dumitru Ilie
- Department of Research, Faculty of Biology, “Alexandru Ioan Cuza” University, Carol I Avenue, no 11, 700505 Iasi, Romania; (I.-M.B.); (O.-D.I.)
| | - Anca Trifan
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, “St. Spiridon” University Hospital, Institute of Gastroenterology and Hepatology, Independence Avenue, no 1, 700111 Iași, Romania; (C.S.); (A.T.); (O.P.); (I.G.); (A.M.S.)
| | - Oana Petrea
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, “St. Spiridon” University Hospital, Institute of Gastroenterology and Hepatology, Independence Avenue, no 1, 700111 Iași, Romania; (C.S.); (A.T.); (O.P.); (I.G.); (A.M.S.)
| | - Camelia Cojocariu
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, “St. Spiridon” University Hospital, Institute of Gastroenterology and Hepatology, Independence Avenue, no 1, 700111 Iași, Romania; (C.S.); (A.T.); (O.P.); (I.G.); (A.M.S.)
- Correspondence: (A.C.); (C.C.)
| | - Irina Gîrleanu
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, “St. Spiridon” University Hospital, Institute of Gastroenterology and Hepatology, Independence Avenue, no 1, 700111 Iași, Romania; (C.S.); (A.T.); (O.P.); (I.G.); (A.M.S.)
| | - Ana Maria Sîngeap
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, “St. Spiridon” University Hospital, Institute of Gastroenterology and Hepatology, Independence Avenue, no 1, 700111 Iași, Romania; (C.S.); (A.T.); (O.P.); (I.G.); (A.M.S.)
| | - Carol Stanciu
- Romanian Academy, Iasi Branch, Nr. 8, Carol I Avenue, no. 8, 700505 Iasi, Romania;
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Zhao J, He Y, Xu P, Liu J, Ye S, Cao Y. Serum ammonia levels on admission for predicting sepsis patient mortality at D28 in the emergency department: A 2-center retrospective study. Medicine (Baltimore) 2020; 99:e19477. [PMID: 32176079 PMCID: PMC7220506 DOI: 10.1097/md.0000000000019477] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
We assessed the predictive value of serum ammonia level on admission for the 28-day mortality of patients with sepsis.We retrospectively included septic patients admitted to the emergency department of West China Hospital, Sichuan University and The Fourth People's Hospital of Zigong city from June 2017 to May 2018. Patients were divided into 2 groups according to 28-day survival. Comparisons of serum ammonia level and sequential organ failure assessment (SOFA) score were made between 2 groups. Multivariate logistic regression models were employed to determine independent risk factors affecting 28-day mortality rate, and receiver operating characteristic (ROC) curve was also used to evaluate the efficacy of risk factors.Total of 316 patients were included into the study, 221 survived to 28 days and 95 were died before 28 days. The 28-day mortality rate was 30.06%. Multivariate logistic regression analyses revealed that the ammonia level, C reactive protein, SOFA score, and the leukocyte were independent risk factors for the 28-day mortality rate. In predicting the 28-day mortality rate, the SOFA score presented an area under the ROC curve (AUC) of 0.815, and the ammonia levels presented the AUC of 0.813.The ammonia level, C reactive protein, SOFA score, and the leukocyte are independent risk factors for 28-day mortality rate in septic patients. Moreover, the serum ammonia and SOFA score have similar predictive values. The serum ammonia level is also a suitable early indicator for prognostic evaluation of patients with sepsis as well.
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Affiliation(s)
- Jie Zhao
- Emergency Department, West China Hospital, Sichuan University, Chengdu
| | - Yarong He
- Emergency Department, West China Hospital, Sichuan University, Chengdu
| | - Ping Xu
- Emergency Department, The Fourth People's Hospital of Zigong City, Zigong
| | - Junzhao Liu
- Emergency Department, West China Hospital, Sichuan University, Chengdu
| | - Sheng Ye
- Emergency Department, West China Hospital, Sichuan University, Chengdu
| | - Yu Cao
- Emergency Department, West China Hospital, Sichuan University, Chengdu
- Disaster Medicine Center, Sichuan University, Chengdu, China
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Toma L, Stanciu AM, Zgura A, Bacalbasa N, Diaconu C, Iliescu L. Electrocardiographic Changes in Liver Cirrhosis-Clues for Cirrhotic Cardiomyopathy. ACTA ACUST UNITED AC 2020; 56:medicina56020068. [PMID: 32050594 PMCID: PMC7073951 DOI: 10.3390/medicina56020068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/02/2020] [Accepted: 02/03/2020] [Indexed: 12/15/2022]
Abstract
Background and Objectives: Cirrhotic cardiomyopathy is a chronic cardiac dysfunction associated with liver cirrhosis, in patients without previous heart disease, irrespective of the etiology of cirrhosis. Electrocardiography (ECG) is an important way to evaluate patients with cirrhosis and may reveal significant changes associated with liver disease. Our study aimed to evaluate ECG changes in patients with diagnosed liver cirrhosis and compare them to patients with chronic hepatitis. Materials and Methods: We evaluated laboratory findings and ECG tracings in 63 patients with cirrhosis and 54 patients with chronic hepatitis of viral etiology. The end points of the study were prolonged QT interval, QRS hypovoltage and T-peak-to-T-end decrease. We confirmed the diagnosis of cirrhotic cardiomyopathy using echocardiography data. Results: Advanced liver disease was associated with prolonged QT intervals. Also, QRS amplitude was lower in patients with decompensated cirrhosis than in patients with compensated liver disease. We found an accentuated deceleration of the T wave in patients with cirrhosis. These findings correlated to serum levels of albumin, cholesterol and ammonia. Conclusions: ECG changes in liver cirrhosis are frequently encountered and are important noninvasive markers for the presence of cirrhotic cardiomyopathy.
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Affiliation(s)
- Letitia Toma
- Department of Internal Medicine II, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.T.); (A.M.S.)
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
| | - Adriana Mercan Stanciu
- Department of Internal Medicine II, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.T.); (A.M.S.)
| | - Anca Zgura
- Chemotherapy Department, OncoFort Hospital, 022328 Bucharest, Romania;
| | - Nicolae Bacalbasa
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
| | - Camelia Diaconu
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
- Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, 022328 Bucharest, Romania;
| | - Laura Iliescu
- Department of Internal Medicine II, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.T.); (A.M.S.)
