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El-Shafie AM, Bahbah WA, Abd El Naby SA, Omar ZA, Basma EM, Hegazy AAA, El Zefzaf HMS. Impact of two ketogenic diet types in refractory childhood epilepsy. Pediatr Res 2023; 94:1978-1989. [PMID: 36906721 PMCID: PMC10007663 DOI: 10.1038/s41390-023-02554-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 02/02/2023] [Accepted: 02/18/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Ketogenic diet (KD) refers to any diet in which food composition induces a ketogenic state of human metabolism. OBJECTIVE To assess short- and long-term efficacy, safety, and tolerability of KD [classic KD and modified Atkins diet (MAD)] in childhood drug-resistant epilepsy (DRE) and to investigate the effect of KD on electroencephalographic (EEG) features of children with DRE. METHODS Forty patients diagnosed with DRE according to International League Against Epilepsy were included and randomly assigned into classic KD or MAD groups. KD was initiated after clinical, lipid profile and EEG documentation, and regular follow-up was done for 24 months. RESULTS Out of 40 patients with DRE, 30 completed this study. Both classic KD and MAD were effective in seizure control as 60% in classic KD group and 53.33% in MAD group became seizure free, and the remaining showed ≥50% seizure reduction. Lipid profile remained within acceptable levels throughout the study period in both groups. Adverse effects were mild and managed medically with an improvement of growth parameters and EEG during the study period. CONCLUSIONS KD is an effective and safe non-pharmacologic, non-surgical therapy for the management of DRE with a positive impact on growth and EEG. IMPACT Both common types of KD (classic KD and MAD) are effective for DRE, but unfortunately, nonadherence and dropout rates are frequent. High serum lipid profile (cardiovascular AE) is often suspected in children following a high-fat diet, but lipid profile remained in the acceptable level up to 24 months. Therefore, KD constitutes a safe treatment. KD had a positive impact on growth, despite inconsistent results of the KD's effect on growth. In addition to showing strong clinical effectiveness, KD also considerably decreased the frequency of interictal epileptiform discharges and enhanced the EEG background rhythm.
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Affiliation(s)
- Ali M El-Shafie
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
| | - Wael A Bahbah
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt.
| | - Sameh A Abd El Naby
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
| | - Zein A Omar
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
| | - Elsayedamr M Basma
- Department of Bioinformatics and Medical Statistics, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Aya A A Hegazy
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
| | - Heba M S El Zefzaf
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
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Shaaban S, Al-Beltagi M, El Rashidy O, Nassar M, El Gendy Y. Ketogenic diet in childhood epilepsy: clinical algorithm in a tertiary care center. Front Pediatr 2023; 11:1221781. [PMID: 37484774 PMCID: PMC10361660 DOI: 10.3389/fped.2023.1221781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 06/16/2023] [Indexed: 07/25/2023] Open
Abstract
Background Dietary therapies play a crucial role in managing patients, especially those who have specific types of epilepsy, display adverse effects, or are not responding to pharmacological treatments. The ketogenic diet (KD) is a high-fat, restricted carbohydrate, and adequate protein regimen. The KD has proven to be an effective nonpharmacological treatment for drug-resistant epilepsy (DRE) by generating ketones that act as an alternative fuel source for the brain, thereby reducing the occurrence of seizures. The advantages of KD have been attributed to its universal availability, numerous administration techniques, and affordability. Objective This article presents the KD algorithm developed by a multidisciplinary team of experts at the Children's Hospital, Ain Shams University, Egypt. The algorithm serves as a guide for implementing the KD in the treatment of DRE in children. The algorithm has been previously validated through a study. Methods The algorithm consists of seven essential stages: (1) referral of patients to the Complex Epilepsy Committee, (2) pre-diet assessment of patients, (3) referral of patients to the Clinical Nutrition (CN) team, (4) diet selection and initiation, (5) seizure follow-up and diet fine-tuning, (6) diet reassessment after 3 months, and (7) evaluation of the KD journey after 24 months. Results The KD algorithm was systematically developed and proved highly influential in facilitating the implementation of the KD. The algorithm yielded significant health benefits in pediatric patients. Conclusion The KD algorithm provides a systematic approach to implementing the ketogenic diet and has demonstrated positive health outcomes in pediatric patients.
