1
|
Dong V, Robinson AM, Dionne JC, Cardoso FS, Rewa OG, Karvellas CJ. Continuous renal replacement therapy and survival in acute liver failure: A systematic review and meta-analysis. J Crit Care 2024; 81:154513. [PMID: 38194760 DOI: 10.1016/j.jcrc.2023.154513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 12/05/2023] [Accepted: 12/26/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVE Acute liver failure (ALF) is a rare syndrome leading to significant morbidity and mortality. An important cause of mortality is cerebral edema due to hyperammonemia. Different therapies for hyperammonemia have been assessed including continuous renal replacement therapy (CRRT). We conducted a systematic review and meta-analysis to determine the efficacy of CRRT in ALF patients. MATERIALS AND METHODS We searched MEDLINE, EMBASE, Cochrane Library, and Web of Science. Inclusion criteria included adult patients admitted to an ICU with ALF. Intervention was the use of CRRT for one or more indications with the comparator being standard care without the use of CRRT. Outcomes of interest were overall survival, transplant-free survival (TFS), mortality and changes in serum ammonia levels. RESULTS In total, 305 patients underwent CRRT while 1137 patients did not receive CRRT. CRRT was associated with improved overall survival [risk ratio (RR) 0.83, 95% confidence interval (CI) 0.70-0.99, p-value 0.04, I2 = 50%] and improved TFS (RR 0.65, 95% CI 0.49-0.85, p-value 0.002, I2 = 25%). There was a trend towards higher mortality with no CRRT (RR 1.24, 95% CI 0.84-1.81, p-value 0.28, I2 = 37%). Ammonia clearance data was unable to be pooled and was not analyzable. CONCLUSION Use of CRRT in ALF patients is associated with improved overall and transplant-free survival compared to no CRRT.
Collapse
Affiliation(s)
- Victor Dong
- Department of Critical Care Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, Alberta T2N 2T9, Canada.
| | - Andrea M Robinson
- Department of Critical Care Medicine, University of Alberta, 2-124 Clinical Sciences Building, Edmonton, Alberta T6G 2G3, Canada.
| | - Joanna C Dionne
- Department of Medicine, Division of Critical Care, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada.
| | - Filipe S Cardoso
- Intensive Care Unit and Transplant Unit, Nova University, R. da Beneficência 8, Lisbon 1050-099, Portugal.
| | - Oleksa G Rewa
- Department of Critical Care Medicine, University of Alberta, 2-124 Clinical Sciences Building, Edmonton, Alberta T6G 2G3, Canada.
| | - Constantine J Karvellas
- Department of Critical Care Medicine, University of Alberta, 2-124 Clinical Sciences Building, Edmonton, Alberta T6G 2G3, Canada; Department of Medicine, Division of Gastroenterology, University of Alberta, 8540 112 St NW, Edmonton, Alberta T6G 2P8, Canada.
| |
Collapse
|
2
|
Boutrid N, Rahmoune H. Cardiomyopathy, carnitine deficiency, and celiac disease. Eur J Pediatr 2024; 183:2507-2508. [PMID: 38358548 DOI: 10.1007/s00431-024-05480-z] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 01/24/2024] [Accepted: 02/10/2024] [Indexed: 02/16/2024]
Affiliation(s)
- Nada Boutrid
- LMCVGN Research Laboratory, Faculty of Medicine, University of Setif, Campus El Bez, 19000, Setif, Algeria
- Department of Pediatrics, EHS El Eulma, El Eulma, Algeria
| | - Hakim Rahmoune
- LMCVGN Research Laboratory, Faculty of Medicine, University of Setif, Campus El Bez, 19000, Setif, Algeria.
- Department of Pediatrics, University Hospital of Setif, Setif, Algeria.
| |
Collapse
|
3
|
Moedas MF, Simões RJM, Silva MFB. Mitochondrial targets in hyperammonemia: Addressing urea cycle function to improve drug therapies. Biochem Pharmacol 2024; 222:116034. [PMID: 38307136 DOI: 10.1016/j.bcp.2024.116034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 12/27/2023] [Accepted: 01/25/2024] [Indexed: 02/04/2024]
Abstract
The urea cycle (UC) is a critically important metabolic process for the disposal of nitrogen (ammonia) produced by amino acids catabolism. The impairment of this liver-specific pathway induced either by primary genetic defects or by secondary causes, namely those associated with hepatic disease or drug administration, may result in serious clinical consequences. Urea cycle disorders (UCD) and certain organic acidurias are the major groups of inherited rare diseases manifested with hyperammonemia (HA) with UC dysregulation. Importantly, several commonly prescribed drugs, including antiepileptics in monotherapy or polytherapy from carbamazepine to valproic acid or specific antineoplastic agents such as asparaginase or 5-fluorouracil may be associated with HA by mechanisms not fully elucidated. HA, disclosing an imbalance between ammoniagenesis and ammonia disposal via the UC, can evolve to encephalopathy which may lead to significant morbidity and central nervous system damage. This review will focus on biochemical mechanisms related with HA emphasizing some poorly understood perspectives behind the disruption of the UC and mitochondrial energy metabolism, namely: i) changes in acetyl-CoA or NAD+ levels in subcellular compartments; ii) post-translational modifications of key UC-related enzymes, namely acetylation, potentially affecting their catalytic activity; iii) the mitochondrial sirtuins-mediated role in ureagenesis. Moreover, the main UCD associated with HA will be summarized to highlight the relevance of investigating possible genetic mutations to account for unexpected HA during certain pharmacological therapies. The ammonia-induced effects should be avoided or overcome as part of safer therapeutic strategies to protect patients under treatment with drugs that may be potentially associated with HA.
Collapse
Affiliation(s)
- Marco F Moedas
- Research Institute for Medicines-iMed.ULisboa, Faculty of Pharmacy, Universidade de Lisboa, Av. Prof. Gama Pinto, 1649-003 Lisboa, Portugal; Centre for Inherited Metabolic Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Ricardo J M Simões
- Research Institute for Medicines-iMed.ULisboa, Faculty of Pharmacy, Universidade de Lisboa, Av. Prof. Gama Pinto, 1649-003 Lisboa, Portugal
| | - Margarida F B Silva
- Research Institute for Medicines-iMed.ULisboa, Faculty of Pharmacy, Universidade de Lisboa, Av. Prof. Gama Pinto, 1649-003 Lisboa, Portugal.
| |
Collapse
|
4
|
Kabat M, Gill S, Kim K, Omidvari K, Lee R. Hepatic veno-occlusive disease complicated with extreme hyperammonaemia (920 µmol/L) treated with defibrotide, lactulose, rifampin and haemodialysis. BMJ Case Rep 2024; 17:e258876. [PMID: 38514165 PMCID: PMC10961531 DOI: 10.1136/bcr-2023-258876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024] Open
Abstract
Hepatic veno-occlusive disease (VOD)/sinusoidal obstructive syndrome (SOS) is a severe complication that can occur following haematopoietic stem cell transplant (HSCT) with high-intensity conditioning chemotherapy regimens. Severe VOD/SOS, often characterised by multiorgan failure, is associated with a high mortality rate. This case report details the complex clinical course of a male patient in his mid-20s, recently diagnosed with B cell acute lymphoblastic leukaemia, who underwent allogeneic HSCT. Based on the 2023 European Society for Blood and Marrow Transplantation (EBMT) criteria, the patient developed very severe VOD/SOS, prompting immediate treatment with defibrotide. Unexpectedly, he developed profound hyperammonaemia exceeding 900 µmol/L, leading to encephalopathy and cerebral oedema. Despite aggressive interventions including defibrotide, lactulose, rifampin and haemodialysis, the patient passed away due to cerebral oedema and pulseless electrical activity arrest. We theorise the hyperammonaemia is disproportionate to his hepatic dysfunction and is possibly secondary to an acquired defect of the urea synthesis consistent with idiopathic hyperammonaemia, a rare complication in patients receiving intense conditioning chemotherapy.
Collapse
Affiliation(s)
- Maciej Kabat
- Internal Medicine, Hackensack Meridian Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Sarvarinder Gill
- Hematology and Oncology, Hackensack Meridian Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Kevin Kim
- Pulmonary and Critical Care Medicine, Hackensack Meridian Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Karan Omidvari
- Pulmonary and Critical Care Medicine, Hackensack Meridian Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Robert Lee
- Pulmonary and Critical Care Medicine, Hackensack Meridian Hackensack University Medical Center, Hackensack, New Jersey, USA
| |
Collapse
|
5
|
Bartlett JA, Kohli R. Hepatic Encephalopathy in Children. Indian J Pediatr 2024; 91:280-285. [PMID: 37310582 PMCID: PMC10867031 DOI: 10.1007/s12098-023-04679-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/20/2023] [Indexed: 06/14/2023]
Abstract
Hepatic encephalopathy, characterized by mental status changes and neuropsychiatric impairment, is associated with chronic liver disease as well as acute liver failure. In children, its clinical manifestations can be challenging to pinpoint. However, careful assessment for the development of hepatic encephalopathy is imperative when caring for these patients as progression of symptoms can indicate impending cerebral edema and systemic deterioration. Hepatic encephalopathy can present with hyperammonemia, but it is important to note that the degree of hyperammonemia is not indicative of severity of clinical manifestations. Newer forms of assessment are undergoing further research, and include imaging, EEG and neurobiomarkers. Mainstay of treatment currently includes management of underlying cause of liver disease, as well as reduction of hyperammonemia with either enteral medications such as lactulose and rifaximin, or even with extracorporeal liver support modalities.
