1
|
Ren Y, Zhang M, Fu X, Zhang Y, Liu F, Wu C, Shi H, Tian F, Liu G, Lin Y, Su Y, Chen W. Ketogenic diet treatment for super-refractory status epilepticus in the intensive care unit: feasibility, safety and effectiveness. Front Neurol 2025; 15:1517850. [PMID: 39871989 PMCID: PMC11769800 DOI: 10.3389/fneur.2024.1517850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2024] [Accepted: 12/24/2024] [Indexed: 01/29/2025] Open
Abstract
Background and aims To investigate the feasibility, safety and effectiveness of the ketogenic diet (KD) for super-refractory status epilepticus (SRSE) in the intensive care unit (ICU). Methods We conducted a prospective investigation on patients with SRSE treated with the KD. The primary outcome measures were ketosis development as a biomarker of feasibility and resolution of SRSE as effectiveness. KD-related side effects were also investigated. Results Twelve patients (9 females and 3 males) with SRSE, with a median age of 34 years [range 16-69, interquartile range (IQR) 18-52], were treated with a KD. The median duration of SRSE prior to KD treatment was 21 days (range 4-46). SRSE resolved in 75% (9/12) of patients at a median of 3 days (range 1-18) after KD initiation. Among the nine KD responders, all were successfully weaned off anesthetic agents at a median of 16 days (range 4-32) after KD initiation, and all were also successfully weaned off ventilator. Side effects varied, and included gastrointestinal intolerances, malnutrition and metabolic abnormalities, electrolyte disturbance, and acute weight loss, although most of them could be corrected. No patient died due to KD, and neurofunctions continued to improve under KD therapy. Conclusion The KD may be feasible and effective for the treatment of SRSE in the ICU. Moreover, it is relatively safe. However, there are numerous adverse events that can be corrected under close monitoring.
Collapse
Affiliation(s)
- Yishu Ren
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Mengyao Zhang
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Xinxiao Fu
- Department of Neurology, Qingyuan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Traditional Chinese Medicine, Qingyuan, China
| | - Yan Zhang
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Fang Liu
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Chenglin Wu
- Department of Neurology, Beijing Fengtai You’anmen Hospital, Beijing, China
| | - Haiyan Shi
- Department of Neurology, Beijing Fengtai You’anmen Hospital, Beijing, China
| | - Fei Tian
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Gang Liu
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Yicong Lin
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Yingying Su
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Weibi Chen
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| |
Collapse
|
2
|
Duraj T, Kalamian M, Zuccoli G, Maroon JC, D'Agostino DP, Scheck AC, Poff A, Winter SF, Hu J, Klement RJ, Hickson A, Lee DC, Cooper I, Kofler B, Schwartz KA, Phillips MCL, Champ CE, Zupec-Kania B, Tan-Shalaby J, Serfaty FM, Omene E, Arismendi-Morillo G, Kiebish M, Cheng R, El-Sakka AM, Pflueger A, Mathews EH, Worden D, Shi H, Cincione RI, Spinosa JP, Slocum AK, Iyikesici MS, Yanagisawa A, Pilkington GJ, Chaffee A, Abdel-Hadi W, Elsamman AK, Klein P, Hagihara K, Clemens Z, Yu GW, Evangeliou AE, Nathan JK, Smith K, Fortin D, Dietrich J, Mukherjee P, Seyfried TN. Clinical research framework proposal for ketogenic metabolic therapy in glioblastoma. BMC Med 2024; 22:578. [PMID: 39639257 PMCID: PMC11622503 DOI: 10.1186/s12916-024-03775-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 11/14/2024] [Indexed: 12/07/2024] Open
Abstract