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Affiliation(s)
- Sanaa Shaaban
- Children's Hospital, Faculty of Medicine, Ain Shams University, Abbassia, Egypt
| | - Mohammed Al-Beltagi
- Paediatric Department, Faculty of Medicine, Tanta University, Tanta, Egypt
- Paediatric Department, University Medical Center, King Abdulla Medical Center, Arabian Gulf University, Dr. Sulaiman Al Habib Medical Group, Manama, Bahrain
| | - Omnia El Rashidy
- Children's Hospital, Faculty of Medicine, Ain Shams University, Abbassia, Egypt
| | - May Nassar
- Children's Hospital, Faculty of Medicine, Ain Shams University, Abbassia, Egypt
| | - Yasmin El Gendy
- Children's Hospital, Faculty of Medicine, Ain Shams University, Abbassia, Egypt
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Armeno M, Caballero E, Verini A, Reyes G, Galarza N, Cresta A, Caraballo RH. Telemedicine- versus outpatient-based initiation and management of ketogenic diet therapy in children with drug-resistant epilepsy during the COVID-19 pandemic. Seizure 2022; 98:37-43. [DOI: 10.1016/j.seizure.2022.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/19/2022] [Accepted: 03/31/2022] [Indexed: 10/18/2022] Open
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Cai M, Xu W, Zheng Y, Ding M. Ketogenic dietary therapy in adult status epilepticus: current progress and clinical application. ACTA EPILEPTOLOGICA 2022. [DOI: 10.1186/s42494-022-00082-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractStatus epilepticus (SE) is a common fatal neurological disease with high morbidity and mortality. Even if a large proportion of patients might be relieved from anti-seizure medications, sedatives and anesthetics, some still remain out of control. The ketogenic dietary (KD) has been proven useful in patients refractory to medications and/or who have failed to respond to surgical intervention. Recently, KD has shown beneficial therapeutic effects in children with SE, but studies in adults have rarely been reported. In this paper, we review the efficacy and utility of KD in adult SE patients and highlight its application for clinical reference and management.
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Tong X, Cai Q, Cao D, Yu L, Sun D, Yang G, Wang J, Li H, Li Z, Wang J, Huang S, Ding M, Fang F, Wang Q, Luo R, Liao J, Qin J. Chinese expert recommendations on ketogenic diet therapy for super-refractory status epilepticus. ACTA EPILEPTOLOGICA 2022. [DOI: 10.1186/s42494-021-00078-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractSuper-refractory status epilepticus (SRSE) is a serious and life-threatening neurological condition. Ketogenic diet (KD) is a diet characterized by high fat, low carbohydrate, and moderate protein. As KD shows effectiveness in controlling seizures in more than half of SRSE patients, it can be a treatment option for SRSE. Currently, KD treatment for SRSE is based on personal experience and observational evidence has been published. In the context of a lack of a validated guideline, we convened a multicenter expert panel within the China Association Against Epilepsy (CAAE) Ketogenic Diet Commission to work out the Chinese expert recommendations on KD for SRSE. We summarize and discuss the latest clinical practice of KD for SRSE in critical care settings. Recommendations are given on patient selection, the timing of KD, diet implementation, and follow-up. More research data are needed in this area to support better clinical practice.
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Abstract
AbstractThe ketogenic diet (KD) is a high-fat, low-carbohydrate diet, in which fat is used as the primary energy source through the production of ketone bodies (KBs) in place of glucose. The KD was formally introduced in 1921 to mimic the biochemical changes associated with fasting and gained recognition as a potent treatment for pediatric epilepsy in the mid-1990s. The clinical and basic scientific knowledge that supports the anti-seizure efficacy, safety, and feasibility of using the KD in patients with epilepsy is huge. Additionally, the International Ketogenic Diet Study Group’s consensus guidelines provide practical information in 2009 and 2018. The KD is a broad-spectrum therapy for drug resistant epilepsy and is gaining attention as a potential therapy for other neurological disorders. This article will review recent aspects on the use of the KD, including its mechanisms of action, KD alternatives, expanding its use across different age groups and regions, its use as a treatment for other neurologic disorders, and future research subjects.
