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Kosenko EA, Alilova GA, Tikhonova LA. Impaired Enzymatic Antioxidant Defense in Erythrocytes of Rats with Ammonia-Induced Encephalopathy: Role of NMDA Receptors. BIOCHEMISTRY. BIOKHIMIIA 2023; 88:1404-1415. [PMID: 37770406 DOI: 10.1134/s0006297923090195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 09/30/2023]
Abstract
Hepatic encephalopathy (HE), a neuropsychiatric disorder developing in patients with severe hepatic dysfunction, has been known for more than a century. However, pathogenetic mechanisms of cerebral dysfunction associated with liver disease are still poorly understood. There is a consensus that the primary cause of HE is accumulation of ammonia in the brain as a result of impaired liver detoxification capacity or the portosystemic shunt. Current evidence suggests that ammonia toxicity is mediated by hyperactivation of glutamate receptors, mainly N-methyl-D-aspartate receptors (NMDARs), and affects brain aerobic metabolism, which provides energy for multiple specific functions and neuronal viability. Recent reports on the presence of functional NMDARs in erythrocytes and the data on the deviations of blood parameters from their normal ranges indicate impaired hemodynamics and reduced oxygen-carrying capacity of erythrocytes in most patients with HE, thus suggesting a relationship between erythrocyte damage and cerebral dysfunction. In order to understand how hyperammonemia (HA)-induced disturbances in the energy metabolism in the brain (which needs a constant supply of large amounts of oxygen in the blood) lead to encephalopathy, it is necessary to reveal ammonia-induced impairments in the energy metabolism and antioxidant defense system of erythrocytes and to explore a potential role of ammonia in reduced brain oxygenation. To identify the said missing link, the activities of antioxidant enzymes and concentrations of reduced glutathione (GSH), oxidized glutathione (GSSG), and H2O2 were measured in the erythrocytes of rats with HA that were injected with the noncompetitive NMDAR antagonist MK-801. We found that in rats with HA, ammonia was accumulated in erythrocytes (cells lacking ammonia removal enzymes), which made them more susceptible to the prooxidant environment created during oxidative stress. This effect was completely or partially inhibited by MK-801. The data obtained might help to identify the risk factors in cognitive disorders and facilitate prediction of unfavorable outcomes of hypoperfusion in patients with a blood elevated ammonia concentration.
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Affiliation(s)
- Elena A Kosenko
- Institute of Theoretical and Experimental Biophysics of the Russian Academy of Sciences, Pushchino, Moscow Region, 142290, Russia.
| | - Gubidat A Alilova
- Institute of Theoretical and Experimental Biophysics of the Russian Academy of Sciences, Pushchino, Moscow Region, 142290, Russia
| | - Lyudmila A Tikhonova
- Institute of Theoretical and Experimental Biophysics of the Russian Academy of Sciences, Pushchino, Moscow Region, 142290, Russia
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Undifferentiated non-hepatic hyperammonemia in the ICU: Diagnosis and management. J Crit Care 2022. [DOI: 10.1016/j.jcrc.2022.154042
expr 979693480 + 932749582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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Fakharbad MJ, Moshiri M, Ommati MM, Talebi M, Etemad L. A review of basic to clinical studies of the association between hyperammonemia, methamphetamine. Naunyn Schmiedebergs Arch Pharmacol 2022; 395:921-931. [PMID: 35604430 DOI: 10.1007/s00210-022-02248-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 04/28/2022] [Indexed: 10/18/2022]
Abstract
Methamphetamine (METH), an addictive psychostimulant drug, is the second most widely used type of drug all around the world. METH abusers are more likely to develop a psycho-neurological complication. Hyperammonemia (HAM) causes neuropsychiatric illnesses such as mental state changes and episodes of acute encephalopathy. Recently, there are some shreds of evidence about the relationship between METH complication and HAM. Both METH intoxication and HAM could induce psychosis, agitation, memory impairment, and psycho-neuronal disorders. They also have similar mechanisms of neuronal damages, such as excitotoxicity, oxidative stress, mitochondrial impairments, and inflammation responses, which can subsequently increase the glutamate level of the brain. Hence, the basic to clinical studies of the association between HAM and METH are reviewed by monitoring six case studies and a good body of animal studies literature. All instances of METH-associated HAM had changes in mental state and some level of confusion that were improved when the ammonia serum level returned to the normal level. Furthermore, most of them had typical vital signs. Several studies suggested some sources for METH-associated HAM, including METH-induced liver and renal damages, muscular hyperactivity, gut bacterial overgrowth, co-abuse of other substances, and using some forms of NH3 in METH cooking. In conclusion, it seems that mental status changes in METH abusers may be related to ammonia intoxication or HAM; therefore, it is important to assess the serum level of ammonia in METH intoxicated patients and resolve it.