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
- Correspondence: ; Tel.: +407-22-235-695
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Arora S, Srivastava MVP, Singh MB, Goyal V, Häberle J, Gupta N, Prabhakar A, Aggarwal B, Agarwal A, Vishnu VY. Adult onset type II citrullinemia--a great masquerader. QJM 2020; 113:49-51. [PMID: 31532496 DOI: 10.1093/qjmed/hcz238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Indexed: 12/30/2022] Open
Affiliation(s)
- S Arora
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - M V Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - M B Singh
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - V Goyal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - J Häberle
- Head Metabolic Laboratory, Division of Metabolism, University Children's Hospital Zurich, Eleonore Foundation, Steinwiesstrasse 75, CH-8032 Zürich, Switzerland
| | - N Gupta
- Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - A Prabhakar
- Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - B Aggarwal
- Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - A Agarwal
- Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - V Y Vishnu
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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Ishikawa T, Endo S, Imai M, Azumi M, Nozawa Y, Sano T, Iwanaga A, Honma T, Yoshida T. Changes in the Body Composition and Nutritional Status after Long-term Rifaximin Therapy for Hyperammonemia in Japanese Patients with Hepatic Encephalopathy. Intern Med 2020; 59:2465-2469. [PMID: 33055469 PMCID: PMC7662066 DOI: 10.2169/internalmedicine.5094-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Objective Rifaximin has become available for treating hyperammonemia in patients with hepatic encephalopathy. This study analyzed the changes in the body composition and nutritional status after long-term rifaximin therapy. Methods Twenty-one patients who underwent rifaximin therapy at 1,200 mg/day for more than 24 weeks were evaluated for the changes in the controlling nutritional status (CONUT) scores for the nutritional assessment, albumin-bilirubin (ALBI) scores for the liver function assessment, and skeletal muscle index (SMI) for the body composition assessment. Results There were 17 men and 4 women, with a mean age of 67.14±8.32 years. Eleven cases had a portosystemic shunt (52.3%), and 10 had hepatocellular carcinoma (47.6%). The Child-Pugh class was A in 9 cases (42.9%), B in 9 cases (42.9%), and C in 3 cases (14.2%). The blood ammonia levels in the rifaximin group improved significantly upon rifaximin therapy, from 124.76±28.68 μg/dL at baseline to 47.00±14.43 μg/dL after 2 weeks (p<0.001) and 49.81±15.02 μg/dL after 24 weeks (p<0.001). The CONUT scores improved significantly during rifaximin therapy, from 6.47±3.25 at baseline to 3.33±2.65 after 24 weeks (p=0.0007). The ALBI scores also improved significantly from -0.39±1.89 at baseline to -2.20±0.55 after 24 weeks (p=0.0002). The SMI scores showed that the body composition had been maintained in response to rifaximin therapy (50.20±7.67 at baseline and 51.29±7.62 after 24 weeks). Conclusion Rifaximin administration for hepatic encephalopathy improved the CONUT and ALBI scores. It may have a secondary effect on the improvement in the nutritional status and hepatic reserve.
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Affiliation(s)
- Toru Ishikawa
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Japan
| | - Saori Endo
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Japan
| | - Michitaka Imai
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Japan
| | - Motoi Azumi
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Japan
| | - Yujiro Nozawa
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Japan
| | - Tomoe Sano
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Japan
| | - Akito Iwanaga
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Japan
| | - Terasu Honma
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Japan
| | - Toshiaki Yoshida
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Japan
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Senzolo M, Zarantonello L, Formentin C, Orlando C, Beltrame R, Vuerich A, Angeli P, Burra P, Montagnese S. Predictive value of induced hyperammonaemia and neuropsychiatric profiling in relation to the occurrence of post-TIPS hepatic encephalopathy. Metab Brain Dis 2019; 34:1803-1812. [PMID: 31506797 DOI: 10.1007/s11011-019-00490-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 05/21/2019] [Accepted: 09/03/2019] [Indexed: 01/16/2023]
Abstract
Hepatic encephalopathy (HE) occurs in 20-50% of patients after transjugular intrahepatic portosystemic shunt (TIPS) placement. Older age, HE history and severe liver failure have all been associated with post-TIPS HE but it remains difficult to identify patients at risk. The aim of the present pathophysiological, pilot study was to assess the role of induced hyperammonaemia and associated neuropsychological and neurophysiological changes as predictors of post-TIPS HE. Eighteen TIPS candidates with no overt HE history (56 ± 8 yrs., MELD 11 ± 3) underwent neurophysiological [Electroencephalography (EEG)], neuropsychological [Psychometric Hepatic Encephalopathy Score (PHES) and Scan tests], ammonia and sleepiness assessment at baseline and after the induction of hyperammonaemia by an oral amino acid challenge (AAC). Pre-AAC, 17% of patients had abnormal EEG, 5% abnormal PHES, and 33% abnormal Scan performance. Post-AAC, 17% had abnormal EEG, 0% abnormal PHES, and 17% abnormal Scan performance. Pre-AAC, ammonia concentrations were 201 ± 73 μg/dL and subjective sleepiness 2.5 ± 1.2 (1-9 scale). Post-AAC, patients exhibited the expected increase in ammonia/sleepiness. Six months post-TIPS, 3 patients developed an episode of HE requiring hospitalization; these showed significantly lower pre-AAC fasting ammonia concentrations compared to patients who did not develop HE (117 ± 63 vs. 227 ± 57 μg/dL p = 0.015). They also showed worse PHES/Scan performance pre-AAC, and worse Scan performance post-AAC. Findings at 12 months follow-up (n = 5 HE episodes) were comparable. In conclusion, baseline ammonia levels and both pre- and post-AAC neuropsychiatric indices hold promise in defining HE risk in TIPS candidates with no HE history.
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Affiliation(s)
- Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgical and Gastroenterological Sciences, University of Padova, Padova, Italy
| | | | | | - Costanza Orlando
- Multivisceral Transplant Unit, Department of Surgical and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Raffaello Beltrame
- Multivisceral Transplant Unit, Department of Surgical and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Anna Vuerich
- Department of Medicine, University of Padova, Padova, Italy
| | - Paolo Angeli
- Department of Medicine, University of Padova, Padova, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgical and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Sara Montagnese
- Department of Medicine, University of Padova, Padova, Italy.