Collapse
Affiliation(s)
- Johanna Ascher Bartlett
- Department of Gastroenterology, Hepatology and Nutrition at Children's Hospital Los Angeles, 4650 Sunset Blvd, MS 78, Los Angeles, CA, 90027, USA.
| | - Rohit Kohli
- Department of Gastroenterology, Hepatology and Nutrition at Children's Hospital Los Angeles, 4650 Sunset Blvd, MS 78, Los Angeles, CA, 90027, USA
| |
Collapse
|
6
|
Long MT, Kruser JM, Quinonez SC. Urea cycle disorders in critically Ill adults. Curr Opin Clin Nutr Metab Care 2024; 27:184-191. [PMID: 37938118 DOI: 10.1097/mco.0000000000000992] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
PURPOSE OF REVIEW Urea cycle disorders (UCDs) cause elevations in ammonia which, when severe, cause irreversible neurologic injury. Most patients with UCDs are diagnosed as neonates, though mild UCDs can present later - even into adulthood - during windows of high physiologic stress, like critical illness. It is crucial for clinicians to understand when to screen for UCDs and appreciate how to manage these disorders in order to prevent devastating neurologic injury or death. RECENT FINDINGS Hyperammonemia, particularly if severe, causes time- and concentration-dependent neurologic injury. Mild UCDs presenting in adulthood are increasingly recognized, so broader screening in adults is recommended. For patients with UCDs, a comprehensive, multitiered approach to management is needed to prevent progression and irreversible injury. Earlier exogenous clearance is increasingly recognized as an important complement to other therapies. SUMMARY UCDs alter the core pathway for ammonia metabolism. Screening for mild UCDs in adults with unexplained neurologic symptoms can direct care and prevent deterioration. Management of UCDs emphasizes decreasing ongoing ammonia production, avoiding catabolism, and supporting endogenous and exogenous ammonia clearance. Core neuroprotective and supportive critical care supplements this focused therapy.
Collapse
Affiliation(s)
- Micah T Long
- Departments of Anesthesiology & Internal Medicine, University of Wisconsin Hospitals and Clinics
| | - Jacqueline M Kruser
- Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Shane C Quinonez
- Departments of Pediatrics and Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
7
|
Walti LN, Del Sorbo L, Husain S. Hyperammonemia syndrome in lung transplant recipients: A survey on current clinical practice. J Heart Lung Transplant 2024; 43:357-358. [PMID: 37952586 DOI: 10.1016/j.healun.2023.11.004] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 11/01/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023] Open
Affiliation(s)
- Laura N Walti
- Division of Infectious Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada; Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Shahid Husain
- Division of Infectious Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada.
| |
Collapse
|
8
|
Ganesh R, Karthik Narayanan R. An Extremely Rare Cause of Hyperammonemic Encephalopathy in an Infant. Indian J Pediatr 2024; 91:88. [PMID: 37610685 DOI: 10.1007/s12098-023-04818-z] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 08/01/2023] [Indexed: 08/24/2023]
Affiliation(s)
- R Ganesh
- Department of Pediatric Inherited Metabolic Diseases, Rainbow Children's Hospital, Chennai, 600015, Tamil Nadu, India.
| | - R Karthik Narayanan
- Department of Pediatric Critical Care, Rainbow Children's Hospital, Chennai, 600015, Tamil Nadu, India
| |
Collapse
|
9
|
Tsykunova G, Kristensen E, Stray-Pedersen A, Bruserud Ø, Sørensen IW, Bruserud Ø, Tvedt THA. Adult presentation of ornithine transcarbamylase deficiency: a possible cause of hyperammonemia after high-dose chemotherapy and stem cell transplantation. Hematology 2023; 28:2265187. [PMID: 38078487 DOI: 10.1080/16078454.2023.2265187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 09/26/2023] [Indexed: 12/18/2023] Open
Abstract
Hyperammonemia is a rare and often fatal complication following the conditioning therapy in autologous and allogeneic stem cell transplant recipients. It is characterized by anorexia, vomiting, lethargy and coma without any other apparent cause. The diagnosis is often delayed because symptoms can be subtle and ammonia is usually not included among the routine analyzes. Previous reports have not identified the molecular mechanisms behind hyperammonemia in stem cell transplant recipients. Urea cycle disorders (UCDs) are inborn errors of metabolism leading to hyperammonemia that usually presents in early childhood, whereas first presentation in adults is less common. Here we describe an adult woman with hyperammonemia following autologous stem cell transplantation for multiple myeloma. No apparent cause of hyperammonemia was identified, including portosystemic shunting, liver dysfunction or recent hyperammonemia-inducing chemotherapy. Hyperammonemia, normal blood glucose as well as anion gap and a previous history of two male newborns that died early after birth, prompted biochemical and genetic investigations for a UCD. A heterozygous variant in the X-linked gene encoding ornithine transcarbamylase (OTC) was identified and was regarded as a cause of UCD. The patient improved after treatment with nitrogen scavengers and high caloric intake according to a UCD protocol. This case report suggests that UCD should be considered as a possible cause of hyperammonemia following stem cell transplantation.
Collapse
Affiliation(s)
- Galina Tsykunova
- Department of Medicine Haukeland University Hospital, Bergen, Norway
| | - Erle Kristensen
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Asbjørg Stray-Pedersen
- The National Unit for Newborn Screening, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Øyvind Bruserud
- Department of Anesthesiology and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Ida Wiig Sørensen
- Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway
| | - Øystein Bruserud
- Department of Medicine Haukeland University Hospital, Bergen, Norway
- Section for Hematology, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Tor Henrik Anderson Tvedt
- Department of Medicine Haukeland University Hospital, Bergen, Norway
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
10
|
Ceschia G, Parolin M, Longo G, Ronco C, Vidal E. Expanding the Spectrum of Extracorporeal Strategies in Small Infants with Hyperammonemia. Blood Purif 2023; 52:729-736. [PMID: 37725911 DOI: 10.1159/000533486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/04/2023] [Indexed: 09/21/2023]
Abstract
Hyperammonemia is a life-threatening condition mainly due to the neurotoxicity of ammonia. Ammonia scavengers may be insufficient, and extracorporeal treatment may be required. Continuous treatments are preferred, and a high-dose continuous renal replacement therapy (CRRT) must be prescribed to ensure a fast ammonia depletion. Many of the children with hyperammonemia are newborns, with lower blood volume than older children. The majority of the CRRT systems are adult-based, with large extracorporeal priming volumes and inadequate UF control. Recent strides have been made in the development of CRRT systems more suitable for young children with smaller sets to use in adult machines and dedicated monitors for neonates and infants. The main advantage of the machines for adults is the higher dialysis fluid flows, however with greater hemodynamic risks. Pediatric monitors have been designed to reduce the extracorporeal volume and to increase the precision of the treatment. However, they have substantial limitation in clearance performances. In this review, we discuss on current strategies to provide CRRT in newborns and small infants with hyperammonemia. We also presented our experience with the use of CARPEDIEM™ implemented in a CVVHDF modality, boosting the diffusive clearance with a post-replacement convective mechanism.
Collapse
Affiliation(s)
- Giovanni Ceschia
- Pediatric Nephrology Unit, Department of Woman's and Child's Health, University Hospital of Padova, Padua, Italy
| | - Mattia Parolin
- Pediatric Nephrology Unit, Department of Woman's and Child's Health, University Hospital of Padova, Padua, Italy
| | - Germana Longo
- Pediatric Nephrology Unit, Department of Woman's and Child's Health, University Hospital of Padova, Padua, Italy
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, IRRIV Foundation, Department of Nephrology, Dialysis and Transplantation, St. Bortolo Hospital, Vicenza, Italy
- Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Enrico Vidal
- Pediatric Nephrology Unit, Department of Woman's and Child's Health, University Hospital of Padova, Padua, Italy
- Department of Medicine (DAME), University of Udine, Udine, Italy
| |
Collapse
|
11
|
Yoshida H, Iwata Y, Fuchigami T, Katagiri J. Acute onset of ornithine transcarbamylase deficiency after total anomalous pulmonary venous connection repair to a 2-day-old neonate. Cardiol Young 2023; 33:1775-1776. [PMID: 37042609 DOI: 10.1017/s1047951123000616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
Ornithine transcarbamylase deficiency is an X-linked disorder which results in the accumulation of ammonia causing irritability and vomiting. Acute hyperammonemia requires rapid and intensive intervention. However, as those clinical features are non-specific and commonly seen in peri-operative situation, ornithine transcarbamylase deficiency could be difficult to diagnose prior to and post-emergency cardiac surgery. We report a 2-day-old male neonate who was diagnosed with ornithine transcarbamylase deficiency presenting hyperammonemia and severe heart failure after total anomalous pulmonary venous connection repair.