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Affiliation(s)
- Marzieh Jafari Fakharbad
- Department of Pharmacodynamics and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Moshiri
- Medical Toxicology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Mehdi Ommati
- College of Life Sciences, Shanxi Agricultural University, Taigu, Shanxi, 030801, China
| | - Mehdi Talebi
- Department of Community and Family Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Leila Etemad
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran. .,Department of Drug Control, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.
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Undifferentiated non-hepatic hyperammonemia in the ICU: Diagnosis and management. J Crit Care 2022; 70:154042. [PMID: 35447602 DOI: 10.1016/j.jcrc.2022.154042] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/17/2022] [Accepted: 04/04/2022] [Indexed: 12/25/2022]
Abstract
Hyperammonemia occurs frequently in the critically ill but is largely confined to patients with hepatic dysfunction or failure. Non-hepatic hyperammonemia (NHHA) is far less common but can be a harbinger of life-threatening diagnoses that warrant timely identification and, sometimes, empiric therapy to prevent seizures, status epilepticus, cerebral edema, coma and death; in children, permanent cognitive impairment can result. Subsets of patients are at particular risk for developing NHHA, including the organ transplant recipient. Unique etiologies include rare infections, such as with Ureaplasma species, and unmasked inborn errors of metabolism, like urea cycle disorders, must be considered in the critically ill. Early recognition and empiric therapy, including directed therapies towards these rare etiologies, is crucial to prevent catastrophic demise. We review the etiologies of NHHA and highlight the first presentation of it associated with a concurrent Ureaplasma urealyticum and Mycoplasma hominis infection in a previously healthy individual with polytrauma. Based on this clinical review, a diagnostic and treatment algorithm to identify and manage NHHA is proposed.
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Kim JH, Jeon H, Lee SS, Heo IR, Choi JW, Kim HJ, Cha RR, Lee JM, Kim HJ. Impact of non-hepatic hyperammonemia on mortality in intensive care unit patients: a retrospective cohort study. Korean J Intern Med 2021; 36:1347-1355. [PMID: 34256430 PMCID: PMC8588975 DOI: 10.3904/kjim.2021.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/26/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS The effect of hyperammonemia on the mortality in patients with liver cirrhosis is well documented. However, little is known about the impact of hyperammonemia on mortality among intensive care unit patients without hepatic disease. We aimed to investigate factors associated with non-hepatic hyperammonemia among intensive care unit patients and to evaluate the factors related to the 7- and 90-day mortality. METHODS Between February 2016 and February 2020, 948 patients without hepatic disease who had 972 episodes of admission to the intensive care unit were retrospectively enrolled and classified as hyperammonemia grades 0 (≤ 80 µg/dL; 585 [60.2%]), 1 (≤ 160 µg/dL; 291 [29.9%]), 2 (≤ 240 µg/dL; 55 [5.7%]), and 3 (> 240 µg/dL; 41 [4.2%]). Factors associated with hyperammonemia and the 7- and 90-day mortality were evaluated by multivariate logistic regression analysis and Cox regression analysis, respectively. Kaplan-Meier survival curves for the 7- and 90-day mortality were constructed. RESULTS The independent risk factors for hyperammonemia were male sex (odds ratio, 1.517), age (0.984/year), acute brain failure (2.467), acute kidney injury (1.437), prothrombin time-international normalized ratio (2.272/unit), and albumin (0.694/g/dL). The 90-day mortality rate in the entire cohort was 24.3% and gradually increased with increasing hyperammonemia grade at admission (17.9%, 28.2%, 43.6%, and 61.0% in patients with grades 0, 1, 2, and 3, respectively). Additionally, non-hepatic hyperammonemia was an independent predictor of the 90- day mortality in intensive care unit patients. CONCLUSION Non-hepatic hyperammonemia is common (39.8%) and associated with the 90-day mortality among intensive care unit patients.