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Pliego Cosano R, Moreno Rosauro JM, Clavero Olmos M. Valproicacid-induced hyperammonemic encephalopathy in the emergency department. Emergencias 2019; 31:364-365. [PMID: 31625314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Raúl Pliego Cosano
- Servicio de Urgencias, Hospital Universitario Hospital Infanta Elena, Madrid, España
| | | | - Marta Clavero Olmos
- Servicio de Urgencias, Hospital Universitario Hospital Infanta Elena, Madrid, España
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Shrivastava J, Ndugwa M, Caneos W, De Boeck G. Physiological trade-offs, acid-base balance and ion-osmoregulatory plasticity in European sea bass (Dicentrarchus labrax) juveniles under complex scenarios of salinity variation, ocean acidification and high ammonia challenge. Aquat Toxicol 2019; 212:54-69. [PMID: 31075620 DOI: 10.1016/j.aquatox.2019.04.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 04/10/2019] [Revised: 04/30/2019] [Accepted: 04/30/2019] [Indexed: 06/09/2023]
Abstract
In this era of global climate change, ocean acidification is becoming a serious threat to the marine ecosystem. Despite this, it remains almost unknown how fish will respond to the co-occurrence of ocean acidification with other conventional environmental perturbations typically salinity fluctuation and high ammonia threat. Therefore, the present work evaluated the interactive effects of elevated pCO2, salinity reduction and high environmental ammonia (HEA) on the ecophysiological performance of European sea bass (Dicentrarchus labrax). Fish were progressively acclimated to seawater (32 ppt), to brackish water (10 ppt) and to hyposaline water (2.5 ppt). Following acclimation to different salinities for at least two weeks, fish were exposed to CO2-induced water acidification representing present-day (control pCO2, 400 μatm, LoCO2) and future (high pCO2, 1000 μatm, HiCO2) sea-surface CO2 level for 3, 7 and 21 days. At the end of each exposure period, fish were challenged with HEA for 6 h (1.18 mM representing 50% of 96 h LC50). Results show that, in response to the individual HiCO2 exposure, fish within each salinity compensated for blood acidosis. Fish subjected to HiCO2 were able to maintain ammonia excretion rate (Jamm) within control levels, suggesting that HiCO2 exposure alone had no impact on Jamm at any of the salinities. For 32 and 10 ppt fish, up-regulated expression of Na+/K+-ATPase was evident in all exposure groups (HEA, HiCO2 and HEA/HiCO2 co-exposed), whereas Na+/K+/2Cl- co-transporter was up-regulated mainly in HiCO2 group. Plasma glucose and lactate content were augmented in all exposure conditions for all salinity regimes. During HEA and HEA/HiCO2, Jamm was inhibited at different time points for all salinities, which resulted in a significant build-up of ammonia in plasma and muscle. Branchial expressions of Rhesus glycoproteins (Rhcg isoforms and Rhbg) were upregulated in response to HiCO2 as well as HEA at 10 ppt, with a more moderate response in 32 ppt groups. Overall, our findings denote that the adverse effect of single exposures of ocean acidification or HEA is exacerbated when present together, and suggests that fish are more vulnerable to these environmental threats at low salinities.
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Affiliation(s)
- Jyotsna Shrivastava
- Systemic Physiological and Ecotoxicological Research, Department of Biology, University of Antwerp, Groenenborgerlaan 171, BE-2020 Antwerp, Belgium.
| | - Moses Ndugwa
- Systemic Physiological and Ecotoxicological Research, Department of Biology, University of Antwerp, Groenenborgerlaan 171, BE-2020 Antwerp, Belgium
| | - Warren Caneos
- Systemic Physiological and Ecotoxicological Research, Department of Biology, University of Antwerp, Groenenborgerlaan 171, BE-2020 Antwerp, Belgium
| | - Gudrun De Boeck
- Systemic Physiological and Ecotoxicological Research, Department of Biology, University of Antwerp, Groenenborgerlaan 171, BE-2020 Antwerp, Belgium
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Celik M, Akdeniz O, Ozgun N, Ipek MS, Ozbek MN. Short-term results of continuous venovenous haemodiafiltration versus peritoneal dialysis in 40 neonates with inborn errors of metabolism. Eur J Pediatr 2019; 178:829-836. [PMID: 30895385 DOI: 10.1007/s00431-019-03361-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 11/28/2018] [Revised: 02/23/2019] [Accepted: 03/04/2019] [Indexed: 12/31/2022]
Abstract
Several recent studies have reported that toxic metabolites accumulated in the body as a product of inborn errors of metabolism (IEM) are eliminated more rapidly with continuous venovenous hemodiafiltration (CVVHDF) than with peritoneal dialysis (PD). However, there is still uncertainty about the impacts of dialysis modalities on the short-term outcome. Here, it was aimed to investigate the effects of dialysis modalities on the short-term outcome. This retrospective study included 40 newborn infants who underwent PD (29 patients) or CVVHDF (11 patients) due to inborn errors of metabolism at a tertiary centre, between June 2013 and March 2018. The outcomes and the potential effects of the dialysis modality were evaluated. Of 40 patients, 21 were urea cycle defect, 14 were organic academia, and 5 were maple syrup urine disease. The median 50% reduction time of toxic metabolites were shorter in patients treated with CVVHDF (p < 0.05). Catheter blockage was the most common complication observed in PD group (24.1%), whereas in CVVHDF group hypotension and filter blockage were more common. There was no significant difference in mortality between dialysis groups (38% vs. 45.4%, p > 0.05). In patients with hyperammonaemia, duration of plasma ammonia > 200 μg/dL was the most important factor influencing mortality (OR 1.05, CI 1.01-1.09, p = 0.007).Conclusion: This study showed that CVVHDF is more efficient than PD to rapidly eliminate toxic metabolites caused by IEM in newborn infants, but not in improving survival. What is Known: •Toxic metabolites are eliminated more rapidly with CVVHDF than with PD. •Higher complication rates were reported with rigid peritoneal catheters in PD and catheter blockage in CVVHDF. What is New: •Prolonged duration of plasma ammonia levels above a safe limit (200 μg/dL) was associated with increased mortality. •Lower catheter-related complication rates may have been associated with the use of Tenckhoff catheters in PD and the use of right internal jugular vein in CVVHDF.
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Affiliation(s)
- Muhittin Celik
- Department of Pediatrics, Division of Neonatology, Gaziantep University, Osmangazi Mahallesi, Üniversite Blv., 27310 Şehitkamil, Gaziantep, Turkey.
| | - Osman Akdeniz
- Department of Pediatrics, Division of Pediatric Cardiology, Diyarbakir Children's Diseases Hospital, Diyarbakir, Turkey
| | - Nezir Ozgun
- Department of Pediatrics, Division of Pediatric Neurology, Diyarbakir Children's Diseases Hospital, Diyarbakir, Turkey
| | - Mehmet Sah Ipek
- Department of Pediatrics, Division of Neonatology, Memorial Dicle Hospital, Diyarbakir, Turkey
| | - Mehmet Nuri Ozbek
- Department of Pediatrics, Division of Pediatric Endocrinology and Metabolism, Gazi Yaşargil Training and Research Hospital, Diyarbakir, Turkey
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Yamada H, Shishido T, Mukai T, Araki M, Naka H, Tokinobu H. [Valproic acid-induced hyperammonemic encephalopathy in a patient receiving valproic acid monotherapy]. Rinsho Shinkeigaku 2019; 59:258-263. [PMID: 31061301 DOI: 10.5692/clinicalneurol.cn-001254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 06/09/2023]
Abstract
A 79-year-old female was diagnosed with epilepsy because she experienced loss of consciousness twice in January and February and then had a seizure in June 2016. She was treated with 800 mg sodium valproate (sustained release). After 3 days, she experienced loss of appetite, and more than 3 days later, disturbance of consciousness. Serum valproic acid (VPA) concentration was 128.3 μg/ml and serum ammonia was 404 μmol/l. Cerebral edema and status epilepticus occurred. Severe neurological dysfunction remained, even after treatment with continuous hemodiafiltration and levocarnitine. VPA is widely used for the treatment of generalized epilepsy. VPA-induced hyperammonemic encephalopathy is a rare but serious adverse event of VPA. Thus, we must pay attention to serum ammonia levels when using VPA, even VPA monotherapy.
