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Lee A, Eldem I, Altintas B, Nguyen H, Willis D, Langley R, Shinawi M. Treatment and outcomes of symptomatic hyperammonemia following asparaginase therapy in children with acute lymphoblastic leukemia. Mol Genet Metab 2023; 139:107627. [PMID: 37327713 DOI: 10.1016/j.ymgme.2023.107627] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/31/2023] [Accepted: 06/02/2023] [Indexed: 06/18/2023]
Abstract
Hyperammonemia has been reported following asparaginase administration, consistent with the mechanisms of asparaginase, which catabolizes asparagine to aspartic acid and ammonia, and secondarily converts glutamine to glutamate and ammonia. However, there are only a few reports on the treatment of these patients, which varies widely from watchful waiting to treatment with lactulose, protein restriction, sodium benzoate, and phenylbutyrate to dialysis. While many patients with reported asparaginase-induced hyperammonemia (AIH) are asymptomatic, some have severe complications and even fatal outcomes despite medical intervention. Here, we present a cohort of five pediatric patients with symptomatic AIH, which occurred after switching patients from polyethylene glycolated (PEG)- asparaginase to recombinant Crisantaspase Pseudomonas fluorescens (4 patients) or Erwinia (1 patient) asparaginase, and discuss their subsequent management, metabolic workup, and genetic testing. We developed an institutional management plan, which gradually evolved based on our local experience and previous treatment modalities. Because of the significant reduction in glutamine levels after asparaginase administration, sodium benzoate should be used as a first-line ammonia scavenger for symptomatic AIH instead of sodium phenylacetate or phenylbutyrate. This approach facilitated continuation of asparaginase doses, which is known to improve cancer outcomes. We also discuss the potential contribution of genetic modifiers to AIH. Our data highlights the need for increased awareness of symptomatic AIH, especially when an asparaginase with higher glutaminase activity is used, and its prompt management. The utility and efficacy of this management approach should be systematically investigated in a larger cohort of patients.
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Affiliation(s)
- Angela Lee
- Department of Pediatrics, Division of Genetics and Genomic Medicine, Washington University School of Medicine, Saint Louis, MO, USA.
| | - Irem Eldem
- Department of Pediatrics, Division of Hematology and Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Burak Altintas
- Department of Pediatrics, Division of Genetics and Genomic Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Hoanh Nguyen
- Department of Pediatrics, Division of Genetics and Genomic Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Daniel Willis
- Department of Pediatrics, Division of Hematology and Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Rachel Langley
- Department of Pharmacy, Washington University School of Medicine, Saint Louis, MO, USA
| | - Marwan Shinawi
- Department of Pediatrics, Division of Genetics and Genomic Medicine, Washington University School of Medicine, Saint Louis, MO, USA
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Martin CE, Kohorst MA, Ferdjallah A, Kalmes JL, Johnson HM, Galardy PJ, Khan SP, Kuhn AK. Symptomatic hyperammonemia secondary to recombinant Erwinia asparaginase. Pediatr Blood Cancer 2023; 70:e30208. [PMID: 36633209 DOI: 10.1002/pbc.30208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 01/13/2023]
Affiliation(s)
- Catherine E Martin
- Department of Pharmacy - Ambulatory Service, Mayo Clinic, Rochester, Minnesota, USA
| | - Mira A Kohorst
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Asmaa Ferdjallah
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jessica L Kalmes
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Heather M Johnson
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul J Galardy
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shakila P Khan
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexis K Kuhn
- Department of Pharmacy - Ambulatory Service, Mayo Clinic, Rochester, Minnesota, USA
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Free TJ, Tucker RW, Simonson KM, Smith SA, Lindgren CM, Pitt WG, Bundy BC. Engineering At-Home Dilution and Filtration Methods to Enable Paper-Based Colorimetric Biosensing in Human Blood with Cell-Free Protein Synthesis. BIOSENSORS 2023; 13:104. [PMID: 36671942 PMCID: PMC9855769 DOI: 10.3390/bios13010104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/28/2022] [Accepted: 12/30/2022] [Indexed: 06/17/2023]
Abstract
Diagnostic blood tests can guide the administration of healthcare to save and improve lives. Most clinical biosensing blood tests require a trained technician and specialized equipment to process samples and interpret results, which greatly limits test accessibility. Colorimetric paper-based diagnostics have an equipment-free readout, but raw blood obscures a colorimetric response which has motivated diverse efforts to develop blood sample processing techniques. This work uses inexpensive readily-available materials to engineer user-friendly dilution and filtration methods for blood sample collection and processing to enable a proof-of-concept colorimetric biosensor that is responsive to glutamine in 50 µL blood drop samples in less than 30 min. Paper-based user-friendly blood sample collection and processing combined with CFPS biosensing technology represents important progress towards the development of at-home biosensors that could be broadly applicable to personalized healthcare.
