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Meier C, Burns K, Manolikos C, Fatovich D, Bell DA. Hyperammonaemia: review of the pathophysiology, aetiology and investigation. Pathology 2024; 56:763-772. [PMID: 39127541 DOI: 10.1016/j.pathol.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 06/14/2024] [Accepted: 06/18/2024] [Indexed: 08/12/2024]
Abstract
Acute hyperammonaemia is a medical emergency as it can progress to cerebral oedema, seizures, coma and death. Hepatic encephalopathy secondary to cirrhotic disease or portosystemic shunting are relatively well-known causes, but non-cirrhotic aetiologies of acute hyperammonaemia are less well-known, especially in the emergency department. However, an elevated ammonia is not required to make the diagnosis of hepatic encephalopathy. Although measurement of plasma ammonia is recommended for patients with acute, unexplained, altered mental status, as early identification allows early effective management which may prevent irreversible brain damage, there is currently reduced awareness among physicians of the non-cirrhotic aetiologies of acute hyperammonaemia. Furthermore, measurement of ammonia in patients with cirrhosis has been shown to have low sensitivity and specificity, and not to have altered management in the majority of cases; thus, measurement of ammonia is currently not recommended in guidelines for management of hepatic encephalopathy. We sought to describe the pathophysiology of hyperammonaemia and review the non-cirrhotic causes. This was achieved by review of MEDLINE, PubMed and Web of Science databases to include published English literature within the last 20 years. We also present a framework for investigating the acute non-cirrhotic causes of hyperammonaemia to assist both chemical pathologists and clinicians managing these often challenging cases.
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Affiliation(s)
- Ciselle Meier
- The University of Western Australia, Perth, WA, Australia
| | - Kharis Burns
- The University of Western Australia, Perth, WA, Australia; Inborn Errors of Metabolism Service, Department of Endocrinology, Royal Perth Hospital, Perth, WA, Australia
| | - Catherine Manolikos
- Inborn Errors of Metabolism Service, Department of Endocrinology, Royal Perth Hospital, Perth, WA, Australia
| | - Daniel Fatovich
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia; Emergency Department, Royal Perth Hospital, The University of Western Australia, Perth, WA, Australia
| | - Damon A Bell
- The University of Western Australia, Perth, WA, Australia; Inborn Errors of Metabolism Service, Department of Endocrinology, Royal Perth Hospital, Perth, WA, Australia; PathWest Laboratory Medicine, Department of Biochemistry, Fiona Stanley Hospital Network, Perth, WA, Australia.
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Zhao R, Han M, Lin S, Lin Z, Yu M, Zhang B, Ma L, Li D, Peng L. Adverse drug events associated with fluorouracil use in patients with metastatic colorectal cancer: a real-world pharmacovigilance study based on the FDA adverse event reporting system. Expert Opin Drug Saf 2024:1-13. [PMID: 39010662 DOI: 10.1080/14740338.2024.2380513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 07/02/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Fluorouracil (5-FU) is widely used to treat metastatic colorectal cancer (mCRC), but real-world safety data is limited. Our study aimed to evaluate 5-FU's safety profile in a large mCRC population using the FAERS database. RESEARCH DESIGN AND METHODS We conducted disproportionality analyses to identify adverse drug events associated with 5-FU use in mCRC patients from 2004 to 2023. Subgroup analyses, gender difference analyses, and logistic regression were also performed. RESULTS We identified 1,458 reports with 5-FU as the primary suspected drug, with males accounting for 48.8% of reports. Gastrointestinal disorders were the most common adverse event (864 cases), while pregnancy-related conditions showed the strongest signal intensity (ROR = 2.97). We found 19 preferred terms with positive signals, including ischemic hepatitis (ROR = 59.32), blood iron increased (ROR = 59.32), and stress cardiomyopathy (ROR = 51.94). Males were more susceptible to weight loss and skin toxicity. Most adverse events occurred within the first month of 5-FU administration. CONCLUSION Our study provides a comprehensive analysis of 5-FU's safety profile in mCRC patients, helping healthcare professionals mitigate risks in clinical practice.