Glioblastoma (GBM) is the most aggressive primary brain tumor in adults, with a universally lethal prognosis despite maximal standard therapies. Here, we present a consensus treatment protocol based on the metabolic requirements of GBM cells for the two major fermentable fuels: glucose and glutamine. Glucose is a source of carbon and ATP synthesis for tumor growth through glycolysis, while glutamine provides nitrogen, carbon, and ATP synthesis through glutaminolysis. As no tumor can grow without anabolic substrates or energy, the simultaneous targeting of glycolysis and glutaminolysis is expected to reduce the proliferation of most if not all GBM cells. Ketogenic metabolic therapy (KMT) leverages diet-drug combinations that inhibit glycolysis, glutaminolysis, and growth signaling while shifting energy metabolism to therapeutic ketosis. The glucose-ketone index (GKI) is a standardized biomarker for assessing biological compliance, ideally via real-time monitoring. KMT aims to increase substrate competition and normalize the tumor microenvironment through GKI-adjusted ketogenic diets, calorie restriction, and fasting, while also targeting glycolytic and glutaminolytic flux using specific metabolic inhibitors. Non-fermentable fuels, such as ketone bodies, fatty acids, or lactate, are comparatively less efficient in supporting the long-term bioenergetic and biosynthetic demands of cancer cell proliferation. The proposed strategy may be implemented as a synergistic metabolic priming baseline in GBM as well as other tumors driven by glycolysis and glutaminolysis, regardless of their residual mitochondrial function. Suggested best practices are provided to guide future KMT research in metabolic oncology, offering a shared, evidence-driven framework for observational and interventional studies.
Collapse
Affiliation(s)
- Tomás Duraj
- Biology Department, Boston College, Chestnut Hill, MA, 02467, USA.
| | | | - Giulio Zuccoli
- Neuroradiology, Private Practice, Philadelphia, PA, 19103, USA
| | - Joseph C Maroon
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Dominic P D'Agostino
- Department of Molecular Pharmacology and Physiology, University of South Florida Morsani College of Medicine, Tampa, FL, 33612, USA
| | - Adrienne C Scheck
- Department of Child Health, University of Arizona College of Medicine, Phoenix, Phoenix, AZ, 85004, USA
| | - Angela Poff
- Department of Molecular Pharmacology and Physiology, University of South Florida Morsani College of Medicine, Tampa, FL, 33612, USA
| | - Sebastian F Winter
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, 02114, USA
| | - Jethro Hu
- Cedars-Sinai Cancer, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Rainer J Klement
- Department of Radiotherapy and Radiation Oncology, Leopoldina Hospital Schweinfurt, 97422, Schweinfurt, Germany
| | | | - Derek C Lee
- Biology Department, Boston College, Chestnut Hill, MA, 02467, USA
| | - Isabella Cooper
- Ageing Biology and Age-Related Diseases Group, School of Life Sciences, University of Westminster, London, W1W 6UW, UK
| | - Barbara Kofler
- Research Program for Receptor Biochemistry and Tumor Metabolism, Department of Pediatrics, University Hospital of the Paracelsus Medical University, Müllner Hauptstr. 48, 5020, Salzburg, Austria
| | - Kenneth A Schwartz
- Department of Medicine, Michigan State University, East Lansing, MI, 48824, USA
| | - Matthew C L Phillips
- Department of Neurology, Waikato Hospital, Hamilton, 3204, New Zealand
- Department of Medicine, University of Auckland, Auckland, 1142, New Zealand
| | - Colin E Champ
- Exercise Oncology & Resiliency Center and Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, PA, 15212, USA
| | | | - Jocelyn Tan-Shalaby
- School of Medicine, University of Pittsburgh, Veteran Affairs Pittsburgh Healthcare System, Pittsburgh, PA, 15240, USA
| | - Fabiano M Serfaty
- Department of Clinical Medicine, State University of Rio de Janeiro (UERJ), Rio de Janeiro, RJ, 20550-170, Brazil
- Serfaty Clínicas, Rio de Janeiro, RJ, 22440-040, Brazil
| | - Egiroh Omene
- Department of Oncology, Cross Cancer Institute, Edmonton, AB, T6G 1Z2, Canada
| | - Gabriel Arismendi-Morillo
- Department of Medicine, Faculty of Health Sciences, University of Deusto, 48007, Bilbao (Bizkaia), Spain
- Facultad de Medicina, Instituto de Investigaciones Biológicas, Universidad del Zulia, Maracaibo, 4005, Venezuela
| | | | - Richard Cheng
- Cheng Integrative Health Center, Columbia, SC, 29212, USA
| | - Ahmed M El-Sakka
- Metabolic Terrain Institute of Health, East Congress Street, Tucson, AZ, 85701, USA
| | - Axel Pflueger
- Pflueger Medical Nephrologyand , Internal Medicine Services P.L.L.C, 6 Nelson Road, Monsey, NY, 10952, USA
| | - Edward H Mathews
- Department of Physiology, Faculty of Health Sciences, University of Pretoria, Pretoria, 0002, South Africa
| | | | - Hanping Shi
