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Nagarur A, Pierce TT, Fenves AZ, Witkowski ER, Gold NB. Case 30-2023: A 50-Year-Old Woman with Confusion. N Engl J Med 2023; 389:1221-1230. [PMID: 37754288 DOI: 10.1056/nejmcpc2300907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Affiliation(s)
- Amulya Nagarur
- From the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Massachusetts General Hospital, and the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Harvard Medical School - both in Boston
| | - Theodore T Pierce
- From the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Massachusetts General Hospital, and the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Harvard Medical School - both in Boston
| | - Andrew Z Fenves
- From the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Massachusetts General Hospital, and the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Harvard Medical School - both in Boston
| | - Elan R Witkowski
- From the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Massachusetts General Hospital, and the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Harvard Medical School - both in Boston
| | - Nina B Gold
- From the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Massachusetts General Hospital, and the Departments of Medicine (A.N., A.Z.F.), Radiology (T.T.P.), Surgery (E.R.W.), and Pediatrics (N.B.G.), Harvard Medical School - both in Boston
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Ibrahim MS, Gold JI, Woodall A, Yilmaz BS, Gissen P, Stepien KM. Diagnostic and Management Issues in Patients with Late-Onset Ornithine Transcarbamylase Deficiency. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1368. [PMID: 37628367 PMCID: PMC10453542 DOI: 10.3390/children10081368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 07/24/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023]
Abstract
Ornithine transcarbamylase deficiency (OTCD) is the most common inherited disorder of the urea cycle and, in general, is transmitted as an X-linked recessive trait. Defects in the OTC gene cause an impairment in ureagenesis, resulting in hyperammonemia, which is a direct cause of brain damage and death. Patients with late-onset OTCD can develop symptoms from infancy to later childhood, adolescence or adulthood. Clinical manifestations of adults with OTCD vary in acuity. Clinical symptoms can be aggravated by metabolic stressors or the presence of a catabolic state, or due to increased demands upon the urea. A prompt diagnosis and relevant biochemical and genetic investigations allow the rapid introduction of the right treatment and prevent long-term complications and mortality. This narrative review outlines challenges in diagnosing and managing patients with late-onset OTCD.
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Affiliation(s)
- Majitha Seyed Ibrahim
- Department of Chemical Pathology, Teaching Hospital Batticaloa, Batticaloa 30000, Sri Lanka
| | - Jessica I. Gold
- Division of Human Genetics, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Alison Woodall
- Adult Inherited Metabolic Diseases, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
| | - Berna Seker Yilmaz
- Great Ormond Street Institute of Child Health, University College London, London WC1E 6BT, UK
| | - Paul Gissen
- Great Ormond Street Institute of Child Health, University College London, London WC1E 6BT, UK
- Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JH, UK
- National Institute of Health Research, Great Ormond Street Biomedical Research Centre, London WC1N 1EH, UK
| | - Karolina M. Stepien
- Adult Inherited Metabolic Diseases, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
- Division of Cardiovascular Sciences, University of Manchester, Manchester M13 9PL, UK
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Rezvani M, Campbell KM, Prada CE, Peters AL. Early allograft dysfunction in a pediatric liver allograft with an occult pathogenic mutation in the urea cycle. Am J Transplant 2023; 23:673-675. [PMID: 36870389 DOI: 10.1016/j.ajt.2023.02.027] [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: 11/28/2022] [Revised: 02/17/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023]
Abstract
Liver transplantation risks transferring a genetic defect in metabolic pathways, including the urea cycle. We present a case of pediatric liver transplantation complicated by metabolic crisis and early allograft dysfunction (EAD) in a previously healthy unrelated deceased donor. Allograft function improved with supportive care, and retransplantation was avoided. Because hyperammonemia suggested an enzymatic defect in the allograft, genetic testing from donor-derived deoxyribonucleic acid revealed a heterozygous mutation in the ASL gene, which encodes the urea cycle enzyme argininosuccinate lyase. Homozygous ASL mutations precipitate metabolic crises during fasting or postoperative states, whereas heterozygous carriers retain sufficient enzyme activity and are asymptomatic. In the described case, postoperative ischemia/reperfusion injury created a metabolic demand that exceeded the enzymatic capacity of the allograft. To our knowledge, this is the first report of an acquired argininosuccinate lyase deficiency by liver transplantation and underscores the importance of considering occult metabolic variants in the allograft during EAD.
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Affiliation(s)
- Milad Rezvani
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Pediatric Gastroenterology, Nephrology and Metabolic Medicine, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
| | - Kathleen M Campbell
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Carlos E Prada
- Division of Genetics, Genomics and Metabolism, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Anna L Peters
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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4
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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: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [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.