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Affiliation(s)
| | | | - Tomoya Mukai
- Department of Neurology, Hiroshima Prefectural Hospital
| | - Mutsuko Araki
- Department of Neurology, Hiroshima Prefectural Hospital
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Abstract
A 52-year-old woman developed vomiting and disturbance of consciousness after consuming raw fish and sushi on a trip. A blood test showed hyperammonemia (310 μg/dL) with a normal liver function. She fell into a deep coma, and her serum ammonia level increased to 684 μg/dL. L-arginine was administered as a diagnostic treatment for urea cycle disorder (UCD) and serum ammonia, and her consciousness levels improved. She was diagnosed with ornithine transcarbamylase deficiency (OTCD) by analyses of plasma amino acids, urinary orotic acid, and the OTC gene mutation. UCD should be considered for patients with hyperammonemia without severe liver function abnormalities.
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Affiliation(s)
- Yudai Koya
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Michihiko Shibata
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Michio Senju
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Yuichi Honma
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Masaaki Hiura
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Masahiro Ishii
- Department of Pediatrics, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Shirou Matsumoto
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Masaru Harada
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
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Gökceoğlu AU, Taşar MA, Yalaki Z, Güneş A, Bakır A. An infant with hypercalcemia and hyperammonia: inborn error of metabolism or not? Answers. Pediatr Nephrol 2019; 34:251-252. [PMID: 30027358 DOI: 10.1007/s00467-018-4022-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 06/26/2018] [Accepted: 06/28/2018] [Indexed: 12/01/2022]
Affiliation(s)
| | | | - Zahide Yalaki
- Ankara Training and Research Hospital, Ankara, Turkey
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Giva S, Finnegan J, Ihidero P, Maguire G, Power B, Knerr I, Monavari A. Hyperammonaemia in Neonates and Young Children: Potential Metabolic Causes, Diagnostic Approaches and Clinical Consequences. Ir Med J 2019; 112:858. [PMID: 30719899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Hyperammonaemia is a metabolic disturbance characterized by accumulation of ammonia in the blood. Entry of ammonia into the brain via the blood-brain barrier leads to hyperammonaemic encephalopathy. The causes of hyperammonaemia in paediatric patients vary. We present 3 cases of hyperammonaemia in critically ill children in whom an inborn metabolic disorder was identified and provide insights into the phenotypes, diagnostic approaches and management. In children with acute overwhelming illness and progressive neurological deterioration plasma ammonia measurement should be included in the urgent diagnostic work-up. We here raise the awareness that hyperammonaemia is a metabolic emergency requiring prompt recognition and treatment to avoid subsequent complications.
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Affiliation(s)
- S Giva
- National Centre for Inherited Metabolic Disorders, Temple Street Children’s University Hospital, Dublin 1, Ireland
| | - J Finnegan
- National Centre for Inherited Metabolic Disorders, Temple Street Children’s University Hospital, Dublin 1, Ireland
| | - P Ihidero
- National Centre for Inherited Metabolic Disorders, Temple Street Children’s University Hospital, Dublin 1, Ireland
| | - G Maguire
- National Centre for Inherited Metabolic Disorders, Temple Street Children’s University Hospital, Dublin 1, Ireland
| | - B Power
- National Centre for Inherited Metabolic Disorders, Temple Street Children’s University Hospital, Dublin 1, Ireland
| | - I Knerr
- National Centre for Inherited Metabolic Disorders, Temple Street Children’s University Hospital, Dublin 1, Ireland
| | - A Monavari
- National Centre for Inherited Metabolic Disorders, Temple Street Children’s University Hospital, Dublin 1, Ireland
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Abstract
BACKGROUND Hepatic encephalopathy is a common and devastating neuropsychiatric complication of acute liver failure or chronic liver disease. Ammonia content in the blood seems to play a role in the development of hepatic encephalopathy. Treatment for hepatic encephalopathy is complex. Acetyl-L-carnitine is a substance that may reduce ammonia toxicity. This review assessed the benefits and harms of acetyl-L-carnitine for patients with hepatic encephalopathy. OBJECTIVES To assess the benefits and harms of acetyl-L-carnitine for patients with hepatic encephalopathy. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, LILACS, and Science Citation Index Expanded for randomised clinical trials. We sought additional randomised clinical trials from the World Health Organization Clinical Trials Search Portal and ClinicalTrials.gov. We performed all electronic searches until 10 September 2018. We looked through the reference lists of retrieved publications and review articles, and we searched the FDA and EMA websites. SELECTION CRITERIA We searched for randomised clinical trials in any setting, recruiting people with hepatic encephalopathy. Trials were eligible for inclusion if they compared acetyl-L-carnitine plus standard care (e.g. antibiotics, lactulose) versus placebo or no acetyl-L-carnitine plus standard care. We are well aware that by selecting randomised clinical trials, we placed greater focus on potential benefits than on potential harms. DATA COLLECTION AND ANALYSIS We selected randomised clinical trials, assessed risk of bias in eight domains, and extracted data in a duplicate and independent fashion. We estimated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes. We measured statistical heterogeneity using I² and D² statistics. We subjected our analyses to fixed-effect and random-effects model meta-analyses. We assessed bias risk domains to control systematic errors. We assessed overall quality of the data for each individual outcome by using the GRADE approach. MAIN RESULTS We identified five randomised clinical trials involving 398 participants. All trials included only participants with cirrhosis as the underlying cause of hepatic encephalopathy. Trials included participants with covert or overt hepatic encephalopathy. All trials were conducted in Italy by a single team and assessed acetyl-L-carnitine compared with placebo. Oral intervention was the most frequent route of administration. All trials were at high risk of