- Department of Gastrointestinal Surgery and Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Raffaele Ivan Cincione
- Department of Clinical and Experimental Medicine, University of Foggia, 71122, Foggia, Puglia, Italy
| | - Jean Pierre Spinosa
- Integrative Oncology, Breast and Gynecologic Oncology Surgery, Private Practice, Rue Des Terreaux 2, 1002, Lausanne, Switzerland
| | | | - Mehmet Salih Iyikesici
- Department of Medical Oncology, Altınbaş University Bahçelievler Medical Park Hospital, Istanbul, 34180, Turkey
| | - Atsuo Yanagisawa
- The Japanese College of Intravenous Therapy, Tokyo, 150-0013, Japan
| | | | - Anthony Chaffee
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Perth, 6009, Australia
| | - Wafaa Abdel-Hadi
- Clinical Oncology Department, Cairo University, Giza, 12613, Egypt
| | - Amr K Elsamman
- Neurosurgery Department, Cairo University, Giza, 12613, Egypt
| | - Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, 6410 Rockledge Drive, Suite 610, Bethesda, MD, 20817, USA
| | - Keisuke Hagihara
- Department of Advanced Hybrid Medicine, Graduate School of Medicine, Osaka University, Osaka, 565-0871, Japan
| | - Zsófia Clemens
- International Center for Medical Nutritional Intervention, Budapest, 1137, Hungary
| | - George W Yu
- George W, Yu Foundation For Nutrition & Health and Aegis Medical & Research Associates, Annapolis, MD, 21401, USA
| | - Athanasios E Evangeliou
- Department of Pediatrics, Medical School, Aristotle University of Thessaloniki, Papageorgiou Hospital, Efkarpia, 56403, Thessaloniki, Greece
| | - Janak K Nathan
- Dr. DY Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, 411018, India
| | - Kris Smith
- Barrow Neurological Institute, Dignity Health St. Joseph's Hospital and Medical Center, Phoenix, AZ, 85013, USA
| | - David Fortin
- Université de Sherbrooke, Sherbrooke, QC, J1K 2R1, Canada
| | - Jorg Dietrich
- Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, 02114, USA
| | | | | |
Collapse
|
4
|
Abdelrahim RA, Mekala SRR, Polepalli KV, Priyatha V, Ezeano C, AlEdani EM, Nassar ST. Nutritional Ketosis as a Therapeutic Approach in Critical Illness: A Systematic Review. Cureus 2024; 16:e65455. [PMID: 39071067 PMCID: PMC11281694 DOI: 10.7759/cureus.65455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 07/25/2024] [Indexed: 07/30/2024] Open
Abstract
Critical illness encompasses the dysfunction of vital organs, the risk of death, and potential reversibility; it is a major cause of morbidity and mortality globally. The pathophysiology underlying many critical illnesses includes bioenergetic failure, inflammation, and oxidative stress. This systematic review aims to explore the use of nutritional ketosis (ketogenic feeds and exogenous ketone body administration) as a potential therapy, affecting the aforementioned pathways in patients with critical illnesses. This study was conducted, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The search was conducted, systematically using PubMed, PubMed Central (PMC), Google Scholar, and the ScienceDirect databases in February 2024. The inclusion criteria were set to free full-text articles published within the past five years: human and animal studies, literature reviews, systematic reviews, meta-analyses, observational studies, randomized controlled trials, case reports, book chapters, gray literature, studies investigating adult samples, and articles in the English language. Exclusion criteria included pediatric studies as the topic has been studied more extensively in children, and this review aims to explore potential benefits in adult patients. The search was conducted through four databases; after the screening process, the remaining studies were assessed through quality appraisal tools appropriate to each study type. In the end, 11 studies were selected, including eight narrative reviews, one cohort study, one animal study, and one randomized controlled trial. The results of this review demonstrated that nutritional ketosis has potential safe and effective benefits for humans and animals. Nutritional ketosis shows therapeutic benefits for a vast variety of complications commonly associated with critical illness, status epilepticus, sepsis, viral infections, and glycemic control. In the end, both randomized and nonrandomized clinical trials are necessary for more conclusive findings.
