Removal of branched-chain amino acids and alpha-ketoisocaproate by haemofiltration and haemodiafiltration

Metabolic crisis in maple syrup urine disease: an unusual complication of a rare disease: a case report

A 19-year-old woman with known maple syrup urine disease presented to hospital with metabolic crisis in the setting of influenza type A infection and intractable vomiting, rapidly progressing to acute cerebral oedema manifesting as refractory seizures and decreased level of consciousness needing emergency intubation and mechanical ventilation, continuous veno-venous haemodiafiltration and thiopentone coma. A computed tomography scan and magnetic resonance imaging of the brain demonstrated classic signs of cerebral oedema secondary to a metabolic crisis from the metabolic disorder. Her management posed multiple challenges to all teams involved due to lack of familiarity and experience in managing this clinical scenario in the adult intensive care setting.

Infusionstherapie und Ernährung von Risikogruppen

Besondere Situationen erfordern ein besonderes Vorgehen. Während bisher das »Standardvorgehen« bezüglich der Ernährung von pädiatrischen Patienten dargestellt wurde, beschäftigt sich das vorliegende Kapitel mit »Sondersituationen« der pädiatrischen Infusionstherapie und Ernährung. Behandlungssituationen, die ein besonderes Vorgehen bei der Therapie oder spezielle Aufmerksamkeit bei der Anpassung der Ernährung erfordern, entstehen in der Regel durch 4 mögliche Situationen:

spezifische Physiologie von Patientengruppen (z. B. Früh- oder Neugeborene),

Auswirkungen von therapeutischen Maßnahmen (z. B. Operationen),

Pathophysiologie von Erkrankungen (z. B. angeborene Stoffwechselerkrankungen, Erkrankungen des onkologischen, rheumatischen oder atopischen Formenkreises, Anorexia nervosa, Bulimie oder Adipositas) oder

besondere körperliche Belastungen [z. B. (Leistungs-)Sport].

Bekannte Strategien werden systematisch und prägnant dargestellt und diskutiert.

Die Beschäftigung mit der Ernährung von »Risikogruppen« übt das Erkennen und den Umgang von potenziellen Gefahrensituationen bei der Verordnung von bilanzierter Ernährung. So sollte auch derjenige von dem Kapitel profitieren, der sich mit den behandelten Patientengruppen, Situationen, Erkrankungen üblicherweise nicht beschäftigen muss.

Amino acid clearance during acute metabolic decompensation in maple syrup urine disease treated with continuous venovenous hemodialysis with filtration

OBJECTIVE

Assessment of amino acid clearances by continuous venovenous hemodialysis with filtration in treatment of a metabolic decompensation in acute maple syrup urine disease.

DESIGN

Single patient assessment.

SETTING

Pediatric intensive care unit.

PATIENTS

A 10-yr-old male with known maple syrup urine disease (branched chain alpha-ketoacid dehydrogenase deficiency) with metabolic decompensation due to an acute viral illness, characterized by altered mental status, progressive obtundation, and severe acidosis.

INTERVENTIONS

Continuous venovenous hemodialysis with filtration.

MEASUREMENTS AND MAIN RESULTS

Continuous venovenous hemodialysis with filtration was instituted with both filtration (500 mL/m(2)/hr) and dialysis (1000 mL/m(2)/hr) utilized, allowing rapid correction of systemic ketoacidosis while providing amino acid clearance. Amino acid clearance was measured at initiation and at 24 hrs into therapy. The procedure was well tolerated, with near normal mental status within 12 hrs and resumption of enteral feedings. During the 24-hr period of continuous venovenous hemodialysis with filtration, serum leucine levels fell from 2352 to 381 micromoles/L, isoleucine fell from 626 to 164, and valine fell from 1117 to 228. Leucine, isoleucine, and valine clearance rates averaged 13.1, 12.8, and 13.2 mL/min, respectively, and were constant during the 24 hrs of treatment. Clearance of other amino acids during this period did not vary significantly between cationic, anionic, neutral, or hydrophobic amino acids.

CONCLUSIONS

Continuous venovenous hemodialysis with filtration provides an effective therapeutic alternative to intermittent hemodialysis during acute metabolic decompensation in maple syrup urine disease.