Collapse
Affiliation(s)
- Hisashi Yoshida
- Department of Pediatric Cardiac Surgery, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Yusuke Iwata
- Department of Pediatric Cardiac Surgery, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Tai Fuchigami
- Department of Pediatric Cardiac Surgery, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Junko Katagiri
- Department of Pediatric Cardiac Surgery, Gifu Prefectural General Medical Center, Gifu, Japan
| |
Collapse
|
12
|
Miller A, Bernshteyn M, Achakzai B, Macfie R. Closure of a distal splenorenal shunt as a therapy for refractory hyperammonaemia in setting of neuropsychiatric symptoms. BMJ Case Rep 2023; 16:e255610. [PMID: 37591624 PMCID: PMC10441096 DOI: 10.1136/bcr-2023-255610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023] Open
Abstract
Before the widespread use of the transjugular intrahepatic portosystemic shunt, portal hypertension was addressed by the creation of an operative distal splenorenal shunt (DSRS). DSRS was largely regarded as a safe and effective therapy, though it did have a risk of precipitating hyperammonaemia and hepatic encephalopathy.A woman suffered a gunshot wound to the abdomen. This trauma led to portal vein thrombosis, cavernous transformation of the vein and eventually bleeding oesophageal varices from portal hypertension. A DSRS was created to decrease portal hypertension. Years later, she had profound depression with psychomotor slowing in the setting of hyperammonaemia. To reduce hepatic encephalopathy as a contributor to her neuropsychiatric condition, her shunt was closed. The hyperammonaemia resolved and neuropsychiatric symptoms improved.This case highlights several interesting clinical features, including portal hypertension due to chronic portal vein occlusion, cavernous transformation, a surgical DSRS causing hyperammonaemia and hepatic encephalopathy manifesting as neuropsychiatric symptoms.
Collapse
Affiliation(s)
- Alexander Miller
- Department of Gastroenterology, Guthrie Robert Packer Hospital, Sayre, PA, USA
| | - Michelle Bernshteyn
- Department of Gastroenterology, Guthrie Robert Packer Hospital, Sayre, PA, USA
| | - Basit Achakzai
- Department of Interventional Radiology, Guthrie Robert Packer Hospital, Sayre, PA, USA
| | - Rebekah Macfie
- Department of Surgical Oncology, Guthrie Robert Packer Hospital, Sayre, PA, USA
| |
Collapse
|
13
|
Youth Commission, Subspecialty Group of Neonatology, Society of Pediatrics, Chinese Medical Association. [Expert consensus on the diagnosis and treatment of neonatal hyperammonemia]. Zhongguo Dang Dai Er Ke Za Zhi 2023; 25:437-47. [PMID: 37272168 DOI: 10.7499/j.issn.1008-8830.2302140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/07/2023] [Indexed: 06/06/2023]
Abstract
Neonatal hyperammonemia is a disorder of ammonia metabolism that occurs in the neonatal period. It is a clinical syndrome characterized by abnormal accumulation of ammonia in the blood and dysfunction of the central nervous system. Due to its low incidence and lack of specificity in clinical manifestations, it is easy to cause misdiagnosis and missed diagnosis. In order to further standardize the diagnosis and treatment of neonatal hyperammonemia, the Youth Commission, Subspecialty Group of Neonatology, Society of Pediatrics, Chinese Medical Association formulated the expert consensus based on clinical evidence in China and overseas and combined with clinical practice experience,and put forward 18 recommendations for the diagnosis and treatment of neonatal hyperaminemia.
Collapse
|
14
|
Lo RS, Cromie GA, Tang M, Teng K, Owens K, Sirr A, Kutz JN, Morizono H, Caldovic L, Ah Mew N, Gropman A, Dudley AM. The functional impact of 1,570 individual amino acid substitutions in human OTC. Am J Hum Genet 2023; 110:863-879. [PMID: 37146589 PMCID: PMC10183466 DOI: 10.1016/j.ajhg.2023.03.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/30/2023] [Indexed: 05/07/2023] Open
Abstract
Deleterious mutations in the X-linked gene encoding ornithine transcarbamylase (OTC) cause the most common urea cycle disorder, OTC deficiency. This rare but highly actionable disease can present with severe neonatal onset in males or with later onset in either sex. Individuals with neonatal onset appear normal at birth but rapidly develop hyperammonemia, which can progress to cerebral edema, coma, and death, outcomes ameliorated by rapid diagnosis and treatment. Here, we develop a high-throughput functional assay for human OTC and individually measure the impact of 1,570 variants, 84% of all SNV-accessible missense mutations. Comparison to existing clinical significance calls, demonstrated that our assay distinguishes known benign from pathogenic variants and variants with neonatal onset from late-onset disease presentation. This functional stratification allowed us to identify score ranges corresponding to clinically relevant levels of impairment of OTC activity. Examining the results of our assay in the context of protein structure further allowed us to identify a 13 amino acid domain, the SMG loop, whose function appears to be required in human cells but not in yeast. Finally, inclusion of our data as PS3 evidence under the current ACMG guidelines, in a pilot reclassification of 34 variants with complete loss of activity, would change the classification of 22 from variants of unknown significance to clinically actionable likely pathogenic variants. These results illustrate how large-scale functional assays are especially powerful when applied to rare genetic diseases.
Collapse
Affiliation(s)
- Russell S Lo
- Pacific Northwest Research Institute, Seattle, WA, USA
| | | | - Michelle Tang
- Pacific Northwest Research Institute, Seattle, WA, USA
| | - Kevin Teng
- Pacific Northwest Research Institute, Seattle, WA, USA
| | - Katherine Owens
- Pacific Northwest Research Institute, Seattle, WA, USA; Department of Applied Mathematics, University of Washington, Seattle, WA, USA
| | - Amy Sirr
- Pacific Northwest Research Institute, Seattle, WA, USA
| | - J Nathan Kutz
- Department of Applied Mathematics, University of Washington, Seattle, WA, USA
| | - Hiroki Morizono
- Center for Genetic Medicine Research, Children's National Research Institute, Children's National Hospital, Washington, DC, USA; Department of Genomics and Precision Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Ljubica Caldovic
- Center for Genetic Medicine Research, Children's National Research Institute, Children's National Hospital, Washington, DC, USA; Department of Genomics and Precision Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Nicholas Ah Mew
- Center for Genetic Medicine Research, Children's National Research Institute, Children's National Hospital, Washington, DC, USA; Department of Genomics and Precision Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Andrea Gropman
- Center for Genetic Medicine Research, Children's National Research Institute, Children's National Hospital, Washington, DC, USA; Department of Genomics and Precision Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA; Department of Neurology, Division of Neurogenetics and Neurodevelopmental Disabilities, Children's National Hospital, Washington, DC, USA; Center for Neuroscience Research, Children's National Research Institute, Children's National Hospital, Washington, DC, USA
| | | |
Collapse
|
15
|
Redant S, Warrillow S, Honoré PM. Ammonia and nutritional therapy in the critically ill: when to worry, when to test and how to treat? Curr Opin Clin Nutr Metab Care 2023; 26:160-166. [PMID: 36892962 DOI: 10.1097/mco.0000000000000899] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
PURPOSE OF REVIEW Hyperammonaemia is almost always develops in patients with severe liver failure and this remains the commonest cause of elevated ammonia concentrations in the ICU. Nonhepatic hyperammonaemia in ICU presents diagnostic and management challenges for treating clinicians. Nutritional and metabolic factors play an important role in the cause and management of these complex disorders. RECENT FINDINGS Nonhepatic hyperammonaemia causes such as drugs, infection and inborn errors of metabolism may be unfamiliar to clinicians and risk being overlooked. Although cirrhotic patients may tolerate marked elevations in ammonia, other causes of acute severe hyperammonaemia may result in fatal cerebral oedema. Any coma of unclear cause should prompt urgent measurement of ammonia and severe elevations warrant immediate protective measures as well as treatments such as renal replacement therapy to avoid life-threatening neurological injury. SUMMARY The current review explores important clinical considerations, the approach to testing and key treatment principles that may prevent progressive neurological damage and improve outcomes for patients with hyperammonaemia, especially from nonhepatic causes.
Collapse
Affiliation(s)
- Sebastien Redant
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Stephen Warrillow
- Department of Intensive Care, Austin Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Patrick M Honoré
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Depatment of Intensive Care, CHU UCL Godinne Namur, UCL Louvain Medical School, Namur, Belgium
| |
Collapse
|
16
|
Nakamura H, Takada K, Murase K, Ikeda H, Iyama S, Manabe T, Kobune M. Multiple Myeloma with Hyperammonemia Treated with Novel Agents: A Case Series of Three Patients. Intern Med 2023; 62:775-778. [PMID: 35871579 PMCID: PMC10037000 DOI: 10.2169/internalmedicine.0010-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Multiple myeloma (MM) is a cancer characterized by the expansion of plasma cells in the bone marrow. Survival times of patients with MM have increased due to the development of novel therapeutic agents. We herein highlight three MM cases that had a poor prognosis despite treatment with novel therapeutic agents. Of note, all patients presented with hyperammonemia that led to a consciousness disorder. The outcome for patients with MM showing high levels of serum ammonia continues to be poor, even with the use of novel therapies. For such patients showing a consciousness disorder, hyperammonemia should be considered as a possible cause.