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Affiliation(s)
- Jae Heon Kim
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju,
Korea
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon,
Korea
| | - Hankyu Jeon
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju,
Korea
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon,
Korea
| | - Sang Soo Lee
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju,
Korea
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon,
Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju,
Korea
| | - I Re Heo
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju,
Korea
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon,
Korea
| | - Jung Woo Choi
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju,
Korea
| | - Hee Jin Kim
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju,
Korea
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon,
Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju,
Korea
| | - Ra Ri Cha
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju,
Korea
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon,
Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju,
Korea
| | - Jae Min Lee
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju,
Korea
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon,
Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju,
Korea
| | - Hyun Jin Kim
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju,
Korea
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon,
Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju,
Korea
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Nilsson CH, Svensson MBT, Säve SJM, Van Meervenne SAE. Transient hyperammonaemia following epileptic seizures in cats. J Feline Med Surg 2021; 23:534-539. [PMID: 33034248 PMCID: PMC10741304 DOI: 10.1177/1098612x20962747] [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] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aim of this study was to determine whether transient postictal hyperammonaemia exists in cats. METHODS The medical records of all feline patients that presented at a Swedish veterinary hospital between 2008 and 2018 were retrospectively reviewed to find those that had a recent or ongoing epileptic seizure. To qualify for inclusion, the medical record had to include information on at least one ammonia value taken in close proximity to, or during, an active seizure, the cat must have exceeded the normal upper limit of blood ammonia concentration on initial testing (reference interval 0-95 μmol/l), and there needed to be a follow-up ammonia value available within a maximum of 3 days. RESULTS Five cats were included in the study, and they had blood ammonia concentrations on initial testing ranging from 146 to 195 µmol/l. They were all retested within a period of 2 h to 3 days of the original reading. All five cats had a spontaneous decrease in ammonia levels without any specific treatment for hyperammonaemia. CONCLUSIONS AND RELEVANCE Pursuant to the findings of this retrospective study, transient hyperammonaemia may be noted after epileptic seizure in cats. Consequently, a differential diagnostic list in feline patients with hyperammonaemia could, depending on the context, include non-hepatic-related pathologies, such as epileptic seizures.