bias and were underpowered. None of the trials were sponsored by the pharmaceutical industry.None of the identified trials reported information on all-cause mortality, serious adverse events, or days of hospitalisation. Only one trial assessed quality of life using the Short Form (SF)-36 scale (67 participants; very low-quality evidence). The effects of acetyl-L-carnitine compared with placebo on general health at 90 days are uncertain (MD -6.20 points, 95% confidence interval (CI) -9.51 to -2.89). Results for additional domains of the SF-36 are also uncertain. One trial assessed fatigue using the Wessely and Powell test (121 participants; very low-quality evidence). The effects are uncertain in people with moderate-grade hepatic encephalopathy (mental fatigue: MD 0.40 points, 95% CI -0.21 to 1.01; physical fatigue: MD -0.20 points, 95% CI -0.92 to 0.52) and mild-grade hepatic encephalopathy (mental fatigue: -0.80 points, 95% CI -1.48 to -0.12; physical fatigue: 0.20 points, 95% CI -0.72 to 1.12). Meta-analysis showed a reduction in blood ammonium levels favouring acetyl-L-carnitine versus placebo (MD -13.06 mg/dL, 95% CI -17.24 to -8.99; 387 participants; 5 trials; very low-quality evidence). It is unclear whether acetyl-L-carnitine versus placebo increases the risk of non-serious adverse events (8/126 (6.34%) vs 3/120 (2.50%); RR 2.51, 95% CI 0.68 to 9.22; 2 trials; very low-quality evidence). Overall, adverse events data were poorly reported and harms may have been underestimated. AUTHORS' CONCLUSIONS This Cochrane systematic review analysed a heterogeneous group of five trials at high risk of bias and with high risk of random errors conducted by only one research team. We assessed acetyl-L-carnitine versus placebo in participants with cirrhosis with covert or overt hepatic encephalopathy. Hence, we have no data on the drug for hepatic encephalopathy in acute liver failure. We found no information about all-cause mortality, serious adverse events, or days of hospitalisation. We found no clear differences in effect between acetyl-L-carnitine and placebo regarding quality of life, fatigue, and non-serious adverse events. Acetyl-L-carnitine reduces blood ammonium levels compared with placebo. We rated all evidence as of very low quality due to pitfalls in design and execution, inconsistency, small sample sizes, and very few events. The harms profile for acetyl-L-carnitine is presently unclear. Accordingly, we need further randomised clinical trials to assess acetyl-L-carnitine versus placebo conducted according to the SPIRIT statements and reported according to the CONSORT statements.
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Affiliation(s)
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Ingrid Arevalo‐Rodriguez
- Hospital Universitario Ramon y Cajal (IRYCIS)Clinical Biostatistics UnitMadridSpain
- CIBER Epidemiology and Public Health (CIBERESP)MadridSpain
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Bennett EE, Hummel K, Smith AG, Longo N. Acute Presentation and Management of the Encephalopathic Child With an Undiagnosed Inborn Error of Metabolism. J Emerg Med 2018; 56:e5-e8. [PMID: 30420308 DOI: 10.1016/j.jemermed.2018.09.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 05/17/2018] [Revised: 08/20/2018] [Accepted: 09/20/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Inborn errors of metabolism (IEM) commonly present in infancy and, less commonly, later in life. CASE REPORT This case describes an IEM, specifically, ornithine transcarbamylase deficiency, in a previously healthy 7-year-old boy who presented to an emergency department with vomiting for approximately 24 h prior to admission. The child became progressively encephalopathic while in the emergency department, but an ammonia level was not obtained until several hours after admission. Irreversible brain damage with cerebral edema was already present at time of diagnosis, leading to death. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case emphasizes that acute hyperammonemia can rapidly cause irreversible neurological damage and, in the case of a newly encephalopathic pediatric patient, ammonia levels should be evaluated early to facilitate proper diagnostic tests and treatment.
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Xie G, Wang X, Jiang R, Zhao A, Yan J, Zheng X, Huang F, Liu X, Panee J, Rajani C, Yao C, Yu H, Jia W, Sun B, Liu P, Jia W. Dysregulated bile acid signaling contributes to the neurological impairment in murine models of acute and chronic liver failure. EBioMedicine 2018; 37:294-306. [PMID: 30344125 PMCID: PMC6284422 DOI: 10.1016/j.ebiom.2018.10.030] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 10/04/2018] [Accepted: 10/10/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Hepatic encephalopathy (HE), a severe neuropsychiatric complication, is associated with increased blood levels of ammonia and bile acids (BAs). We sought to determine (1) whether abnormally increased blood BAs in liver cirrhotic patients with HE is caused by elevation of apical sodium-dependent BA transporter (ASBT)-mediated BA reabsorption; and (2) whether increased BA reabsorption would exacerbate ammonia-induced brain injuries. METHODS We quantitatively measured blood BA and ammonia levels in liver cirrhosis patients with or without HE and healthy controls. We characterized ASBT expression, BA profiles, and ammonia concentrations in a chronic liver disease (CLD) mouse model induced by streptozotocin-high fat diet (STZ-HFD) and an azoxymethane (AOM) - induced acute liver failure (ALF) mouse model. These two mouse models were treated with SC-435 (ASBT inhibitor) and budesonide (ASBT activator), respectively. FINDINGS Blood concentrations of ammonia and conjugated BAs were substantially increased in cirrhotic patients with HE (n = 75) compared to cirrhotic patients without HE (n = 126). Pharmacological inhibition of the enterohepatic BA circulation using a luminal- restricted ASBT inhibitor, SC-435, in mice with AOM-induced ALF and STZ-HFD -induced CLD effectively reduced BA and ammonia concentrations in the blood and brain, and alleviated liver and brain damages. Budesonide treatment induced liver and brain damages in normal mice, and exacerbated these damages in AOM-treated mice. INTERPRETATION ASBT mediated BA reabsorption increases intestinal luminal pH and facilitates conversion of intestinal ammonium to ammonia, leading to abnormally high levels of neurotoxic ammonia and cytotoxic BAs in the blood and brain. Inhibition of intestinal ASBT with SC-435 can effectively remove neurotoxic BAs and ammonia from the bloodstream and thus, mitigate liver and brain injuries resulting from liver failure.