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Sourbron J, Thevissen K, Lagae L. The Ketogenic Diet Revisited: Beyond Ketones. Front Neurol 2021; 12:720073. [PMID: 34393987 PMCID: PMC8363000 DOI: 10.3389/fneur.2021.720073] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/29/2021] [Indexed: 12/25/2022] Open
Affiliation(s)
- Jo Sourbron
- Department of Development and Regeneration, Section Pediatric Neurology, University Hospital Katholieke Universiteit Leuven, Leuven, Belgium
| | - Karin Thevissen
- Centre of Microbial and Plant Genetics, Department of Microbial and Molecular Systems, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Lieven Lagae
- Department of Development and Regeneration, Section Pediatric Neurology, University Hospital Katholieke Universiteit Leuven, Leuven, Belgium
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Boon P, Ferrao Santos S, Jansen AC, Lagae L, Legros B, Weckhuysen S. Recommendations for the treatment of epilepsy in adult and pediatric patients in Belgium: 2020 update. Acta Neurol Belg 2021; 121:241-257. [PMID: 33048338 PMCID: PMC7937601 DOI: 10.1007/s13760-020-01488-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 08/26/2020] [Indexed: 12/31/2022]
Abstract
To guide health care professionals in Belgium in selecting the appropriate antiepileptic drugs (AEDs) for their epilepsy patients, a group of Belgian epilepsy experts developed recommendations for AED treatment in adults and children (initial recommendations in 2008, updated in 2012). As new drugs have become available, others have been withdrawn, new indications have been approved and recommendations for pregnant women have changed, a new update was pertinent. A group of Belgian epilepsy experts (partly overlapping with the group in charge of the 2008/2012 recommendations) evaluated the most recent international guidelines and relevant literature for their applicability to the Belgian situation (registration status, reimbursement, clinical practice) and updated the recommendations for initial monotherapy in adults and children and add-on treatment in adults. Recommendations for add-on treatment in children were also included (not covered in the 2008/2012 publications). Like the 2008/2012 publications, the current update also covers other important aspects related to the management of epilepsy, including the importance of early referral in drug-resistant epilepsy, pharmacokinetic properties and tolerability of AEDs, comorbidities, specific considerations in elderly and pregnant patients, generic substitution and the rapidly evolving field of precision medicine.
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Affiliation(s)
- Paul Boon
- Reference Center for Refractory Epilepsy, Department of Neurology, Ghent University Hospital, Ghent, Belgium.
| | | | - Anna C Jansen
- Pediatric Neurology Unit, Department of Pediatrics, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lieven Lagae
- Reference Center for Refractory Epilepsy, Pediatric Neurology, Department of Development and Regeneration, University Hospitals Leuven, Leuven, Belgium
| | - Benjamin Legros
- Department of Neurology, Reference Center for the Treatment of Refractory Epilepsy, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Sarah Weckhuysen
- Department of Neurology, Antwerp University Hospital, Antwerp, Belgium
- VIB-Center for Molecular Neurology, University of Antwerp, Antwerp, Belgium
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Ferrere G, Tidjani Alou M, Liu P, Goubet AG, Fidelle M, Kepp O, Durand S, Iebba V, Fluckiger A, Daillère R, Thelemaque C, Grajeda-Iglesias C, Alves Costa Silva C, Aprahamian F, Lefevre D, Zhao L, Ryffel B, Colomba E, Arnedos M, Drubay D, Rauber C, Raoult D, Asnicar F, Spector T, Segata N, Derosa L, Kroemer G, Zitvogel L. Ketogenic diet and ketone bodies enhance the anticancer effects of PD-1 blockade. JCI Insight 2021; 6:145207. [PMID: 33320838 PMCID: PMC7934884 DOI: 10.1172/jci.insight.145207] [Citation(s) in RCA: 147] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/09/2020] [Indexed: 02/06/2023] Open
Abstract
Limited experimental evidence bridges nutrition and cancer immunosurveillance. Here, we show that ketogenic diet (KD) — or its principal ketone body, 3-hydroxybutyrate (3HB), most specifically in intermittent scheduling — induced T cell–dependent tumor growth retardation of aggressive tumor models. In conditions in which anti–PD-1 alone or in combination with anti–CTLA-4 failed to reduce tumor growth in mice receiving a standard diet, KD, or oral supplementation of 3HB reestablished therapeutic responses. Supplementation of KD with sucrose (which breaks ketogenesis, abolishing 3HB production) or with a pharmacological antagonist of the 3HB receptor GPR109A abolished the antitumor effects. Mechanistically, 3HB prevented the immune checkpoint blockade–linked upregulation of PD-L1 on myeloid cells, while favoring the expansion of CXCR3+ T cells. KD induced compositional changes of the gut microbiota, with distinct species such as Eisenbergiella massiliensis commonly emerging in mice and humans subjected to carbohydrate-low diet interventions and highly correlating with serum concentrations of 3HB. Altogether, these results demonstrate that KD induces a 3HB-mediated antineoplastic effect that relies on T cell–mediated cancer immunosurveillance.