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Cumulative Electroconvulsive Therapy-Associated Severe Hyperammonemic Encephalopathy: A Case Report. Am J Ther 2020; 26:e784-e786. [PMID: 30829663 DOI: 10.1097/mjt.0000000000000960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Nass RD, Zur B, Elger CE, Holdenrieder S, Surges R. Acute metabolic effects of tonic-clonic seizures. Epilepsia Open 2019; 4:599-608. [PMID: 31819916 PMCID: PMC6885665 DOI: 10.1002/epi4.12364] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/11/2019] [Accepted: 10/07/2019] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE Tonic-clonic seizures (TCS) lead to metabolic stress and changes in related blood markers. Such markers may indicate harmful conditions but can also help to identify TCS as a cause of transient loss of consciousness. In this study, we hypothesized that the alterations of circulating markers of metabolic stress depend on the clinical features of TCS. METHODS Ninety-one adults undergoing video-EEG monitoring participated in this prospective study. Electrolytes, renal parameters, creatine kinase (CK), prolactin (PRL), lactate, ammonia, glucose, and other parameters were measured at inclusion and different time points after TCS. RESULTS A total of 39 TCS were recorded in 32 patients (six generalized onset tonic-clonic seizures in 6 and 33 focal to bilateral tonic-clonic seizures in 26 patients). Shortly after TCS, mean lactate, ammonia, and PRL levels were significantly increased 8.7-fold, 2.6-fold, and 5.1-fold, respectively, with levels of more than twofold above the upper limits of the normal (ULN) in 90%, 71%, and 70% of the TCS and returned to baseline levels within 2 hours. Only postictal lactate levels were significantly correlated with the total duration of the tonic-clonic phase. In contrast, CK elevations above the ULN were found in three TCS (~10%) only with a peak after 48 hours. Immediately after the TCS, hyperphosphatemia occurred in one third of the patients, whereas hypophosphatemia was observed in one third 2 hours later. TCS led to subtle but significant alterations of other electrolytes, creatinine, and uric acid, whereas glucose levels were moderately increased. SIGNIFICANCE Lactate is a robust metabolic marker of TCS with elevations found in ~90% of cases within 30 minutes after seizure termination, whereas ammonia rises in ~ 70%, similarly to PRL. Phosphate levels show an early increase and a decrease 2 hours after TCS in a third of patients. CK elevations are rare after video-EEG-documented TCS, challenging its value as a diagnostic marker.
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Affiliation(s)
- Robert D. Nass
- Department of EpileptologyUniversity of Bonn Medical CenterBonnGermany
| | - Berndt Zur
- Institute for Clinical Chemistry and Clinical PharmacologyUniversity of Bonn Medical CenterBonnGermany
| | | | - Stefan Holdenrieder
- Institute for Clinical Chemistry and Clinical PharmacologyUniversity of Bonn Medical CenterBonnGermany
- Institute for Laboratory MedicineGerman Heart Centre MunichMunichGermany
| | - Rainer Surges
- Department of EpileptologyUniversity of Bonn Medical CenterBonnGermany
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Fujita A, Ota M, Kato K. Urinary volatile metabolites of amygdala-kindled mice reveal novel biomarkers associated with temporal lobe epilepsy. Sci Rep 2019; 9:10586. [PMID: 31332211 PMCID: PMC6646363 DOI: 10.1038/s41598-019-46373-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/26/2019] [Indexed: 11/11/2022] Open
Abstract
Epilepsy is a chronic neurological disorder affecting mammals, including humans. Uncontrolled epilepsy is associated with poor quality of life, accidents, and sudden death. In particular, temporal lobe epilepsy (TLE) is the most common type of pharmacoresistant epilepsy, which easily gets out of control in human adults. The aim of this study was to profile urinary volatile organic compounds (VOCs) in a mouse model of TLE using solid-phase microextraction (SPME) gas chromatography mass spectrometry (GC-MS). Thirteen urinary VOCs exhibited differential abundance between epileptic and control mice, and the corresponding areas under the receiver operating characteristic (ROC) curve were greater than 0.8. Principal component analysis (PCA) based on these 13 VOCs separated epileptic from sham operated-mice, suggesting that all these 13 VOCs are epilepsy biomarkers. Promax rotation and dendrogram analysis concordantly separated the 13 VOCs into three groups. Stepwise linear discriminant analysis extracted methanethiol; disulfide, dimethyl; and 2-butanone as predictors. Based on known metabolic systems, the results suggest that TLE induced by amygdala stimulation could affect both endogenous metabolites and the gut flora. Future work will elucidate the physiological meaning of the VOCs as end-products of metabolic networks and assess the impact of the metabolic background involved in development of TLE.