Collapse
Affiliation(s)
- Hajime Nakamura
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Japan
| | - Kohichi Takada
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Japan
| | - Kazuyuki Murase
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Japan
| | - Hiroshi Ikeda
- Department of Hematology, Sapporo Medical University School of Medicine, Japan
| | - Satoshi Iyama
- Department of Hematology, Sapporo Medical University School of Medicine, Japan
| | - Tatsuo Manabe
- Department of Neurology, Sapporo Medical University School of Medicine, Japan
| | - Masayoshi Kobune
- Department of Hematology, Sapporo Medical University School of Medicine, Japan
| |
Collapse
|
17
|
Abstract
Hepatic encephalopathy (HE) is a brain dysfunction caused by liver insufficiency and/or portosystemic shunts. Between 30%-40% of patients with cirrhosis will present overt HE during their lifetime. While the pathophysiology of HE is not entirely understood, three critical factors have been identified: hyperammonaemia, systemic inflammation and oxidative stress by glutaminase gene alterations. Minimal HE is defined by the presence of signs of cognitive abnormalities in a patient without asterixis or disorientation; it can only be diagnosed with neuropsychological or psychometric tests. The diagnosis of overt HE is based on clinical examination with clinical scales. Currently, only overt HE should be routinely treated. The aims of treatment in an acute episode should be to improve the mental status, identify and treat the precipitating factor, reduce duration and limit consequences. Treatment strategies are targeted at reducing ammonia production and/or increasing its elimination. Even though minimal HE has negative effects on the patient's quality of life and effects on prognosis, indications for treatment are still controversial. There are still many unanswered questions regarding the pathophysiology and management of HE. We should also endeavor to develop more accurate and objective diagnostic methods for overt HE that would permit early detection and help improve outcomes on quality of life and economic burden.
Collapse
Affiliation(s)
- Paulina Vidal-Cevallos
- Obesity and Digestive Disease Unit, Medica Sur Clinic and Foundation, Puente de Piedra 150, col. Toriello Guerra, C.P. 14050, Mexico City, Mexico
| | - Norberto C Chávez-Tapia
- Obesity and Digestive Disease Unit, Medica Sur Clinic and Foundation, Puente de Piedra 150, col. Toriello Guerra, C.P. 14050, Mexico City, Mexico
| | - Misael Uribe
- Obesity and Digestive Disease Unit, Medica Sur Clinic and Foundation, Puente de Piedra 150, col. Toriello Guerra, C.P. 14050, Mexico City, Mexico.
| |
Collapse
|
18
|
Fernández-Elías VE, Tornero-Aguilera JF, Parraca JA, Clemente-Suárez VJ. Psychological Stress Triggers a Hyperammonemia Episode in Patient with Ornithine Transcarbamylase Deficiency. Int J Environ Res Public Health 2022; 19:11516. [PMID: 36141788 PMCID: PMC9517620 DOI: 10.3390/ijerph191811516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/01/2022] [Accepted: 09/08/2022] [Indexed: 06/16/2023]
Abstract
An 18-year-old male motorcycle racer, who was a participant in the FIM Road Racing World Championship and had a history of Ornithine Transcarbamylase deficiency, developed nausea and dizziness while driving his motorcycle and became unconscious right after he stopped at the box. He was rapidly attended to by the medical personnel of the circuit, and once he recovered consciousness, he was taken to the local hospital where the blood analysis showed hyperammonemia (307 μg/dL) and excess alkalosis. The patient was properly following the prescribed treatment, and there were no environmental stressors. Hence, psychological stress and its somatization due to the risky task that the patient was performing could have triggered the episode. Stress must be considered as a potential cause, triggering strenuous metabolic stress that leads to hyperammonemia.
Collapse
Affiliation(s)
| | | | - Jose Alberto Parraca
- Departamento de Desporto e Saúde, Escola de Saúde e Desenvolvimento Humano, Universidade de Évora, Largo dos Colegiais, 7000 Évora, Portugal
- Comprehensive Health Research Centre (CHRC), Universidade de Évora, 7000 Évora, Portugal
| | | |
Collapse
|
19
|
Han ST, Anderson KJ, Bjornsson HT, Longo N, Valle D. A promoter variant in the OTC gene associated with late and variable age of onset hyperammonemia. J Inherit Metab Dis 2022; 45:710-718. [PMID: 35605046 DOI: 10.1002/jimd.12524] [Citation(s) in RCA: 4] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/12/2022] [Accepted: 05/20/2022] [Indexed: 11/11/2022]
Abstract
Ornithine transcarbamylase deficiency (OTCD) is an X-linked inborn error caused by loss of function variants in the OTC gene typically associated with severe neonatal hyperammonemia. Rare examples of late-onset OTCD have also been described. Here, we describe an OTC promoter variant, c.-106C>A, in a conserved HNF4a binding site, identified in two male siblings in Family 1 whose first and only recognized episodes of severe hyperammonemia occurred at ages 14 and 39 years, respectively. We identified the same OTC variant segregating in a large family with late-onset OTCD with variable expressivity (Family 2). We show that this OTC promoter variant reduces expression >5-fold in a dual-luciferase assay that tests promoter function. Addition of an upstream OTC enhancer increases expression of both the wild type and the c.-106C>A variant promoter constructs >5-fold with the mutant promoter still about fourfold lower than the wild type. Thus, in both contexts, the promoter variant results in substantially lower OTC expression. Under normal demand on urea cycle function, OTC expression in hemizygous males, although reduced, is sufficient to meet the demand for waste nitrogen excretion. However, in response to severe metabolic stress with attendant increased requirements on urea cycle function, the impaired promoter function results in inadequate OTC expression with resultant hyperammonemia. In the absence of precipitating events, hemizygotes with this allele are asymptomatic, explaining the late age of onset of hyperammonemia in affected individuals and the incomplete penetrance observed in some individuals in Family 2.
Collapse
Affiliation(s)
- Sangwoo T Han
- Predoctoral Training Program in Human Genetics, McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Katherine J Anderson
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Hans T Bjornsson
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
- Landspitali University Hospital, Reykjavik, Iceland
| | - Nicola Longo
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - David Valle
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
20
|
Starr MC, Cater DT, Wilson AC, Wallace S, Bennett WE, Hains DS. Association Between Continuous Kidney Replacement Therapy Clearance and Outcome in Pediatric Patients With Hyperammonemia Not Due to Inborn Error of Metabolism. Pediatr Crit Care Med 2022; 23:e356-e360. [PMID: 35383692 DOI: 10.1097/pcc.0000000000002949] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe a single-center experience of pediatric patients with hyperammonemia not due to inborn errors of metabolism and determine the association between use of continuous kidney replacement therapy (CKRT) treatment and outcomes. DESIGN Retrospective cohort study. SETTING Tertiary-care children's hospital. PATIENTS All children less than 21 years old admitted to the hospital with hyperammonemia defined as an elevated ammonia levels (>100 µmol/L) not due to inborn error of metabolism. INTERVENTIONS None. MEASURES AND MAIN RESULTS Of 135 children with hyperammonemia, the most common reason for admission was infection in 57 of 135 (42%), congenital heart disease in 20 of 135 (14%), and bone marrow transplantation in 10 of 135 (7%). The overall mortality was 61% (82 of 135), which increased with degree of hyperammonemia (17 of 23 [74%] in those with ammonia >250 µmol/L). After multivariable regression, hyperammonemia severity was not associated with mortality (aOR, 1.4; 95% CI, 0.92-2.1; p = 0.11). Of the 43 patients (32%) receiving CKRT, 21 were prescribed standard clearance and 22 high clearance. The most common indications for CKRT were fluid overload in 17 of 43 (42%) and acute kidney injury or uremia in 16 of 43 (37%). Mean CKRT duration was 13 days. There was no difference between standard and high clearance groups in risk of death (76% vs 86%; p = 0.39), cerebral edema on CT scan (19% vs 27%; p = 0.52), nor decrease in ammonia levels after 24 or 48 hours of CKRT ( p = 0.20, p = 0.94). Among those receiving CKRT, we failed to find an association between high clearance and decreased risk of death in multivariable analysis (aOR, 1.2; 95% CI, 0.64-2.3; p = 0.55). CONCLUSIONS In our single-center retrospective study, we failed to find an association between clearance on CKRT and improved survival nor decreased cerebral edema on head imaging. In fact, we failed to find an association between ammonia level and mortality, after controlling for illness severity.
