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Edwards MGP, Andersen JR, Curtis DJ, Riberholt CG, Poulsen I. Diet-induced ketosis in adult patients with subacute acquired brain injury: a feasibility study. Front Med (Lausanne) 2024; 10:1305888. [PMID: 38571572 PMCID: PMC10990248 DOI: 10.3389/fmed.2023.1305888] [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: 10/02/2023] [Accepted: 11/23/2023] [Indexed: 04/05/2024] Open
Abstract
Background Research in animal models on cerebral metabolism after brain injury highlights the potential benefits of ketosis in reducing secondary brain injury, but studies in humans are lacking. Aim This study aimed to examine if a 6-week ketogenic diet intervention with added medium-chain triglycerides (MCT) was feasible in adult patients with acquired brain injury in the subacute phase, whether ketosis could be achieved and maintained, and to what extent serious adverse reactions, adverse reactions, serious adverse events, and adverse events occured. Methods Patients ≥18 years of age diagnosed with subacute acquired brain injury and an expectation of hospitalisation ≥6 weeks were included in the intervention group. Patients not included in the intervention group were included in a standard care reference group. The intervention consisted of a ketogenic diet supplemented with MCT to obtain a plasma concentration of β-hydroxybutyrate (BHB) ≥0.5 mmol/L. Patients who were enterally fed were given KetoCal® 2.5:1 LQ MCT Multi Fiber (Nutricia A/S, Allerød, Denmark), supplemented with Liquigen® (Nutricia A/S, Allerød, Denmark). Patients consuming oral nutrition were given KetoCal® 2.5:1 LQ MCT Multi Fiber supplemented with Liquigen®, in addition to ketogenic meals. Results During a 13-week inclusion period, 12 of 13 eligible patients (92% [95% CI: 67% to 99%]) were included in the intervention group, and 17 of 18 excluded patients (94% [95% CI: 74% to 99%]) were included in the reference group. Eight patients (67%) completed the 6-week intervention. It took a median of 1 day to achieve ketosis from starting a 100% MCT ketogenic diet, and it was maintained for 97% of the intervention period after ketosis was obtained. There were no serious adverse reactions to the MCT ketogenic diet, and patients experienced adverse reactions not considered serious in 9.5% of days with the intervention. The MCT ketogenic diet was accepted by patients on all intervention days, and in the two patients transitioning from enteral feeding to oral intake, there were no complications related to transitioning. Conclusion Intervention with MCT ketogenic diet is feasible and tolerated for 6 weeks in hospitalised adult patients with subacute acquired brain injury. Randomised controlled trials are needed to assess the benefits and harms of the MCT ketogenic diet and the effect on patients' recovery.Clinical trial registration: ClinicalTrials.gov, identifier [NCT04308577].
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Affiliation(s)
- Maria G. P. Edwards
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Department of Brain and Spinal Cord Injury, Neuroscience Centre, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Jens R. Andersen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Derek J. Curtis
- Department of Brain and Spinal Cord Injury, Neuroscience Centre, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Christian G. Riberholt
- Department of Brain and Spinal Cord Injury, Neuroscience Centre, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Ingrid Poulsen
- Department of Brain and Spinal Cord Injury, Neuroscience Centre, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
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Abstract
PURPOSE OF REVIEW Outcome following traumatic brain injury (TBI) remains variable, and derangements in cerebral metabolism are a common finding in patients with poor outcome. This review compares our understanding of cerebral metabolism in health with derangements seen following TBI. RECENT FINDINGS Ischemia is common within the first 24 h of injury and inconsistently detected by bedside monitoring. Metabolic derangements can also result from tissue hypoxia in the absence of ischemic reductions in blood flow due to microvascular ischemia and mitochondrial dysfunction. Glucose delivery across the injured brain is dependent on blood glucose and regional cerebral blood flow, and is an important contributor to derangements in glucose metabolism. Alternative energy substrates such as lactate, ketone bodies and succinate that may support mitochondrial function, and can be utilized when glucose availability is low, have been studied following TBI but require further investigation. SUMMARY Mitochondrial dysfunction and the use of alternative energy substrates are potential therapeutic targets, but improved understanding of the causes, impact and significance of metabolic derangements in clinical TBI are needed. Maintaining adequate oxygen and glucose delivery across the injured brain may accelerate the recovery of mitochondrial function and cerebral energy metabolism and remain important management targets.