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Affiliation(s)
- Akiko Fujita
- Faculty of Life Sciences, Kyoto Sangyo University, Motoyama, Kamigamo, Kita-ku, Kyoto, Japan
| | - Manami Ota
- Faculty of Life Sciences, Kyoto Sangyo University, Motoyama, Kamigamo, Kita-ku, Kyoto, Japan
| | - Keiko Kato
- Faculty of Life Sciences, Kyoto Sangyo University, Motoyama, Kamigamo, Kita-ku, Kyoto, Japan.
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Doğan EA, Ünal A, Ünal A, Erdoğan Ç. Clinical utility of serum lactate levels for differential diagnosis of generalized tonic-clonic seizures from psychogenic nonepileptic seizures and syncope. Epilepsy Behav 2017; 75:13-17. [PMID: 28806632 DOI: 10.1016/j.yebeh.2017.07.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 07/01/2017] [Accepted: 07/04/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND The differential diagnosis of generalized tonic-clonic seizures (GTCS), psychogenic nonepileptic seizures (PNES), and syncope constitutes a major challenge. Misdiagnosis rates up to 20 to 30% are reported in the literature. PURPOSE To assess the clinical utility of serum lactate levels for differentiation of GTCS, PNES, and syncope based on gender differences. METHODS Data from 270 patients were evaluated retrospectively. Only patients ≥18 years old with the final diagnosis of GTCS, PNES, or syncope in their chart were recruited. Serum lactate levels were measured in the first 2h of the index event. RESULTS Serum lactate levels in patients with GTCS (n=157) were significantly higher than in the patients with PNES (n=25) (p<0.001) and syncope (n=88) (p<0.001). When compared with the females, serum lactate levels in patients with GTCS were significantly higher in the male subgroup (p=0.004). In male patients the ROC analysis yielded a serum lactate value of 2.43mmol/l with a sensitivity of 0.85 and a specificity of 0.88 as the optimal cut-off value to distinguish GTCS from other events. The ROC analysis for the AUC yielded a high estimate of 0.94 (95% confidence interval: 0.91-0.98). When a cut-off value of 2.43mmol/l was chosen for the females, which was an optimal value for male patients, the specificity was 0.85, however, the sensitivity was 0.64. CONCLUSION We propose that serum lactate level when measured in the first 2h after the index event has a high clinical utility in the differential diagnosis of GTCS, PNES, and syncope. With concomitant clinical signs and physical examination findings besides neuroimaging and EEG, elevated levels of lactate should be taken into account when evaluating a patient with impaired consciousness. On the other hand, the suggested cut-off value 2.43mmol/l might not have a discriminative effect between GTCS, PNES, and syncope in female patients. This finding should be verified in a prospectively designed study with a larger patient population.
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Affiliation(s)
- Ebru Apaydın Doğan
- Akdeniz University School of Medicine, Neurology Department, Antalya, Turkey.
| | - Ali Ünal
- Akdeniz University School of Medicine, Neurology Department, Antalya, Turkey
| | - Aslıhan Ünal
- Akdeniz University School of Medicine, Emergency Department, Antalya, Turkey
| | - Çağla Erdoğan
- Akdeniz University School of Medicine, Neurology Department, Antalya, Turkey
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The role of postictal laboratory blood analyses in the diagnosis and prognosis of seizures. Seizure 2017; 47:51-65. [DOI: 10.1016/j.seizure.2017.02.013] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 12/18/2022] Open
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Aswani P, Kalina M. Hyperammonemia as a Marker of Subclinical Seizures After Traumatic Cardiac Arrest. ARCHIVES OF TRAUMA RESEARCH 2017; 5:e33361. [PMID: 28144602 PMCID: PMC5251203 DOI: 10.5812/atr.33361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 12/07/2015] [Accepted: 12/11/2015] [Indexed: 11/16/2022]
Abstract
This report details the presence of hyperammonemia in a patient who sustained cardiac arrest after a traumatic amputation. Serum ammonia levels may rise due to numerous etiologies; however, few reports detail its usefulness in diagnosing subclinical seizures. In this case, we successfully utilized persistently elevated serum ammonia levels as a marker of subclinical seizures in a patient who sustained traumatic cardiac arrest.