Collapse
Affiliation(s)
- Rana A Abdelrahim
- Medicine, The Royal College of Surgeons in Ireland-Bahrain, Busaiteen, BHR
| | - Sai Rohit R Mekala
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, USA
- School of Medicine, Armed forces Medical College, Pune, IND
| | - Krishna V Polepalli
- Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Vemparala Priyatha
- Internal Medicine, All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar, IND
| | - Chimezirim Ezeano
- Department of Pediatrics and Women's Health, University of North Texas Health Science Center, Fort Worth, USA
| | - Esraa M AlEdani
- Dermatology, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Sondos T Nassar
- Medicine and Surgery, Jordan University of Science and Technology, Amman, JOR
| |
Collapse
|
7
|
Chen Y, Rong S, Luo H, Huang B, Hu F, Chen M, Li C. Ketogenic Diet Attenuates Refractory Epilepsy of Harel-Yoon Syndrome With ATAD3A Variants: A Case Report and Review of Literature. Pediatr Neurol 2023; 143:79-83. [PMID: 37031571 DOI: 10.1016/j.pediatrneurol.2023.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 02/07/2023] [Accepted: 03/04/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Harel-Yoon syndrome is a disease caused by variants in the ATAD3A gene, which manifest as global developmental delay, hypotonia, intellectual disability, and axonal neuropathy. The aim of this study is to summarize the clinical and gene mutation characteristics of a child with refractory epilepsy caused by ATAD3A gene mutation. METHODS The whole-exome sequencing combined with copy number variation analysis could help to understand the genetic diversity and underlying disease mechanisms in ATAD3A gene mutation. RESULTS We report a Chinese boy with Harel-Yoon syndrome presenting with refractory epilepsy, hypotonia, global developmental delay, and congenital cataract through whole-exome sequencing. Genetic analysis showed a missense mutation, c.251T>C(p.Thr84Met) in the ATAD3A gene (NM_001170535.1). Further copy number variation analysis identified a novel heterozygous deletion on chromosome1p36.33, which spans ATAD3A exon 1 and 2 regions. Multiple antiepileptic drugs failed to control his seizures. Eventually, seizure was controlled through ketogenic diet (KD). CONCLUSION Our case shows the potential diagnostic role of whole-exome sequencing in Harel-Yoon syndrome and expands the ATAD3A gene mutation spectrum. Multiple antiepileptic drugs failed to control refractory epilepsy in Harel-Yoon syndrome. The KD therapy may be effective for patients with refractory epilepsy who carry the ATAD3A variants.
Collapse
Affiliation(s)
- Yinhui Chen
- Department of Pediatrics, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong Province, People's Republic of China
| | - Shiwen Rong
- Department of Pediatrics, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong Province, People's Republic of China
| | - Han Luo
- Department of Pediatrics, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong Province, People's Republic of China
| | - Binglong Huang
- Department of Pediatrics, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong Province, People's Republic of China
| | - Fang Hu
- Department of Pediatrics, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong Province, People's Republic of China
| | - Min Chen
- Department of Pediatrics, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong Province, People's Republic of China
| | - Chengyan Li
- Department of Pediatrics, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong Province, People's Republic of China.
| |
Collapse
|