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Affiliation(s)
- Guoxiang Xie
- Shanghai Key Laboratory of Diabetes Mellitus and Center for Translational Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China; University of Hawaii Cancer Center, Honolulu, HI 96813, USA
| | - Xiaoning Wang
- E-institute of Shanghai Municipal Education Committee, Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China; Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Runqiu Jiang
- University of Hawaii Cancer Center, Honolulu, HI 96813, USA; Liver Transplantation Center of the First Affiliated Hospital, State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Aihua Zhao
- Shanghai Key Laboratory of Diabetes Mellitus and Center for Translational Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Jingyu Yan
- E-institute of Shanghai Municipal Education Committee, Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Xiaojiao Zheng
- Shanghai Key Laboratory of Diabetes Mellitus and Center for Translational Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Fengjie Huang
- Shanghai Key Laboratory of Diabetes Mellitus and Center for Translational Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Xinzhu Liu
- E-institute of Shanghai Municipal Education Committee, Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Jun Panee
- Department of Cell and Molecular Biology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI 96813, USA
| | - Cynthia Rajani
- University of Hawaii Cancer Center, Honolulu, HI 96813, USA
| | - Chun Yao
- Guangxi University of Chinese Medicine, Nanning, Guangxi 530001, China
| | - Herbert Yu
- University of Hawaii Cancer Center, Honolulu, HI 96813, USA
| | - Weiping Jia
- Shanghai Key Laboratory of Diabetes Mellitus and Center for Translational Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Beicheng Sun
- Liver Transplantation Center of the First Affiliated Hospital, State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Ping Liu
- E-institute of Shanghai Municipal Education Committee, Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China; Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China.
| | - Wei Jia
- Shanghai Key Laboratory of Diabetes Mellitus and Center for Translational Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China; University of Hawaii Cancer Center, Honolulu, HI 96813, USA.
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Wiwattanadittakul N, Prust M, Gaillard WD, Massaro A, Vezina G, Tsuchida TN, Gropman AL. The utility of EEG monitoring in neonates with hyperammonemia due to inborn errors of metabolism. Mol Genet Metab 2018; 125:235-240. [PMID: 30197275 DOI: 10.1016/j.ymgme.2018.08.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 08/21/2018] [Accepted: 08/21/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Continuous EEG studies demonstrate that neonates with seizures due to cerebral pathology, such as hypoxia ischemia, exhibit predominantly electrographic seizures (i.e. those only detected with EEG because they lack clinical features). Previous small case series demonstrate EEG changes and seizures during hyperammonemia associated with inborn errors of metabolism (IEM) but there are no reports utilizing continuous EEG in these conditions. OBJECTIVE To characterize seizures and evaluate the utility of continuous EEG recording during hyperammonemia due to inborn errors of metabolism. METHODS We retrospectively reviewed medical records and EEG tracings of neonates who presented with hyperammonemia due to inborn errors of metabolism who had continuous EEG and full medical records available for review, including follow up. RESULTS Eight neonates with hyperammonemia were studied, 7 had urea cycle defects: Argininosuccinate lyase deficiency [3], (ornithine transcarbamylase deficiency [3], carbomyl phosphate synthase deficiency [1] and one had an organic acidemia: Methylmalonic acidemia [1]. Most common presentations were lethargy and poor feeding at 12-72 h of life. The highest blood ammonia level was 874 μmol/L (median); range 823-1647 μmol/L (normal value <50 μmol/L in term neonates). Seven were treated with hemodialysis in addition to nitrogen scavengers. Seven neonates had seizures; six had only electrographic seizures. Seizures initially occurred within 24-36 h of clinical presentation, sometimes with normal ammonia and glutamine levels. Neonates with seizures all lacked state changes on EEG. Inter burst interval duration correlated with degree of hyperammonemia. Two cases with normal plasma ammonia but increasing interburst interval duration were proven to have stroke by MRI. CONCLUSIONS Seizures occur frequently in neonates with hyperammonemia; most can be detected only with continuous EEG. Seizures may occur when ammonia and glutamine levels are normal. Interburst interval duration is associated with ammonia levels or cerebral dysfunction from other brain pathology. Continuous EEG can be a useful tool for managing infants with hyperammonemia and may be essential for seizure management especially for infants in deep metabolic coma.
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MESH Headings
- Amino Acid Metabolism, Inborn Errors/blood
- Amino Acid Metabolism, Inborn Errors/diagnostic imaging
- Amino Acid Metabolism, Inborn Errors/physiopathology
- Ammonia/blood
- Argininosuccinate Synthase/blood
- Argininosuccinic Aciduria/blood
- Argininosuccinic Aciduria/diagnostic imaging
- Argininosuccinic Aciduria/physiopathology
- Electroencephalography
- Female
- Glutamine/blood
- Humans
- Hyperammonemia/blood
- Hyperammonemia/diagnostic imaging
- Hyperammonemia/physiopathology
- Hypoxia-Ischemia, Brain/blood
- Hypoxia-Ischemia, Brain/diagnostic imaging
- Hypoxia-Ischemia, Brain/physiopathology
- Infant
- Infant, Newborn
- Male
- Metabolism, Inborn Errors/blood
- Metabolism, Inborn Errors/diagnostic imaging
- Metabolism, Inborn Errors/physiopathology
- Ornithine Carbamoyltransferase Deficiency Disease/blood
- Ornithine Carbamoyltransferase Deficiency Disease/diagnostic imaging
- Ornithine Carbamoyltransferase Deficiency Disease/physiopathology
- Seizures/blood
- Seizures/diagnostic imaging
- Seizures/physiopathology
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Affiliation(s)
- Natrujee Wiwattanadittakul
- Department of Pediatrics, Chiang Mai University Hospital, Chiang Mai University, Chiang Mai, Thailand; Center for Neuroscience, Children Neuroscience, Medical System, George Washington University, Washington, DC, United States
| | - Morgan Prust
- Department of Neurology, Harvard Medical School, Boston, MA, United States
| | - William Davis Gaillard
- Center for Neuroscience, Children Neuroscience, Medical System, George Washington University, Washington, DC, United States
| | - An Massaro
- Center for Neuroscience, Children Neuroscience, Medical System, George Washington University, Washington, DC, United States
| | - Gilbert Vezina
- Center for Neuroscience, Children Neuroscience, Medical System, George Washington University, Washington, DC, United States
| | - Tammy N Tsuchida
- Center for Neuroscience, Children Neuroscience, Medical System, George Washington University, Washington, DC, United States
| | - Andrea L Gropman
- Center for Neuroscience, Children Neuroscience, Medical System, George Washington University, Washington, DC, United States.
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Abstract
A 69-year-old man developed reduced consciousness of sudden onset. Examination and parameters were normal, except for a Glasgow Coma Scale (GCS) score of six. Brain imaging and blood tests were also normal, except for high plasma ammonia. His past medical history included epilepsy, hypertension and colitis. He was taking multiple antiepileptic medications, including sodium valproate, with no recent dose alterations. Medical intervention led to the sodium valproate being stopped and naloxone being administered. The patient's level of responsiveness and ammonia levels gradually improved. The patient was also being treated with ciprofloxacin for a urinary tract infection and a newly developed syndrome of inappropriate antidiuretic hormone secretion treated with demeclocycline. There is an association between long-term sodium valproate use and low carnitine levels, especially in the setting of polypharmacy. This in turn precipitates hyperammonaemia and encephalopathy. This case highlights the importance of an adequate drug history and the awareness of serious but uncommon adverse effects.