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Multiple Asparaginase Infusions Cause Increasingly Severe Acute Hyperammonemia. Med Sci (Basel) 2022; 10:medsci10030043. [PMID: 35997335 PMCID: PMC9397007 DOI: 10.3390/medsci10030043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/05/2022] [Accepted: 08/09/2022] [Indexed: 12/05/2022] Open
Abstract
Adverse reactions during and shortly after infusing asparaginase for the treatment of acute lymphoblastic leukemia can increase in severity with later doses, limiting further use and increasing relapse risk. Although asparaginase is associated with hyperammonemia, the magnitude of the increase in serum ammonia immediately after the infusion and in response to multiple infusions has not been examined. The concurrence of hyperammonemia and infusion reactions was studied using weaned juvenile pigs that received 12 infusions of Erwinia asparaginase (Erwinase; 1250 U/kg) over 28 days, with two 5-day recovery periods without asparaginase after the eighth and eleventh doses. Infusion reactions and prolonged hyperammonemia (>50 µM ammonia 48 h after the infusion) began after the fourth dose and increased with later doses. Dense sampling for 60 min revealed an acute phase of hyperammonemia that peaked within 20 min after starting the first infusion (298 + 62 µM) and lasted less than 1 h, without apparent symptoms. A pronounced acute hyperammonemia after the final infusion (1260 + 250 µM) coincided with severe symptoms and one mortality during the infusion. The previously unrecognized acute phase of hyperammonemia associated with asparaginase infusion coincides with infusion reactions. The juvenile pig is a translational animal model for understanding the causes of acute and chronic hyperammonemia, differentiating from hypersensitivity reactions, and for improving infusion protocols to reduce acute hyperammonemia and to allow the continued use of asparaginase.
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Hunt JP, Barnett RJ, Robinson H, Soltani M, Nelson JAD, Bundy BC. Rapid sensing of clinically relevant glutamine concentrations in human serum with metabolically engineered E. coli-based cell-free protein synthesis. J Biotechnol 2020; 325:389-394. [PMID: 32961202 DOI: 10.1016/j.jbiotec.2020.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 09/06/2020] [Accepted: 09/14/2020] [Indexed: 12/27/2022]
Abstract
Bioavailable glutamine (Gln) is critical for metabolism, intestinal health, immune function, and cell signaling. Routine measurement of serum Gln concentrations could facilitate improved diagnosis and treatment of severe infections, anorexia nervosa, chronic kidney disease, diabetes, and cancer. Current methods for quantifying tissue Gln concentrations rely mainly on HPLC, which requires extensive sample preparation and expensive equipment. Consequently, patient Gln levels may be clinically underutilized. Cell-free protein synthesis (CFPS) is an emerging sensing platform with promising clinical applications, including detection of hormones, amino acids, nucleic acids, and other biomarkers. In this work, in vitro E. coli amino acid metabolism is engineered with methionine sulfoximine to inhibit glutamine synthetase and create a CFPS Gln sensor. The sensor features a strong signal-to-noise ratio and a detection range ideally suited to physiological Gln concentrations. Furthermore, it quantifies Gln concentration in the presence of human serum. This work demonstrates that CFPS reactions which harness the metabolic power of E. coli lysate may be engineered to detect clinically relevant analytes in human samples. This approach could lead to transformative point-of-care diagnostics and improved treatment regimens for a variety of diseases including cancer, diabetes, anorexia nervosa, chronic kidney disease, and severe infections.
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Affiliation(s)
- J Porter Hunt
- Department of Chemical Engineering, Brigham Young University, Provo, UT, United States
| | - R Jordan Barnett
- Department of Chemical Engineering, Brigham Young University, Provo, UT, United States
| | - Hannah Robinson
- Department of Chemical Engineering, Brigham Young University, Provo, UT, United States
| | - Mehran Soltani
- Department of Chemical Engineering, Brigham Young University, Provo, UT, United States
| | - J Andrew D Nelson
- Department of Chemical Engineering, Brigham Young University, Provo, UT, United States
| | - Bradley C Bundy
- Department of Chemical Engineering, Brigham Young University, Provo, UT, United States.
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Costa-Silva T, Costa I, Biasoto H, Lima G, Silva C, Pessoa A, Monteiro G. Critical overview of the main features and techniques used for the evaluation of the clinical applicability of L-asparaginase as a biopharmaceutical to treat blood cancer. Blood Rev 2020; 43:100651. [DOI: 10.1016/j.blre.2020.100651] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 12/14/2019] [Accepted: 12/23/2019] [Indexed: 12/16/2022]
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Survival and Neurologic Recovery After Prompt Diagnosis and Aggressive Management of Severe Idiopathic Hyperammonemic Encephalopathy in a Patient with Acute Myeloid Leukemia. J Pediatr Hematol Oncol 2020; 42:e452-e455. [PMID: 31415019 DOI: 10.1097/mph.0000000000001579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
A case of a 19-year-old female with low-risk acute myeloid leukemia is presented who was diagnosed with idiopathic hyperammonemic encephalopathy following the development of abrupt neurologic decline, respiratory alkalosis, and elevated plasma ammonia levels of unknown etiology. Delayed symptom recognition of this exceedingly rare condition contributes to the often fatal outcomes of idiopathic hyperammonemic encephalopathy. As illustrated by this case, prompt diagnosis and utilization of a variety of ammonia-modulating treatment modalities can result in remarkable clinical recovery. This case provides guidance to clinicians in counseling families about the possibility of neurologic recovery in similar clinical scenarios.
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