Collapse
Affiliation(s)
- Michelle C Starr
- Division of Pediatric Nephrology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
- Center for Pediatric and Adolescent Comparative Effectiveness Research, Department of Pediatrics, Indiana University, Indianapolis, IN
| | - Daniel T Cater
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Amy C Wilson
- Division of Pediatric Nephrology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Samantha Wallace
- Center for Pediatric and Adolescent Comparative Effectiveness Research, Department of Pediatrics, Indiana University, Indianapolis, IN
| | - William E Bennett
- Center for Pediatric and Adolescent Comparative Effectiveness Research, Department of Pediatrics, Indiana University, Indianapolis, IN
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - David S Hains
- Division of Pediatric Nephrology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| |
Collapse
|
21
|
Abstract
PURPOSE OF REVIEW Hyperammonemia syndrome is an increasingly recognized and often fatal condition that occurs in immunosuppressed individuals, most commonly lung transplant recipients. Growing evidence suggests hyperammonemia syndrome is associated with systemic infections caused by urease-producing organisms, namely Ureaplasma spp., an organism unable to grow with routine culturing techniques. This review will summarize the epidemiology and clinical manifestations of hyperammonemia syndrome, as well as diagnostic and management strategies once hyperammonemia syndrome is suspected. RECENT FINDINGS Hyperammonemia syndrome is being described in increasing frequency in the solid organ transplant population. Morbidity and mortality, even with treatment, is high once hyperammonemia syndrome occurs. Surveillance studies indicate the prevalence of lung donor colonization with Ureaplasma spp. is high, suggesting screening and treatment may be of benefit. Antibiotic resistance is common, and rapid diagnostics can facilitate appropriate antimicrobial therapy in the peri-transplant period. SUMMARY Hyperammonemia syndrome is most commonly seen in lung transplant recipients and has a high mortality rate once it occurs. Screening for Ureaplasma spp. should be considered in all lung transplant donors.
Collapse
Affiliation(s)
- Scott C Roberts
- Division of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut
| | - Waleed Malik
- Division of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut
| | - Michael G Ison
- Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| |
Collapse
|
22
|
Kamel AY, Emtiazjoo AM, Adkins L, Shahmohammadi A, Alnuaimat H, Pelaez A, Machuca T, Pipkin M, Lee HW, Weiner ID, Chandrashekaran S. Hyperammonemia After Lung Transplantation: Systematic Review and a Mini Case Series. Transpl Int 2022; 35:10433. [PMID: 35620675 PMCID: PMC9128545 DOI: 10.3389/ti.2022.10433] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 03/18/2022] [Indexed: 11/21/2022]
Abstract
Background: Hyperammonemia after lung transplantation (HALT) is a rare but serious complication with high mortality. This systematic review delineates possible etiologies of HALT and highlights successful strategies used to manage this fatal complication. Methods: Seven biomedical databases and grey literature sources were searched using keywords relevant to hyperammonemia and lung transplantation for publications between 1995 and 2020. Additionally, we retrospectively analyzed HALT cases managed at our institution between January 2016 and August 2018. Results: The systematic review resulted in 18 studies with 40 individual cases. The mean peak ammonia level was 769 μmol/L at a mean of 14.1 days post-transplant. The mortality due to HALT was 57.5%. In our cohort of 120 lung transplants performed, four cases of HALT were identified. The mean peak ammonia level was 180.5 μmol/L at a mean of 11 days after transplantation. HALT in all four patients was successfully treated using a multimodal approach with an overall mortality of 25%. Conclusion: The incidence of HALT (3.3%) in our institution is comparable to prior reports. Nonetheless, ammonia levels in our cohort were not as high as previously reported and peaked earlier. We attributed these significant differences to early recognition and prompt institution of multimodal treatment approach.
Collapse
Affiliation(s)
- Amir Y. Kamel
- Department of Pharmacy, UF Health Shands Hospital, College of Pharmacy, University of Florida, Gainesville, FL, United States
- *Correspondence: Amir Y. Kamel,
| | - Amir M. Emtiazjoo
- Division of Pulmonary, Critical Care and Sleep Medicine, UF Lung Transplant Program, College of Medicine, University of Florida Health Hospital, Gainesville, FL, United States
| | - Lauren Adkins
- College of Pharmacy Liaison Librarian, Health Science Center Libraries, Gainesville, FL, United States
| | - Abbas Shahmohammadi
- Division of Pulmonary, Critical Care and Sleep Medicine, UF Lung Transplant Program, College of Medicine, University of Florida Health Hospital, Gainesville, FL, United States
| | - Hassan Alnuaimat
- Division of Pulmonary, Critical Care and Sleep Medicine, UF Lung Transplant Program, College of Medicine, University of Florida Health Hospital, Gainesville, FL, United States
| | - Andres Pelaez
- Division of Pulmonary, Critical Care and Sleep Medicine, UF Lung Transplant Program, College of Medicine, University of Florida Health Hospital, Gainesville, FL, United States
| | - Tiago Machuca
- Division of Cardiothoracic Surgery, UF Lung Transplant Program, University of Florida Health Hospital, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Mauricio Pipkin
- Division of Cardiothoracic Surgery, UF Lung Transplant Program, University of Florida Health Hospital, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Hyun-wook Lee
- Division of Nephrology, Hypertension and Renal Transplantation, College of Medicine, University of Florida, Gainesville, FL, United States
| | - I. David Weiner
- Division of Nephrology, Hypertension and Renal Transplantation, College of Medicine, University of Florida, Gainesville, FL, United States
- North Florida/South Georgia Veterans Health System, Gainesville, FL, United States
| | - Satish Chandrashekaran
- Division of Pulmonary, Critical Care and Sleep Medicine, UF Lung Transplant Program, College of Medicine, University of Florida Health Hospital, Gainesville, FL, United States
| |
Collapse
|
23
|
Refardt J, den Hoed CM, Langendonk J, Zandee WT, Charehbili A, Feelders RA, de Herder WW, Brabander T, Hofland J. Prognostic significance of hyperammonemia in neuroendocrine neoplasm patients with liver metastases. Endocr Relat Cancer 2022; 29:241-250. [PMID: 35171111 DOI: 10.1530/erc-21-0346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/16/2022] [Indexed: 11/08/2022]
Abstract
Neuroendocrine neoplasms (NENs) are rare, usually slow-growing tumors, often presenting with extensive liver metastases. Hyperammonemia due to insufficient hepatic clearance has been described in NEN cases; however, no systematic evaluation of risk factors and outcomes of NEN-associated hyperammonemia exists so far. This case report and retrospective review of NEN patients developing hyperammonemia from the years 2000 to 2020 at the Erasmus Medical Center in Rotterdam, the Netherlands, aimed to describe these patients and determine prognostic factors to improve evaluation and treatment. Forty-four NEN patients with documented hyperammonemia were identified. All patients had liver metastases with 30% (n = 13) showing signs of portal hypertension. Patients who developed encephalopathy had higher median ammonia levels, but there was no association between the severity of hyperammonemia and liver tumor burden or presence of liver insufficiency. Eighty-four percent (n = 37) of patients died during follow-up. The median (IQR) time from diagnosis of hyperammonemia to death was 1.7 months (0.1-22.7). Hyperbilirubinemia, hypoalbuminemia, elevated international normalized ratio, presence of liver insufficiency, encephalopathy and ascites were associated with worse outcomes. Their role as independent risk factors for mortality was confirmed using the Child-Pugh score as a summary factor (P < 0.001). No difference was seen concerning overall survival between our hyperammonemia patients and a propensity score-matched control stage IV NEN cohort. In conclusion, hyperammonemia comprises a relevant and potentially underdiagnosed complication of NEN liver metastases and is associated with worse outcomes. Assessment of signs of encephalopathy, risk factors and the Child-Pugh score could be helpful in selecting patients in whom ammonia levels should be measured.
Collapse
Affiliation(s)
- Julie Refardt
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus Medical Center and Erasmus Cancer Institute, Rotterdam, The Netherlands
- ENETS Center of Excellence, Department of Endocrinology, University Hospital Basel, Basel, Switzerland
| | - Caroline M den Hoed
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Janneke Langendonk
- Department of Internal Medicine, Center for Lysosomal and Metabolic Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Wouter T Zandee
- Division of Endocrinology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ayoub Charehbili
- ENETS Center of Excellence, Department of Radiology & Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Richard A Feelders
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus Medical Center and Erasmus Cancer Institute, Rotterdam, The Netherlands
| | - Wouter W de Herder
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus Medical Center and Erasmus Cancer Institute, Rotterdam, The Netherlands
| | - Tessa Brabander
- ENETS Center of Excellence, Department of Radiology & Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Johannes Hofland
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus Medical Center and Erasmus Cancer Institute, Rotterdam, The Netherlands
| |
Collapse
|
24
|
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
| |
Collapse
|
25
|
Durer S, Durer C, Hoilat GJ. Adult-onset ornithine transcarbamylase deficiency as a rare cause of fatal hyperammonaemia. Lancet 2021; 398:e11. [PMID: 34454677 DOI: 10.1016/s0140-6736(21)01606-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 04/25/2021] [Revised: 05/25/2021] [Accepted: 07/06/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Seren Durer
- Department of Internal Medicine, State University of New York Upstate Medical University Hospital, Syracuse, NY, USA.
| | - Ceren Durer
- Department of Internal Medicine, State University of New York Upstate Medical University Hospital, Syracuse, NY, USA
| | - Gilles Jadd Hoilat
- Department of Internal Medicine, State University of New York Upstate Medical University Hospital, Syracuse, NY, USA
| |
Collapse
|
26
|
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.