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Affiliation(s)
- Ruiqi Zhao
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, Guangdong, China
| | - Mengyao Han
- The Second Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Sen Lin
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, Guangdong, China
| | - Zhimei Lin
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, Guangdong, China
| | - Mengjiao Yu
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, Guangdong, China
| | - Bei Zhang
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, Guangdong, China
| | - Lanyue Ma
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, Guangdong, China
| | - Danfei Li
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, Guangdong, China
| | - Lisheng Peng
- Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, Guangdong, China
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Shakerdi L, Ryan A. Drug-induced hyperammonaemia. J Clin Pathol 2023:jcp-2022-208644. [PMID: 37164630 DOI: 10.1136/jcp-2022-208644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 04/28/2023] [Indexed: 05/12/2023]
Abstract
Hyperammonaemia (HA) as a consequence of numerous primary or secondary causes, gives rise to clinical manifestations due to its toxic effects on the brain. The neurological consequences broadly reflect the ammonia level, duration and age, with paediatric patients being more susceptible. Drug-induced HA may arise due to either decreased ammonia elimination or increased production. This is associated most frequently with use of valproate and presents a dilemma between ongoing therapeutic need, toxicity and the possibility of an alternative cause. As there is no specific test for drug-induced HA, prompt discussion with a metabolic physician is recommended, as the neurotoxic effects are time-dependent. Specific guidelines for managing drug-induced HA have yet to be published and hence the treatment approach outlined in this review reflects that outlined in relevant urea cycle disorder guidelines.
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Affiliation(s)
- Loai Shakerdi
- National Centre for Inherited Metabolic Disorders, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Aidan Ryan
- Chemical Pathology, Cork University Hospital Biochemistry Laboratory, Cork, Ireland
- Pathology, University College Cork College of Medicine and Health, Cork, Ireland
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Okamoto K, Nozawa H, Hongo K, Iida Y, Kawai K, Sasaki K, Murono K, Kita Y, Ishihara Y, Takabayashi N, Kobayashi R, Hiramatsu T, Ishihara S. Risk factors of mFOLFOX6-induced hyperammonemia in patients with colorectal cancer: an observational study. Int J Clin Oncol 2021; 26:1477-1484. [PMID: 33991268 DOI: 10.1007/s10147-021-01932-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 05/01/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND FOLFOX therapy, a standard treatment for colorectal cancer (CRC), causes a rare, but serious adverse event, hyperammonemia. However, the risk factors of hyperammonemia remain unknown. METHODS We examined 74 patients who received mFOLFOX6 therapy with or without biologics for CRC between April 2013 and March 2018 in Yaizu City Hospital. Clinicopathological factors were retrospectively reviewed in association with hyperammonemia, and risk factors of hyperammonemia during mFOLFOX6 therapy were analyzed in 32 patients with the available data. RESULTS Seven patients developed hyperammonemia, with onset exclusively on day 2 or 3 in the first cycle of therapy. They were treated with branched chain amino acid administration and hydration; however, one patient with stage G4 chronic kidney disease (CKD) died. By multivariate analysis, estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 was independently associated with hyperammonemia during FOLFOX therapy (odds ratio: 9.0, p = 0.040). CONCLUSIONS Reduced eGFR is considered a risk factor of developing hyperammonemia during FOLFOX therapy. Serum ammonia levels should be monitored especially during the first cycle of FOLFOX therapy in patients with CKD stage G3 or higher.
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Affiliation(s)
- Kazuaki Okamoto
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan. .,Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan.
| | - Hiroaki Nozawa
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kumiko Hongo
- Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan.,Department of Surgery, Hiratsuka City Hospital, 1-19-1, Minamihara, Hiratsuka-shi, Kanagawa, 254-0065, Japan
| | - Yuuki Iida
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.,Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan
| | - Kazushige Kawai
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kazuhito Sasaki
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Koji Murono
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yusuke Kita
- Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan
| | - Yukio Ishihara
- Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan
| | - Naoki Takabayashi
- Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan
| | - Ryo Kobayashi
- Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan
| | - Takeyuki Hiramatsu
- Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Marella HK, Peravali R, Jain AL, Nair S, Maliakkal B, Agbim U, Verma R. Hyperammonemic encephalopathy associated with 5-fluorouracil in a patient with previous orthotopic liver transplantation. Proc (Bayl Univ Med Cent) 2020; 33:256-257. [DOI: 10.1080/08998280.2019.1708689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/13/2019] [Accepted: 12/19/2019] [Indexed: 10/25/2022] Open
Affiliation(s)
- Hemnishil K. Marella
- Department of Gastroenterology and Hepatology, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Rahul Peravali
- Department of Gastroenterology and Hepatology, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Amit L. Jain
- Department of Gastroenterology and Hepatology, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Satheesh Nair
- Department of Gastroenterology and Hepatology, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Benedict Maliakkal
- Department of Gastroenterology and Hepatology, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Uchenna Agbim
- Department of Gastroenterology and Hepatology, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Rajanshu Verma
- Department of Gastroenterology and Hepatology, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
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