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Kim JY, Lee Y, Cho H. Optimal Prescriptions of Continuous Renal Replacement Therapy in Neonates with Hyperammonemia. Blood Purif 2018; 47:16-22. [PMID: 30219811 DOI: 10.1159/000492660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 08/05/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS The aim of this study was to evaluate patients' outcomes, determine the prescriptions of continuous renal replacement therapy (CRRT) that effectively reduce serum ammonia levels, and analyze the prognostic factors in neonates with hyperammonemia. METHODS The medical records of 12 Korean neonates with inborn error of metabolism (IEM) who underwent CRRT for hyperammonemia were retrospectively analyzed. RESULTS All patients received continuous venovenous hemodiafiltration. The median ultrafiltration rate (UFR) at the initiation of CRRT was 2,288.4 mL/h/1.73 m2. The median ammonia level at CRRT initiation was 1,320 µmol/L, and the median time to reduce the initial ammonia level by at least 50% was 12.8 h. The survival rate during hospitalization was 83.3%. There were significant differences between patients with neurologic sequelae and those without poor outcomes in peak serum ammonia level before CRRT and serum ammonia level at CRRT initiation. CONCLUSION This study suggested that CRRT could be a therapeutic option for neonates with IEM. However, it is necessary to raise the UFR above 4,000 mL/h/1.73 m2 in patients with high initial ammonia level.
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Hayasaka K, Numakura C, Yamakawa M, Mitsui T, Watanabe H, Haga H, Yazaki M, Ohira H, Ochiai Y, Tahara T, Nakahara T, Yamashiki N, Nakayama T, Kon T, Mitsubuchi H, Yoshida H. Medium-chain triglycerides supplement therapy with a low-carbohydrate formula can supply energy and enhance ammonia detoxification in the hepatocytes of patients with adult-onset type II citrullinemia. J Inherit Metab Dis 2018; 41:777-784. [PMID: 29651749 DOI: 10.1007/s10545-018-0176-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 03/19/2018] [Accepted: 03/21/2018] [Indexed: 10/17/2022]
Abstract
Citrin, encoded by SLC25A13, constitutes the malate-aspartate shuttle, the main NADH-shuttle in the liver. Citrin deficiency causes neonatal intrahepatic cholestasis (NICCD) and adult-onset type II citrullinemia (CTLN2). Citrin deficiency is predicted to impair hepatic glycolysis and de novo lipogenesis, resulting in hepatic energy deficit. Secondary decrease in hepatic argininosuccinate synthetase (ASS1) expression has been considered a cause of hyperammonemia in CTLN2. We previously reported that medium-chain triglyceride (MCT) supplement therapy with a low-carbohydrate formula was effective in CTLN2 to prevent a relapse of hyperammonemic encephalopathy. We present the therapy for six CTLN2 patients. All the patients' general condition steadily improved and five patients with hyperammonemic encephalopathy recovered from unconsciousness in a few days. Before the treatment, plasma glutamine levels did not increase over the normal range and rather decreased to lower than the normal range in some patients. The treatment promptly decreased the blood ammonia level, which was accompanied by a decrease in plasma citrulline levels and an increase in plasma glutamine levels. These findings indicated that hyperammonemia was not only caused by the impairment of ureagenesis at ASS1 step, but was also associated with an impairment of glutamine synthetase (GS) ammonia-detoxification system in the hepatocytes. There was no decrease in the GS expressing hepatocytes. MCT supplement with a low-carbohydrate formula can supply the energy and/or substrates for ASS1 and GS, and enhance ammonia detoxification in hepatocytes. Histological improvement in the hepatic steatosis and ASS1-expression was also observed in a patient after long-term treatment.
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Affiliation(s)
- Kiyoshi Hayasaka
- Department of Pediatrics, Yamagata University School of Medicine, 2-2-2 Iida-nishi, Yamagata, 990-9585, Japan.
- Department of Pediatrics, Miyukikai Hospital, Kaminoyama, Japan.
| | - Chikahiko Numakura
- Department of Pediatrics, Yamagata University School of Medicine, 2-2-2 Iida-nishi, Yamagata, 990-9585, Japan
| | - Mitsunori Yamakawa
- Department of Pathological Diagnostics, Yamagata University School of Medicine, Yamagata, Japan
| | - Tetsuo Mitsui
- Department of Pediatrics, Yamagata University School of Medicine, 2-2-2 Iida-nishi, Yamagata, 990-9585, Japan
| | - Hisayoshi Watanabe
- Department of Gastroenterology, Yamagata University School of Medicine, Yamagata, Japan
| | - Hiroaki Haga
- Department of Gastroenterology, Yamagata University School of Medicine, Yamagata, Japan
| | - Masahide Yazaki
- Department of Biological Sciences for Intractable Neurological Disorders, Institute for Biomedical Sciences, Shinshu University, Nagano, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yasuo Ochiai
- Department of Gastroenterology, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | - Toshiyuki Tahara
- Department of Gastroenterology, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | - Tamio Nakahara
- Department of Gastroenterology, Hikone Municipal Hospital, Hikone, Shiga, Japan
| | | | - Takahiro Nakayama
- Division of Internal Medicine, Nihonkai General Hospital, Sakata, Japan
| | - Takashi Kon
- Department of Gastroenterology, Yonezawa Municipal Hospital, Yonezawa, Japan
| | - Hiroshi Mitsubuchi
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroshi Yoshida
- Department of Pediatrics, Tsuruoka Municipal Shonai Hospital, Tsuruoka, Japan
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Xia X, Chen J, Xia J, Wang B, Liu H, Yang L, Wang Y, Ling Z. Role of probiotics in the treatment of minimal hepatic encephalopathy in patients with HBV-induced liver cirrhosis. J Int Med Res 2018; 46:3596-3604. [PMID: 29806520 PMCID: PMC6135989 DOI: 10.1177/0300060518776064] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/19/2018] [Indexed: 12/20/2022] Open
Abstract
Objective This study was performed to investigate the role of probiotics ( Clostridium butyricum combined with Bifidobacterium infantis) in the treatment of minimal hepatic encephalopathy (MHE) in patients with hepatitis B virus (HBV)-induced liver cirrhosis. Methods Sixty-seven consecutive patients with HBV-induced cirrhosis without overt hepatic encephalopathy were screened using the number connection test and digit symbol test. The patients were randomized to receive probiotics (n = 30) or no probiotics (n = 37) for 3 months. At the end of the trial, changes in cognition, intestinal microbiota, venous ammonia, and intestinal mucosal barriers were analyzed using recommended systems biology techniques. Results The patients' cognition was significantly improved after probiotic treatment. The predominant bacteria ( Clostridium cluster I and Bifidobacterium) were significantly enriched in the probiotics-treated group, while Enterococcus and Enterobacteriaceae were significantly decreased. Probiotic treatment was also associated with an obvious reduction in venous ammonia. Additionally, the parameters of the intestinal mucosal barrier were obviously improved after probiotic treatment, which might have contributed to the improved cognition and the decreased ammonia levels. Conclusion Treatment with probiotics containing C. butyricum and B. infantis represents a new adjuvant therapy for the management of MHE in patients with HBV-induced cirrhosis.