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Affiliation(s)
- Patricia Aswani
- Department of Research, Staten Island University Hospital, New York, United States
| | - Michael Kalina
- Department of Surgery, Staten Island University Hospital, New York, United States
- Corresponding author: Michael Kalina, Department of Surgery, Staten Island University Hospital, Director of Emergency Surgery, 256 Mason Avenue, Suite C Staten Island, New York, United States. Tel: +718-2256398, Fax: +718-2261247, E-mail:
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Sato K, Arai N, Omori A, Hida A, Kimura A, Takeuchi S. Hyperammonaemia and associated factors in unprovoked convulsive seizures: A cross-sectional study. Seizure 2016; 43:6-12. [PMID: 27768938 DOI: 10.1016/j.seizure.2016.09.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 08/20/2016] [Accepted: 09/28/2016] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Hyperammonaemia is frequently observed in patients who have experienced convulsive seizures. Although excessive muscle contraction is presumed to be responsible for the elevated levels of ammonia, the underlying mechanism is poorly understood. The present study aimed to identify the independent factors associated with ammonia elevation using large-scale multivariate analysis. METHODS We conducted a cross-sectional study involving 379 adult patients who had been transported to our emergency department and treated for unprovoked convulsive seizures between August 2010 and September 2015. Elevation of venous plasma ammonia levels was set as the primary endpoint, and patients' clinical and laboratory data were obtained. Those with severe liver dysfunction, known hepatic encephalopathy, or convulsions due to cardiovascular or psychogenic causes, and those taking valproate were excluded. RESULTS Using a cut-off value of 50μg/dL, 183 patients (48.3%) were found to have elevated levels of plasma ammonia. Four factors were identified as independent variables associated with hyperammonaemia following seizures: elevated venous lactate, lowered venous pH, sex (male), and longer duration of convulsion. CONCLUSIONS The results of the present study revealed independent factors associated with hyperammonaemia following unprovoked convulsive seizures in a larger scale and with more plausible statistical analysis. The authors further suggest that the excessive skeletal muscle contraction and/or respiratory failure during/after convulsive seizure may be the primary mechanism of hyperammonaemia.
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Affiliation(s)
- Kenichiro Sato
- Department of Neurology, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan
| | - Noritoshi Arai
- Department of Neurology, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan.
| | - Aki Omori
- Department of Neurology, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan
| | - Ayumi Hida
- Department of Neurology, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan
| | - Akio Kimura
- Department of Emergency Medicine and Critical Care, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan
| | - Sousuke Takeuchi
- Department of Neurology, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan
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Alfadhel M, Mutairi FA, Makhseed N, Jasmi FA, Al-Thihli K, Al-Jishi E, AlSayed M, Al-Hassnan ZN, Al-Murshedi F, Häberle J, Ben-Omran T. Guidelines for acute management of hyperammonemia in the Middle East region. Ther Clin Risk Manag 2016; 12:479-87. [PMID: 27099506 PMCID: PMC4820220 DOI: 10.2147/tcrm.s93144] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background Hyperammonemia is a life-threatening event that can occur at any age. If treated, the early symptoms in all age groups could be reversible. If untreated, hyperammonemia could be toxic and cause irreversible brain damage to the developing brain. Objective There are major challenges that worsen the outcome of hyperammonemic individuals in the Middle East. These include: lack of awareness among emergency department physicians about proper management of hyperammonemia, strained communication between physicians at primary, secondary, and tertiary hospitals, and shortage of the medications used in the acute management of hyperammonemia. Therefore, the urge to develop regional guidelines is extremely obvious. Method We searched PubMed and Embase databases to include published materials from 2011 to 2014 that were not covered by the European guidelines, which was published in 2012. We followed the process of a Delphi conference and involved one preliminary meeting and two follow-up meetings with email exchanges between the Middle East Hyperammonemia and Urea Cycle Disorders Scientific Group regarding each draft of the manuscript. Results and discussion We have developed consensus guidelines based on the highest available level of evidence. The aim of these guidelines is to homogenize and harmonize the treatment protocols used for patients with acute hyperammonemia, and to provide a resource to not only metabolic physicians, but also physicians who may come in contact with individuals with acute hyperammonemia. Conclusion These suggested guidelines aim to ease the challenges faced by physicians dealing with acute hyperammonemia in the region. In addition, guidelines have demonstrated useful collaboration between experts in the region, and provides information that will hopefully improve the outcomes of patients with acute hyperammonemia.