Collapse
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
| |
Collapse
|
27
|
Diaz GA, Schulze A, McNutt MC, Leão‐Teles E, Merritt JL, Enns GM, Batzios S, Bannick A, Zori RT, Sloan LS, Potts SL, Bubb G, Quinn AG. Clinical effect and safety profile of pegzilarginase in patients with arginase 1 deficiency. J Inherit Metab Dis 2021; 44:847-856. [PMID: 33325055 PMCID: PMC8359196 DOI: 10.1002/jimd.12343] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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: 01/24/2020] [Revised: 11/30/2020] [Accepted: 12/14/2020] [Indexed: 12/29/2022]
Abstract
Hyperargininemia in patients with arginase 1 deficiency (ARG1-D) is considered a key driver of disease manifestations, including spasticity, developmental delay, and seizures. Pegzilarginase (AEB1102) is an investigational enzyme therapy which is being developed as a novel arginine lowering approach. We report the safety and efficacy of intravenously (IV) administered pegzilarginase in pediatric and adult ARG1-D patients (n = 16) from a Phase 1/2 study (101A) and the first 12 weeks of an open-label extension study (102A). Substantial disease burden at baseline included lower-limb spasticity, developmental delay, and previous hyperammonemic episodes in 75%, 56%, and 44% of patients, respectively. Baseline plasma arginine (pArg) was elevated (median 389 μM, range 238-566) on standard disease management. Once weekly repeat dosing resulted in a median decrease of pArg of 277 μM after 20 cumulative doses (n = 14) with pArg in the normal range (40 to 115 μM) in 50% of patients at 168 hours post dose (mean pegzilarginase dose 0.10 mg/kg). Lowering pArg was accompanied by improvements in one or more key mobility assessments (6MWT, GMFM-D & E) in 79% of patients. In 101A, seven hypersensitivity reactions occurred in four patients (out of 162 infusions administered). Other common treatment-related adverse events (AEs) included vomiting, hyperammonemia, pruritus, and abdominal pain. Treatment-related serious AEs that occurred in five patients were all observed in 101A. Pegzilarginase was effective in lowering pArg levels with an accompanying clinical response in patients with ARG1-D. The improvements with pegzilarginase occurred in patients receiving standard treatment approaches, which suggests that pegzilarginase could offer benefit over existing disease management.
Collapse
Affiliation(s)
- George A. Diaz
- Icahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
| | - Andreas Schulze
- University of Toronto and The Hospital for Sick ChildrenTorontoOntarioCanada
| | | | | | | | | | | | - Allison Bannick
- Children's Hospital of MichiganWayne State UniversityDetroitMichiganUSA
| | | | | | | | | | | |
Collapse
|
28
|
Sjölund I, Kragsbjerg P. [A case of hyperammonemia presented in a patient with multiple myeloma]. Lakartidningen 2021; 118:21024. [PMID: 34151998] [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: 06/13/2023]
Abstract
Hyperammonemia-induced encephalopathy is a rare complication of untreated multiple myeloma. This case report illustrates a 78-year-old woman with multiple myeloma who developed acute delirium due to elevated level of serum ammonia in the absence of hepatic failure. One should suspect the condition when common management is ineffective. The adequate treatment of underlaying multiple myeloma is necessary.
Collapse
Affiliation(s)
| | - Peter Kragsbjerg
- docent, överläkare, medicinkliniken, Västmanlands sjukhus, Västerås
| |
Collapse
|
29
|
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.
Collapse
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
| |
Collapse
|
30
|
Nøhr TK, Eriksen PL, Lund A, Vilstrup H, Thomsen KL. [Hyperammonaemic encephalopathy in adults without liver diseases]. Ugeskr Laeger 2021; 183:V11200825. [PMID: 33829995] [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: 06/12/2023]
Abstract
Hyperammonaemic encephalopathy (HAE) in adults in the absence of acute or chronic liver disease is a severe condition caused by inborn errors of metabolism or acquired conditions like bariatric surgery, medications or malignancy as summarised in this review. Metabolic defects are most often caused by partial defects in the urea cycle enzymes demasked by stressors, whereas mechanisms underlying the acquired causes are complex and often multifactorial. Awareness of HAE and knowledge of the causes can help the clinician to deal appropriately with patients presenting with symptoms suggesting HAE and no signs of liver disease.
Collapse
|
31
|
Kurihara C, Manerikar A, Kandula V, Cerier E, Bharat A. Prophylactic Ureaplasma-directed Antimicrobials in Lung Donors Can Prevent Fatal Hyperammonemia. Transplantation 2021; 105:e35-e36. [PMID: 33617207 PMCID: PMC7905692 DOI: 10.1097/tp.0000000000003540] [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] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Chitaru Kurihara
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, 676 N. St Clair St, Suite 650, Chicago, Illinois 60611
| | - Adwaiy Manerikar
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, 676 N. St Clair St, Suite 650, Chicago, Illinois 60611
| | - Viswajit Kandula
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, 676 N. St Clair St, Suite 650, Chicago, Illinois 60611
| | - Emily Cerier
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, 676 N. St Clair St, Suite 650, Chicago, Illinois 60611
| | - Ankit Bharat
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, 676 N. St Clair St, Suite 650, Chicago, Illinois 60611
| |
Collapse
|
32
|
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.
Collapse
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
| |
Collapse
|
33
|
Division of Genetics and Metabolism, Child Diseases and Health Care Branch, Chinese Association for Maternal and Child Health. [Consensus on diagnosis and treatment of ornithine trans-carbamylase deficiency]. Zhejiang Da Xue Xue Bao Yi Xue Ban 2020; 49:539-547. [PMID: 33210478 PMCID: PMC8800749 DOI: 10.3785/j.issn.1008-9292.2020.04.11] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 01/15/2020] [Indexed: 12/11/2022]
Abstract
Ornithine transcarbamylase deficiency(OTCD)is a most common ornithine cycle (urea cycle) disorder. It is a X-link inherited disorder caused by OTC gene mutation that in turn leads to reduction or loss of OTC enzyme activity. Its onset time is related to the lack of enzyme activity. Patients with neonatal onset usually have complete absence of OTC enzyme activity, which is mainly associated with male semi-zygotic mutations; and the disease progresses rapidly with high mortality rates. Patients with late onset vary in onset age and clinical manifestations, and the course of disease can be progressive or intermittent. The acute attack mainly manifests neuropsychiatric symptoms accompanied by digestive symptoms like liver function damage or even acute liver failure. Elevated blood ammonia is the main biochemical indicator of OTCD patients. Increased glutamine, decreased citrulline in blood, and increased orotic acid in urine are typical clinical manifestations for OTCD patients. Genetic testing of OTC gene is important for OTCD diagnosis. The goal of treatment is to minimize the neurological damage caused by hyperammonemia while ensuring the nutritional needs for patient development. For patients with poor response to medication and diet, liver transplantation is recommended under the condition of stable metabolic state and absence of severe neurological damage. During long-term treatment, physical growth indicators, nutrition status, liver function, blood ammonia and amino acids should be regularly monitored. This consensus aims to standardize the diagnosis and treatment of OTCD, improve the prognosis, reduce the mortality and disability of patients.
Collapse
|
34
|
Hanai T, Shiraki M, Imai K, Suetugu A, Takai K, Shimizu M. Usefulness of Carnitine Supplementation for the Complications of Liver Cirrhosis. Nutrients 2020; 12:nu12071915. [PMID: 32610446 PMCID: PMC7401279 DOI: 10.3390/nu12071915] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [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] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 02/07/2023] Open
Abstract
Carnitine is a vitamin-like substance that regulates lipid metabolism and energy production. Carnitine homeostasis is mainly regulated by dietary intake and biosynthesis in the organs, including the skeletal muscle and the liver. Therefore, liver cirrhotic patients with reduced food intake, malnutrition, biosynthetic disorder, and poor storage capacity of carnitine in the skeletal muscle and liver are more likely to experience carnitine deficiency. In particular, liver cirrhotic patients with sarcopenia are at a high risk for developing carnitine deficiency. Carnitine deficiency impairs the important metabolic processes of the liver, such as gluconeogenesis, fatty acid metabolism, albumin biosynthesis, and ammonia detoxification by the urea cycle, and causes hypoalbuminemia and hyperammonemia. Carnitine deficiency should be suspected in liver cirrhotic patients with severe malaise, hepatic encephalopathy, sarcopenia, muscle cramps, and so on. Importantly, the blood carnitine level does not always decrease in patients with liver cirrhosis, and it sometimes exceeds the normal level. Therefore, patients with liver cirrhosis should be treated as if they are in a state of relative carnitine deficiency at the liver, skeletal muscle, and mitochondrial levels, even if the blood carnitine level is not decreased. Recent clinical trials have revealed the effectiveness of carnitine supplementation for the complications of liver cirrhosis, such as hepatic encephalopathy, sarcopenia, and muscle cramps. In conclusion, carnitine deficiency is not always rare in liver cirrhosis, and it requires constant attention in the daily medical care of this disease. Carnitine supplementation might be an important strategy for improving the quality of life of patients with liver cirrhosis.