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Affiliation(s)
- Simon Demers-Marcil
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
- Department of Anesthesiology and Critical Care, CHU de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Jonathan P. Coles
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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Krakovski MA, Arora N, Jain S, Glover J, Dombrowski K, Hernandez B, Yadav H, Sarma AK. Diet-microbiome-gut-brain nexus in acute and chronic brain injury. Front Neurosci 2022; 16:1002266. [PMID: 36188471 PMCID: PMC9523267 DOI: 10.3389/fnins.2022.1002266] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
In recent years, appreciation for the gut microbiome and its relationship to human health has emerged as a facilitator of maintaining healthy physiology and a contributor to numerous human diseases. The contribution of the microbiome in modulating the gut-brain axis has gained significant attention in recent years, extensively studied in chronic brain injuries such as Epilepsy and Alzheimer’s Disease. Furthermore, there is growing evidence that gut microbiome also contributes to acute brain injuries like stroke(s) and traumatic brain injury. Microbiome-gut-brain communications are bidirectional and involve metabolite production and modulation of immune and neuronal functions. The microbiome plays two distinct roles: it beneficially modulates immune system and neuronal functions; however, abnormalities in the host’s microbiome also exacerbates neuronal damage or delays the recovery from acute injuries. After brain injury, several inflammatory changes, such as the necrosis and apoptosis of neuronal tissue, propagates downward inflammatory signals to disrupt the microbiome homeostasis; however, microbiome dysbiosis impacts the upward signaling to the brain and interferes with recovery in neuronal functions and brain health. Diet is a superlative modulator of microbiome and is known to impact the gut-brain axis, including its influence on acute and neuronal injuries. In this review, we discussed the differential microbiome changes in both acute and chronic brain injuries, as well as the therapeutic importance of modulation by diets and probiotics. We emphasize the mechanistic studies based on animal models and their translational or clinical relationship by reviewing human studies.
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Affiliation(s)
| | - Niraj Arora
- Department of Neurology, University of Missouri, Columbia, MO, United States
| | - Shalini Jain
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, United States
| | - Jennifer Glover
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, United States
| | - Keith Dombrowski
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, United States
| | - Beverly Hernandez
- Clinical Nutrition Services, Tampa General Hospital, Tampa, FL, United States
| | - Hariom Yadav
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, United States
- USF Center for Microbiome Research, Microbiomes Institute, University of South Florida, Tampa, FL, United States
- *Correspondence: Hariom Yadav,
| | - Anand Karthik Sarma
- Wake Forest University School of Medicine, Winston-Salem, NC, United States
- Department of Neurology, Atrium Health Wake Forest Baptist, Winston-Salem, NC, United States
- Anand Karthik Sarma,
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Omori NE, Woo GH, Mansor LS. Exogenous Ketones and Lactate as a Potential Therapeutic Intervention for Brain Injury and Neurodegenerative Conditions. Front Hum Neurosci 2022; 16:846183. [PMID: 36267349 PMCID: PMC9577611 DOI: 10.3389/fnhum.2022.846183] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Metabolic dysfunction is a ubiquitous underlying feature of many neurological conditions including acute traumatic brain injuries and chronic neurodegenerative conditions. A central problem in neurological patients, in particular those with traumatic brain injuries, is an impairment in the utilization of glucose, which is the predominant metabolic substrate in a normally functioning brain. In such patients, alternative substrates including ketone bodies and lactate become important metabolic candidates for maintaining brain function. While the potential neuroprotective benefits of ketosis have been recognized for up to almost a century, the majority of work has focused on the use of ketogenic diets to induce such a state, which is inappropriate in cases of acute disease due to the prolonged periods of time (i.e., weeks to months) required for the effects of a ketogenic diet to be seen. The following review seeks to explore the neuroprotective effects of exogenous ketone and lactate preparations, which have more recently become commercially available and are able to induce a deep ketogenic response in a fraction of the time. The rapid response of exogenous preparations makes their use as a therapeutic adjunct more feasible from a clinical perspective in both acute and chronic neurological conditions. Potentially, their ability to globally moderate long-term, occult brain dysfunction may also be relevant in reducing lifetime risks of certain neurodegenerative conditions. In particular, this review explores the association between traumatic brain injury and contusion-related dementia, assessing metabolic parallels and highlighting the potential role of exogenous ketone and lactate therapies.