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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
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5
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Aggarwal N, Kitano S, Puah GRY, Kittelmann S, Hwang IY, Chang MW. Microbiome and Human Health: Current Understanding, Engineering, and Enabling Technologies. Chem Rev 2022; 123:31-72. [PMID: 36317983 PMCID: PMC9837825 DOI: 10.1021/acs.chemrev.2c00431] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The human microbiome is composed of a collection of dynamic microbial communities that inhabit various anatomical locations in the body. Accordingly, the coevolution of the microbiome with the host has resulted in these communities playing a profound role in promoting human health. Consequently, perturbations in the human microbiome can cause or exacerbate several diseases. In this Review, we present our current understanding of the relationship between human health and disease development, focusing on the microbiomes found across the digestive, respiratory, urinary, and reproductive systems as well as the skin. We further discuss various strategies by which the composition and function of the human microbiome can be modulated to exert a therapeutic effect on the host. Finally, we examine technologies such as multiomics approaches and cellular reprogramming of microbes that can enable significant advancements in microbiome research and engineering.
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Affiliation(s)
- Nikhil Aggarwal
- NUS
Synthetic Biology for Clinical and Technological Innovation (SynCTI), National University of Singapore, Singapore 117456, Singapore,Synthetic
Biology Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117456, Singapore
| | - Shohei Kitano
- NUS
Synthetic Biology for Clinical and Technological Innovation (SynCTI), National University of Singapore, Singapore 117456, Singapore,Synthetic
Biology Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117456, Singapore
| | - Ginette Ru Ying Puah
- NUS
Synthetic Biology for Clinical and Technological Innovation (SynCTI), National University of Singapore, Singapore 117456, Singapore,Synthetic
Biology Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117456, Singapore,Wilmar-NUS
(WIL@NUS) Corporate Laboratory, National
University of Singapore, Singapore 117599, Singapore,Wilmar
International Limited, Singapore 138568, Singapore
| | - Sandra Kittelmann
- Wilmar-NUS
(WIL@NUS) Corporate Laboratory, National
University of Singapore, Singapore 117599, Singapore,Wilmar
International Limited, Singapore 138568, Singapore
| | - In Young Hwang
- NUS
Synthetic Biology for Clinical and Technological Innovation (SynCTI), National University of Singapore, Singapore 117456, Singapore,Synthetic
Biology Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117456, Singapore,Department
of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117596, Singapore,Singapore
Institute of Technology, Singapore 138683, Singapore
| | - Matthew Wook Chang
- NUS
Synthetic Biology for Clinical and Technological Innovation (SynCTI), National University of Singapore, Singapore 117456, Singapore,Synthetic
Biology Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117456, Singapore,Wilmar-NUS
(WIL@NUS) Corporate Laboratory, National
University of Singapore, Singapore 117599, Singapore,Department
of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117596, Singapore,E-mail:
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Delgado TC, de las Heras J, Martínez-Chantar ML. Understanding gut-liver axis nitrogen metabolism in Fatty Liver Disease. Front Endocrinol (Lausanne) 2022; 13:1058101. [PMID: 36589817 PMCID: PMC9797658 DOI: 10.3389/fendo.2022.1058101] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2022] Open
Abstract
The homeostasis of the most important nitrogen-containing intermediates, ammonia and glutamine, is a tightly regulated process in which the gut-liver axis plays a central role. Several studies revealed that nitrogen metabolism is altered in Metabolic Dysfunction-Associated Fatty Liver Disease (MAFLD), a consensus-driven novel nomenclature for Non-Alcoholic Fatty Liver Disease (NAFLD), the most common chronic liver disease worldwide. Both increased ammonia production by gut microbiota and decreased ammonia hepatic removal due to impaired hepatic urea cycle activity or disrupted glutamine synthetase activity may contribute to hepatic ammonia accumulation underlying steatosis, which can eventually progress to hyperammonemia in more advanced stages of steatohepatitis and overt liver fibrosis. Furthermore, our group recently showed that augmented hepatic ammoniagenesis via increased glutaminase activity and overexpression of the high activity glutaminase 1 isoenzyme occurs in Fatty Liver Disease. Overall, the improved knowledge of disrupted nitrogen metabolism and metabolic miscommunication between the gut and the liver suggests that the reestablishment of altered gut-liver axis nitrogenous balance is an appealing and attractive therapeutic approach to tackle Fatty Liver Disease, a growing and unmet health problem.
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Affiliation(s)
- Teresa C. Delgado
- Liver Disease Lab, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Derio, Bizkaia, Spain
- Congenital Metabolic Disorders, Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- *Correspondence: Teresa C. Delgado,
| | - Javier de las Heras
- Congenital Metabolic Disorders, Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Division of Pediatric Metabolism, Department of Pediatrics, CIBERer, Cruces University Hospital, Barakaldo, Spain
- Department of Pediatrics, University of the Basque Country (UPV/EHU), Leioa, Spain
| | - María L. Martínez-Chantar
- Liver Disease Lab, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Derio, Bizkaia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Carlos III National Health Institute, Madrid, Spain
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