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Affiliation(s)
- Majid Alfadhel
- Department of Pediatrics, Division of Genetics, King Abdulaziz Medical City, Riyadh, Saudi Arabia; King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Fuad Al Mutairi
- Department of Pediatrics, Division of Genetics, King Abdulaziz Medical City, Riyadh, Saudi Arabia; King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Nawal Makhseed
- Department of Pediatrics, Jahra Hospital, Ministry of Health, Jahra City, Kuwait
| | - Fatma Al Jasmi
- Department of Pediatric, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Khalid Al-Thihli
- Genetic and Developmental Medicine Clinic, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | | | - Moeenaldeen AlSayed
- Department of Medical Genetics, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Zuhair N Al-Hassnan
- Department of Medical Genetics, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia; The National Newborn Screening Program, Ministry of Health, Riyadh, Saudi Arabia
| | - Fathiya Al-Murshedi
- Genetic and Developmental Medicine Clinic, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Johannes Häberle
- Department of Pediatrics, Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Tawfeg Ben-Omran
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
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15
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Mojumder DK, De Oleo RR. Differential ammonia decay kinetics indicates more than one concurrent etiological mechanism for symptomatic hyperammonemia caused by valproate overdose. Indian J Pharmacol 2015; 46:345-7. [PMID: 24987188 PMCID: PMC4071718 DOI: 10.4103/0253-7613.132200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 11/16/2013] [Accepted: 01/23/2014] [Indexed: 11/29/2022] Open
Abstract
Valproic acid (VPA) has successfully been used in the therapy of a number of conditions including absence seizures, partial seizures, tonic-clonic seizures, bipolar disorder, schizoaffective disorder, social phobias, neuropathic pain and migraine headaches. There is a high rise in number of cases of toxicity due to overdose of VPA. Hyperammonemia, a common side-effect of VPA, is caused by several proposed etiologies, reported as having uncertain correlation with VPA dose or concentration. We present here a case of a 25-year-old female patient with a past history of psychiatric complaints, presented with elevated serum VPA levels associated with elevated venous ammonia levels subsequent to VPA overdose. Later in the presence of sub-therapeutic serum VPA levels her venous ammonia levels remained raised and slowly down-trending. VPA levels and ammonia levels were found to be normal after 14 days. Patient was treated with levocarnitine. Her liver enzymes were never elevated. Different decay kinetics of venous ammonia in presence of high and low concentrations of VPA indicates that VPA can cause symptomatic hyperammonemia via more than one concurrent etiological mechanism. In this patient, the mechanisms causing hyperammonia secondary to VPA use were not related to hepatic damage or carnitine deficiency.
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Affiliation(s)
- Deb Kumar Mojumder
- Department of Neurology, Texas Tech University Health Sciences Center, School of Medicine, Lubbock, TX 79430, USA ; Department of Internal Medicine, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554, USA
| | - Radhames Ramos De Oleo
- Department of Internal Medicine, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554, USA
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16
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Kumar S, Asrani SK. Non-cirrhotic Hyperammonemia—When High Ammonia Is not Always from Cirrhosis. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s11901-015-0252-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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