Collapse
Affiliation(s)
- Tatsunori Hanai
- Correspondence: ; Tel.: +81-(58)-230-6308; Fax: +81-(58)-230-6310
| | | | | | | | | | | |
Collapse
|
35
|
Warrillow S, Fisher C, Bellomo R. Correction and Control of Hyperammonemia in Acute Liver Failure: The Impact of Continuous Renal Replacement Timing, Intensity, and Duration. Crit Care Med 2020; 48:218-224. [PMID: 31939790 DOI: 10.1097/ccm.0000000000004153] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Hyperammonemia is a key contributing factor for cerebral edema in acute liver failure. Continuous renal replacement therapy may help reduce ammonia levels. However, the optimal timing, mode, intensity, and duration of continuous renal replacement therapy in this setting are unknown. We aimed to study continuous renal replacement therapy use in acute liver failure patients and to assess its impact on hyperammonemia. DESIGN Retrospective observational study. SETTING ICU within a specialized liver transplant hospital. PATIENTS Fifty-four patients with acute liver failure. INTERVENTIONS Data were obtained from medical records and analyzed for patient characteristics, continuous renal replacement therapy use, ammonia dynamics, and outcomes. MAIN RESULTS Forty-five patients (83%) had high grade encephalopathy. Median time to continuous renal replacement therapy commencement was 4 hours (interquartile range, 2-4.5) with 35 (78%) treated with continuous venovenous hemodiafiltration and 10 (22%) with continuous venovenous hemofiltration. Median hourly effluent flow rate was 43 mL/kg (interquartile range, 37-62). The median ammonia concentration decreased every day during treatment from 151 µmol/L (interquartile range, 110-204) to 107 µmol/L (interquartile range, 84-133) on day 2, 75 µmol/L (interquartile range, 63-95) on day 3, and 52 µmol/L (interquartile range, 42-70) (p < 0.0001) on day 5. The number of patients with an ammonia level greater than 150 µmol/L decreased on the same days from 26, to nine, then two, and finally none. Reductions in ammonia levels correlated best with the cumulative duration of therapy hours (p = 0.03), rather than hourly treatment intensity. CONCLUSIONS Continuous renal replacement therapy is associated with reduced ammonia concentrations in acute liver failure patients. This effect is related to greater cumulative dose. These findings suggest that continuous renal replacement therapy initiated early and continued or longer may represent a useful approach to hyperammonemia control in acute liver failure patients.
Collapse
Affiliation(s)
- Stephen Warrillow
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
- Critical Care Institute, Epworth HealthCare, Melbourne, VIC, Australia
- Centre for Integrated Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Caleb Fisher
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
- Centre for Integrated Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital and University of Melbourne, Melbourne, VIC, Australia
| |
Collapse
|
36
|
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
| |
Collapse
|
37
|
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.
Collapse
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
| |
Collapse
|
38
|
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.
Collapse
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.
| |
Collapse
|
39
|
Abstract
The capacity to metabolize proteins is closely related to the hepatic functional reserve in patients with chronic liver disease, and hypoalbuminemia and hyperammonemia develop along with hepatic disease progression. Zinc deficiency, which is frequently observed in patients with chronic liver disease, significantly affects protein metabolism. Ornithine transcarbamylase is a zinc enzyme involved in the urea cycle. Its activity decreases because of zinc deficiency, thereby reducing hepatic capacity to metabolize ammonia. Because the glutamine-synthesizing system in skeletal muscles compensates for the decrease in ammonia metabolism, hyperammonemia does not develop in the early stages of chronic liver disease. However, branched-chain amino acids (BCAAs) are consumed with the increase in glutamine-synthesizing system reactions, leading to a decreased capacity to synthesize proteins, including albumin, due to amino acid imbalance. Upon further disease progression, skeletal muscle mass decreases because of nutritional deficiency, as well as the further decreased capacity to metabolize ammonia in the liver, whereby the capacity to detoxify ammonia reduces as a whole, resulting in hyperammonemia. BCAA supplementation therapy for nutritional deficiency in liver cirrhosis improves survival by correcting amino acid imbalance via recovery of the capacity to synthesize albumin, while zinc supplementation therapy improves the capacity to metabolize ammonia in the liver. Here, the efficacy of a combination of BCAA and zinc preparation for nutritional deficiency in liver cirrhosis, as well as its theoretical background, was reviewed.
Collapse
Affiliation(s)
- Kazuhiro Katayama
- Department of Hepato-Biliary and Pancreatic Oncology, Osaka, International Cancer Institute, Osaka, Japan.
| |
Collapse
|
40
|
Affiliation(s)
- Johannes Häberle
- Division of Metabolism, University Children's Hospital Zurich, Zurich, Switzerland
| | - Beat Thöny
- Division of Metabolism, University Children's Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
41
|
Abstract
RATIONALE Adult hyperammonemia is most often the result of hepatic dysfunction. Hyperammonemia in the setting of normal hepatic function is a much less common phenomenon and has usually been associated with medications and certain disease states. Here, we present an unusual case of severe hyperammonemia caused physiologically by intense muscle activity in a patient lacking any evidence of liver disease. PATIENT CONCERNS A 36-year-old woman was brought to the emergency department for a suicide attempt after being found covered in Lysol and Clorox germicidal bleach. She was noted to be in a state of violent psychosis with extreme agitation and had to be sedated and intubated for airway protection. DIAGNOSIS AND INTERVENTIONS Initial labs revealed hyperammonemia, lactic acidosis, and anion gap metabolic acidosis. Aminotransferases, bilirubin, and creatine kinase (CK) were normal. Renal function, prothrombin time, activated partial thromboplastin time, and international normalized ratio were also unremarkable and remained so at 24 hours. Ethyl alcohol, acetaminophen, salicylate, and valproic acid were all undetectable in blood. She received 2 doses of lactulose overnight, with a subsequent bowel movement. Next day, her mentation, serum ammonia level, and lactic acid level were back to normal, and she was extubated. Aminotransferases and CK levels were elevated but improved with supportive care. A detailed history and relevant biochemical investigations were unremarkable for any other etiology of hyperammonemia including the common inborn errors of metabolism (IEM). The combination of clinical findings of extreme skeletal muscle activity along with hyperammonemia and lactic acidosis, and subsequently rhabdomyolysis in the setting of unremarkable history and otherwise normal hepatic function strongly suggest the myokinetic origin of hyperammonemia in the patient. OUTCOME The patient recovered well with supportive care and was discharged on day 5. LESSONS This unique case illustrates the important role of skeletal muscle in the human metabolism of ammonia. In our discussion, we also elucidate the underlying pathophysiology, with the objective of improving clinician understanding of various differential diagnoses.
Collapse
Affiliation(s)
| | - Haneesh Jasuja
- Materials and Nanotechnology Program, North Dakota State University, Fargo, ND
| |
Collapse
|
42
|
Soria LR, Brunetti-Pierri N. Ammonia and autophagy: An emerging relationship with implications for disorders with hyperammonemia. J Inherit Metab Dis 2019; 42:1097-1104. [PMID: 30671986 DOI: 10.1002/jimd.12061] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 10/04/2018] [Accepted: 01/16/2019] [Indexed: 12/11/2022]
Abstract
(Macro)autophagy/autophagy is a highly regulated lysosomal degradative process by which cells recycle their own nutrients, such as amino acids and other metabolites, to be reused in different biosynthetic pathways. Ammonia is a diffusible compound generated daily from catabolism of nitrogen-containing molecules and from gastrointestinal microbiome. Ammonia homeostasis is tightly controlled in humans and ammonia is efficiently converted by the healthy liver into non-toxic urea (through ureagenesis) and glutamine (through glutamine synthetase). Impaired ammonia detoxification leads to systemic hyperammonemia, a life-threatening condition resulting in detrimental effects on central nervous system. Here, we review current understanding on the role of ammonia in modulation of autophagy and the potential implications in the pathogenesis and treatment of disorders with hyperammonemia.