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Arora N, Litofsky NS, Golzy M, Aneja R, Staudenmyer D, Qualls K, Patil S. Phase I single center trial of ketogenic diet for adults with traumatic brain injury. Clin Nutr ESPEN 2022; 47:339-345. [DOI: 10.1016/j.clnesp.2021.11.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/19/2021] [Accepted: 11/07/2021] [Indexed: 01/09/2023]
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Daines SA. The Therapeutic Potential and Limitations of Ketones in Traumatic Brain Injury. Front Neurol 2021; 12:723148. [PMID: 34777197 PMCID: PMC8579274 DOI: 10.3389/fneur.2021.723148] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/13/2021] [Indexed: 12/21/2022] Open
Abstract
Traumatic brain injury (TBI) represents a significant health crisis. To date, no FDA approved pharmacotherapies are available to prevent the neurological deficits caused by TBI. As an alternative to pharmacotherapy treatment of TBI, ketones could be used as a metabolically based therapeutic strategy. Ketones can help combat post-traumatic cerebral energy deficits while also reducing inflammation, oxidative stress, and neurodegeneration. Experimental models of TBI suggest that administering ketones to TBI patients may provide significant benefits to improve recovery. However, studies evaluating the effectiveness of ketones in human TBI are limited. Unanswered questions remain about age- and sex-dependent factors, the optimal timing and duration of ketone supplementation, and the optimal levels of circulating and cerebral ketones. Further research and improvements in metabolic monitoring technology are also needed to determine if ketone supplementation can improve TBI recovery outcomes in humans.
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Affiliation(s)
- Savannah Anne Daines
- Department of Biology, Utah State University, Logan, UT, United States
- Department of Kinesiology and Health Science, Utah State University, Logan, UT, United States
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Yarar-Fisher C, Li J, Womack ED, Alharbi A, Seira O, Kolehmainen KL, Plunet WT, Alaeiilkhchi N, Tetzlaff W. Ketogenic regimens for acute neurotraumatic events. Curr Opin Biotechnol 2021; 70:68-74. [PMID: 33445134 DOI: 10.1016/j.copbio.2020.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/14/2020] [Accepted: 12/07/2020] [Indexed: 12/20/2022]
Abstract
Dietary modification would be the most translatable, cost-efficient, and, likely, the safest approach available that can reduce the reliance on pharmaceutical treatments for treating acute or chronic neurological disorders. A wide variety of evidence suggests that the ketogenic diet (KD) could have beneficial effects in acute traumatic events, such as spinal cord injury and traumatic brain injury. Review of existing human and animal studies revealed that KD can improve motor neuro-recovery, gray matter sparing, pain thresholds, and neuroinflammation and decrease depression. Although the exact mechanism by which the KD provides neuroprotection is not fully understood, its effects on cellular energetics, mitochondria function and inflammation are likely to have a role.
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Affiliation(s)
- Ceren Yarar-Fisher
- Department of Physical Medicine and Rehabilitation, School of Medicine, The University of Alabama at Birmingham, USA.
| | - Jia Li
- Department of Physical Medicine and Rehabilitation, School of Medicine, The University of Alabama at Birmingham, USA
| | - Erika D Womack
- Department of Physical Medicine and Rehabilitation, School of Medicine, The University of Alabama at Birmingham, USA
| | - Amal Alharbi
- Department of Physical Medicine and Rehabilitation, School of Medicine, The University of Alabama at Birmingham, USA; Graduate Program in School of Health Professions, The University of Alabama at Birmingham, 1716 9th Avenue South Birmingham, AL 35294, USA
| | - Oscar Seira
- International Collaboration on Repair Discoveries, University of British Columbia, Blusson Spinal Cord Centre, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada; Department of Zoology, University of British Columbia, 4200 - 6270 University Blvd, Vancouver, BC V6T 1Z4, Canada
| | - Kathleen L Kolehmainen
- International Collaboration on Repair Discoveries, University of British Columbia, Blusson Spinal Cord Centre, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada; Graduate Program in Biochemistry and Molecular Biology, University of British Columbia, 2350 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
| | - Ward T Plunet
- International Collaboration on Repair Discoveries, University of British Columbia, Blusson Spinal Cord Centre, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Nima Alaeiilkhchi
- International Collaboration on Repair Discoveries, University of British Columbia, Blusson Spinal Cord Centre, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada; Graduate Program in Neuroscience, University of British Columbia, Canada
| | - Wolfram Tetzlaff
- International Collaboration on Repair Discoveries, University of British Columbia, Blusson Spinal Cord Centre, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
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