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Affiliation(s)
- Xiaoxue Xia
- Department of Infectious Diseases, Changxing People’s Hospital,
Huzhou, Zhejiang, China
| | - Jiang Chen
- Department of Infectious Diseases, Changxing People’s Hospital,
Huzhou, Zhejiang, China
| | - Jiayun Xia
- Department of Infectious Diseases, Changxing People’s Hospital,
Huzhou, Zhejiang, China
| | - Bin Wang
- Department of Infectious Diseases, Changxing People’s Hospital,
Huzhou, Zhejiang, China
| | - Hua Liu
- Department of Infectious Diseases, Changxing People’s Hospital,
Huzhou, Zhejiang, China
| | - Ling Yang
- Department of Infectious Diseases, Changxing People’s Hospital,
Huzhou, Zhejiang, China
| | - Ying Wang
- Department of Infectious Diseases, Changxing People’s Hospital,
Huzhou, Zhejiang, China
| | - Zongxin Ling
- Collaborative Innovation Center for Diagnosis and Treatment of
Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of
Infectious Diseases, the First Affiliated Hospital, School of Medicine, Zhejiang
University, Hangzhou, Zhejiang, China
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Waisbren SE, Cuthbertson D, Burgard P, Holbert A, McCarter R, Cederbaum S. Biochemical markers and neuropsychological functioning in distal urea cycle disorders. J Inherit Metab Dis 2018; 41:657-667. [PMID: 29423830 PMCID: PMC6041144 DOI: 10.1007/s10545-017-0132-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [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: 08/21/2017] [Revised: 11/29/2017] [Accepted: 12/28/2017] [Indexed: 10/18/2022]
Abstract
Urea cycle disorders often present as devastating metabolic conditions, resulting in high mortality and significant neuropsychological damage, despite treatment. The Urea Cycle Disorders Longitudinal Study is a natural history study that collects data from regular clinical follow-up and neuropsychological testing. This report examines links between biochemical markers (ammonia, glutamine, arginine, citrulline) and primary neuropsychological endpoints in three distal disorders, argininosuccinic acid synthetase deficiency (ASD or citrullinemia type I), argininosuccinic acid lyase deficiency (ASA or ALD), and arginase deficiency (ARGD). Laboratory results and test scores from neuropsychological evaluations were assessed in 145 study participants, ages 3 years and older, with ASD (n = 64), ASA (n = 65) and ARGD (n = 16). Mean full scale IQ was below the population mean of 100 ± 15 for all groups: (ASD = 79 ± 24; ASA = 71 ± 21; ARGD = 65 ± 19). The greatest deficits were noted in visual performance and motor skills for all groups. While ammonia levels remain prominent as prognostic biomarkers, other biomarkers may be equally valuable as correlates of neuropsychological functioning. Cumulative exposure to the biomarkers included in the study proved to be highly sensitive indicators of neuropsychological outcomes, even when below the cut-off levels generally considered toxic. Blood levels of biomarkers obtained on the day of neuropsychological evaluations were not correlated with measures of functioning for any disorder in any domain. The importance of cumulative exposure supports early identification and confirms the need for well-controlled management of all biochemical abnormalities (and not just ammonia) that occur in urea cycle disorders.
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Affiliation(s)
- Susan E Waisbren
- Division of Genetics and Genomics, Boston Children's Hospital and Department of Medicine, Harvard Medical School, 1 Autumn Street #525, Boston, MA, 02115, USA.
| | - David Cuthbertson
- Health Informatics Institute, University of South Florida, Tampa, FL, USA
| | - Peter Burgard
- Centre for Child and Adolescent Medicine, Division of Neuropediatrics and Inherited Metabolic Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
| | - Amy Holbert
- Health Informatics Institute, University of South Florida, Tampa, FL, USA
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Hediger N, Landolt MA, Diez-Fernandez C, Huemer M, Häberle J. The impact of ammonia levels and dialysis on outcome in 202 patients with neonatal onset urea cycle disorders. J Inherit Metab Dis 2018. [PMID: 29520739 DOI: 10.1007/s10545-018-0157-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Neonatal onset hyperammonemia in patients with urea cycle disorders (UCDs) is still associated with high morbidity and mortality. Current protocols consistently recommend emergency medical and dietary management. In case of increasing or persistent hyperammonemia, with continuous or progressive neurological signs, dialysis is performed, mostly as ultima ratio. It is presently unknown whether the currently defined ammonia threshold (e.g., at 500 μmol/L) to start dialysis is useful to improve clinical outcome. A systematic review of clinical and biochemical data from published neonatal onset UCD patients was performed to identify factors determining clinical outcome and to investigate in which clinical and biochemical setting dialysis was most effective. A total of 202 patients (118 proximal and 84 distal UCDs) described in 90 case reports or case series were included according to predefined inclusion/exclusion criteria. Median age at onset was three days and mean ammonia that triggered start of dialysis was 1199 μmol/L. Seventy-one percent of all patients received any form of dialysis. Total mortality was 25% and only 20% of all patients had a "normal" outcome. In general, patients with higher ammonia levels were more likely to receive dialysis, but this had for most patients no influence on outcome. In conclusion, in severe neonatal onset hyperammonemia, the current practice of dialysis, which effectively clears ammonia, had no impact on outcome. It may be essential for improving outcome to initiate all available treatment options, including dialysis, as early as possible.
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Affiliation(s)
- Nina Hediger
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, 8032, Zurich, Switzerland
| | - Markus A Landolt
- Department of Psychosomatics and Psychiatry, University Children's Hospital Zurich, 8032, Zurich, Switzerland
- Division of Child and Adolescent Health Psychology, Department of Psychology, University of Zurich, Zurich, Switzerland
| | - Carmen Diez-Fernandez
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, 8032, Zurich, Switzerland
| | - Martina Huemer
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, 8032, Zurich, Switzerland
- Department of Paediatrics, Landeskrankenhaus Bregenz, Bregenz, Austria
| | - Johannes Häberle
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, 8032, Zurich, Switzerland.
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