Collapse
Affiliation(s)
- Leandro R Soria
- Telethon Institute of Genetics and Medicine, Pozzuoli, Italy
| | - Nicola Brunetti-Pierri
- Telethon Institute of Genetics and Medicine, Pozzuoli, Italy
- Department of Translational Medicine, Federico II University, Naples, Italy
| |
Collapse
|
43
|
Stepien KM, Geberhiwot T, Hendriksz CJ, Treacy EP. Challenges in diagnosing and managing adult patients with urea cycle disorders. J Inherit Metab Dis 2019; 42:1136-1146. [PMID: 30932189 DOI: 10.1002/jimd.12096] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [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: 10/23/2018] [Accepted: 03/28/2019] [Indexed: 12/15/2022]
Abstract
Urea cycle disorders (UCD) are a group of rare inherited metabolic conditions of amino acid catabolism caused by an enzyme deficiency within the hepatic ammonia detoxification pathway. The presentation of these disorders ranges from life-threatening intoxication in the neonate to asymptomatic status in adults. Late-onset UCDs can present for the first time in adulthood and may mimic other causes of acute confusion or psychiatric diseases, and are often associated with neurological symptoms. Late-onset UCDs may become apparent during periods of metabolic stress such as rapid weight loss, gastric bypass surgery, chronic starvation or the postpartum period. Early diagnosis is critical for effective treatment and to prevent long-term complications of hyperammonemia. The challenges of management of adults include for example: (a) poor compliance to dietary and medical treatment which can result in recurrent hospital admissions; (b) severe neurological dysfunction; (c) the management of pregnancy and the postpartum period; and (d) access to multidisciplinary care peri-operatively. In this review, we highlight a number of challenges in the diagnosis and management of adult patient with late-onset UCDs and suggest a systematic management approach.
Collapse
Affiliation(s)
- Karolina M Stepien
- Mark Holland Metabolic Unit, Adult Inherited Metabolic Diseases Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Tarekegn Geberhiwot
- Centre for Endocrinology, Diabetes and Metabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Christian J Hendriksz
- Department of Paediatrics, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Eileen P Treacy
- National Centre for Inherited Metabolic Diseases, The Mater Misericordiae University Hospital, Dublin, Ireland
- Department of Paediatrics, Trinity College, Dublin, Ireland
| |
Collapse
|
44
|
Tokumoto K, Kikukawa T, Saeki M, Nishio M, Nishitani N. [A case of acute hyperammonemic encephalopathy with extensive cortical high-intensity lesions in diffusion weighted imaging]. Rinsho Shinkeigaku 2019; 59:659-661. [PMID: 31564702 DOI: 10.5692/clinicalneurol.cn-001310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
A 49-year-old woman with hepatic failure owing to alcoholic liver cirrhosis went into a deep coma. Her serum ammonia concentration was elevated at 436 μg/dl, and she had a generalized convulsion. Electroencephalogram and cerebrospinal fluid examination did not suggest encephalitis and epilepsy. Hyperammonemia may be occur because of generalized convulsions; however, it can spontaneously resolve if the convulsions are stopped. If hyperammonemia is the primary cause of generalized convulsion, the serum ammonia concentration will remain high until the cause is eliminated. However, despite stopping the convulsions, her ammonia concentration remained high. Diffusion-weighted brain MRI revealed symmetric high-intensity lesions in the frontal, temporal, and parietal cortices, especially the cingulate and insular cortices of the bilateral hemispheres. These findings were in line with those of previous reports that revealed symmetric cortical lesions, including cingulate and insula cortices that are distinctive in acute hyperammonemic encephalopathy. Therefore, we diagnosed that the coma, generalized convulsions, and abnormal brain MRI findings were caused by acute hyperammonemic encephalopathy.
Collapse
Affiliation(s)
- Kazuki Tokumoto
- Department of Neurology, Bellland General Hospital, Osaka, Japan
| | | | - Masashi Saeki
- Department of Neurology, Bellland General Hospital, Osaka, Japan
| | - Motonobu Nishio
- Department of Neurology, Bellland General Hospital, Osaka, Japan
| | | |
Collapse
|
45
|
Lu K, Zimmermann M, Görg B, Bidmon HJ, Biermann B, Klöcker N, Häussinger D, Reichert AS. Hepatic encephalopathy is linked to alterations of autophagic flux in astrocytes. EBioMedicine 2019; 48:539-553. [PMID: 31648987 PMCID: PMC6838440 DOI: 10.1016/j.ebiom.2019.09.058] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [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: 03/13/2019] [Revised: 09/18/2019] [Accepted: 09/19/2019] [Indexed: 02/07/2023] Open
Abstract
Background Hepatic encephalopathy (HE) is a severe neuropsychiatric syndrome caused by various types of liver failure resulting in hyperammonemia-induced dysfunction of astrocytes. It is unclear whether autophagy, an important pro-survival pathway, is altered in the brains of ammonia-intoxicated animals as well as in HE patients. Methods Using primary rat astrocytes, a co-culture model of primary mouse astrocytes and neurons, an in vivo rat HE model, and post mortem brain samples of liver cirrhosis patients with HE we analyzed whether and how hyperammonemia modulates autophagy. Findings We show that autophagic flux is efficiently inhibited after administration of ammonia in astrocytes. This occurs in a fast, reversible, time-, dose-, and ROS-dependent manner and is mediated by ammonia-induced changes in intralysosomal pH. Autophagic flux is also strongly inhibited in the cerebral cortex of rats after acute ammonium intoxication corroborating our results using an in vivo rat HE model. Transglutaminase 2 (TGM2), a factor promoting autophagy, is upregulated in astrocytes of in vitro- and in vivo-HE models as well as in post mortem brain samples of liver cirrhosis patients with HE, but not in patients without HE. LC3, a commonly used autophagy marker, is significantly increased in the brain of HE patients. Ammonia also modulated autophagy moderately in neuronal cells. We show that taurine, known to ameliorate several parameters caused by hyperammonemia in patients suffering from liver failure, is highly potent in reducing ammonia-induced impairment of autophagic flux. This protective effect of taurine is apparently not linked to inhibition of mTOR signaling but rather to reducing ammonia-induced ROS formation. Interpretation Our data support a model in which autophagy aims to counteract ammonia-induced toxicity, yet, as acidification of lysosomes is impaired, possible protective effects thereof, are hampered. We propose that modulating autophagy in astrocytes and/or neurons, e.g. by taurine, represents a novel strategy to treat liver diseases associated with HE. Funding Supported by the DFG, CRC974 “Communication and Systems Relevance in Liver Injury and Regeneration“, Düsseldorf (Project number 190586431) Projects A05 (DH), B04 (BG), B05 (NK), and B09 (ASR).
Collapse
Affiliation(s)
- Kaihui Lu
- Institute of Biochemistry and Molecular Biology I, Heinrich Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Marcel Zimmermann
- Institute of Biochemistry and Molecular Biology I, Heinrich Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Boris Görg
- Department of Gastroenterology, Hepatology and Infectious Diseases, Heinrich Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Hans-Jürgen Bidmon
- C. & O. Vogt Institute for Brain Research, Heinrich Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Barbara Biermann
- Institute of Neural and Sensory Physiology, Heinrich Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Nikolaj Klöcker
- Institute of Neural and Sensory Physiology, Heinrich Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Dieter Häussinger
- Department of Gastroenterology, Hepatology and Infectious Diseases, Heinrich Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Andreas S Reichert
- Institute of Biochemistry and Molecular Biology I, Heinrich Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany.
| |
Collapse
|
46
|
Driessen LM, du Pré BC, Schuit SCE, Langendonk JG, Zandbergen AAM, Wagenmakers MAEM. [Reduced consciousness levels caused by hyperammonaemia]. Ned Tijdschr Geneeskd 2019; 163:D4013. [PMID: 31609561] [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: 06/10/2023]
Abstract
Hyperammonaemia is an important cause of lethargy. In this article, we describe a lesser-known but potential fatal cause of hyperammonaemia. A 27-year-old woman presented with lethargy caused by hyperammonaemia. She was treated with the emergency regime that is used to treat hyperammonaemia in urea cycle defects. Although this effectively lowered the ammonia levels, the clinical situation of the patient initially deteriorated and she was transferred to the Intensive Care Unit and intubated. Urine culture identified Proteus mirabilis, a urea-splitting bacterium that caused the hyperammonaemia. Prompt and adequate treatment with antibiotics and adequate drainage of urine was started and she completely recovered. Although every patient can get hyperammonaemia caused by urinary tract infection with urea-splitting bacteria, patients with structural bladder abnormalities are at greater risk. Lethargy can be the only presenting symptom. When recognized early, it is quite treatable and has a good prognosis.
Collapse
|
47
|
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.
Collapse
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
| |
Collapse
|
48
|
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
| | | | | |
Collapse
|
49
|
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.
Collapse
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
| |
Collapse
|
50
|
van Son J, Rietbroek RC, Vaz FM, Hollak CEM. Bizarre behavior and decreased level of consciousness in an adult patient. Neth J Med 2019; 77:25-28. [PMID: 30774101] [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: 06/09/2023]
Abstract
This case report presents an adult patient with decreased levels of consciousness and bizarre behavior. A silent delirium was first suspected however, symptoms did not improve and further examination revealed elevated ammonia levels. A hepatic cause and portosystemic shunting were excluded and eventually a diagnosis of ornithine transcarbamylase deficiency was made. After treatment with high carbohydrate intake, a low protein diet and supplementation with arginine and sodium benzoate, the patient recovered.
Collapse
Affiliation(s)
- J van Son
- Red Cross Hospital, Beverwijk, the Netherlands
| | | | | | | |
Collapse
|