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Affiliation(s)
| | | | - Peng Liu
- Equipe labellisée par la Ligue contre le cancer, Université de Paris, Sorbonne Université, INSERM UMR1138, Centre de Recherche des Cordeliers, Paris, France
| | | | | | - Oliver Kepp
- Equipe labellisée par la Ligue contre le cancer, Université de Paris, Sorbonne Université, INSERM UMR1138, Centre de Recherche des Cordeliers, Paris, France
| | - Sylvère Durand
- Equipe labellisée par la Ligue contre le cancer, Université de Paris, Sorbonne Université, INSERM UMR1138, Centre de Recherche des Cordeliers, Paris, France
| | - Valerio Iebba
- Department of Medical Sciences, University of Trieste, Trieste, Italy
| | | | | | | | | | | | - Fanny Aprahamian
- Equipe labellisée par la Ligue contre le cancer, Université de Paris, Sorbonne Université, INSERM UMR1138, Centre de Recherche des Cordeliers, Paris, France
| | - Déborah Lefevre
- Equipe labellisée par la Ligue contre le cancer, Université de Paris, Sorbonne Université, INSERM UMR1138, Centre de Recherche des Cordeliers, Paris, France
| | - Liwei Zhao
- Equipe labellisée par la Ligue contre le cancer, Université de Paris, Sorbonne Université, INSERM UMR1138, Centre de Recherche des Cordeliers, Paris, France
| | | | | | | | - Damien Drubay
- Gustave Roussy, Department of Biostatistics and Epidemiology, University Paris-Saclay, Villejuif, France
| | | | - Didier Raoult
- URMITE, Aix Marseille Université, UM63, CNRS 7278, IRD 198, INSERM 1095, IHU-Méditerranée Infection, Marseille, France
| | - Francesco Asnicar
- Department Cellular, computational and integrative biology (CIBIO), University of Trento, Trento, Italy
| | - Tim Spector
- The Department of Twin Research & Genetic Epidemiology, King's College London, United Kingdom
| | - Nicola Segata
- Department Cellular, computational and integrative biology (CIBIO), University of Trento, Trento, Italy
| | - Lisa Derosa
- Gustave Roussy, INSERM U1015, Villejuif, France
| | - Guido Kroemer
- Equipe labellisée par la Ligue contre le cancer, Université de Paris, Sorbonne Université, INSERM UMR1138, Centre de Recherche des Cordeliers, Paris, France
| | - Laurence Zitvogel
- Gustave Roussy, INSERM U1015, Villejuif, France.,University Paris Saclay, Saint-Aubin, France.,CIC 1428 BIOTHERIS, Gustave Roussy, Villejuif, France
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Semprino M, Fasulo L, Fortini S, Martorell Molina CI, González L, Ramos PA, Martínez C, Caraballo R. Telemedicine, drug-resistant epilepsy, and ketogenic dietary therapies: A patient survey of a pediatric remote-care program during the COVID-19 pandemic. Epilepsy Behav 2020; 112:107493. [PMID: 33181913 PMCID: PMC7532773 DOI: 10.1016/j.yebeh.2020.107493] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The purpose of this study was to assess parent satisfaction with the management of ketogenic diet therapies (KDTs) through telemedicine using WhatsApp as the main tool. METHODS Parent satisfaction was longitudinally evaluated through questionnaires. The survey was developed with Google Questionnaire forms and sent via WhatsApp. The questionnaire consisted of 13 items concerning the management of KDTs using telemedicine in the context of the coronavirus disease 2019 (COVID-19) pandemic. Our population of patients has limited financial resources and low levels of education. Given that many families did not have either computers or WIFI, or any other access to information or communication technology, WhatsApp was chosen as a tool as it was available on the cell phones of all families and the professionals. RESULTS Our survey showed that 96.3% of the parents were satisfied with the management of KDTs through telemedicine. The main benefits observed were the possibility of continuing treatment during the COVID-19 pandemic and the ease of accessing the professional team from the comfort of their home. Overall, 72.2% of the families would recommend using telemedicine for KDTs in any situation regardless of the pandemic. None of the families reported that they would recommend against treatment by telemedicine. The availability of a social support network (parents WhatsApp group) coordinated by professionals from the KDT team was considered to be useful by most respondents (90%). CONCLUSIONS Our study suggests that management of children with DRE on KDTs through telemedicine is feasible, well accepted by the families, and probably as safe as conventional medicine. WhatsApp may be an interesting telemedicine tool to start and maintain KDTs.
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Affiliation(s)
- Marcos Semprino
- Department of Neurology, Clínica San Lucas, Neuquén, Argentina,Department of Nutrition, Clínica San Lucas, Neuquén, Argentina
| | - Lorena Fasulo
- Department of Neurology, Clínica San Lucas, Neuquén, Argentina,Department of Nutrition, Clínica San Lucas, Neuquén, Argentina
| | - Sebastian Fortini
- Department of Neurology, Hospital de Pediatría Niño Jesús, Tucumán, Argentina
| | | | - Lara González
- Department of Neurology, Hospital de Pediatría Niño Jesús, Tucumán, Argentina
| | | | - Carolina Martínez
- Department of Nutrition, Hospital de Pediatría Niño Jesús, Tucumán, Argentina
| | - Roberto Caraballo
- Department of Neurology, Hospital de Pediatría "Prof. Dr. Juan P Garrahan", Buenos Aires, Argentina.
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