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Kumar P, Hamza N, Madhok B, De Alwis N, Sharma M, Miras AD, Mahawar KK. Copper Deficiency after Gastric Bypass for Morbid Obesity: a Systematic Review. Obes Surg 2018; 26:1335-42. [PMID: 27034062 DOI: 10.1007/s11695-016-2162-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A large number of patients undergoing bariatric surgery are deficient in copper, and Roux-en-Y gastric bypass can further aggravate it. Delays in diagnosis and treatment of copper deficiency can leave patients with residual neurological disability. This has led to recommendation from the British Obesity and Metabolic Surgery Society that copper levels should be monitored annually after gastric bypass. This review concludes that copper deficiency in adequately supplemented patients is rare and can be adequately treated if a related haematological or neurological disorder is diagnosed. The cost of routine monitoring may therefore not be justified for adequately supplemented, asymptomatic patients who have undergone Roux-en-Y gastric bypass. The screening may however be necessary for high-risk patient groups to prevent severe complications and permanent disability.
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Affiliation(s)
- Parveen Kumar
- Department of General Surgery, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia
| | - Numan Hamza
- Bariatric Unit, Department of General Surgery, Sunderland Royal Hospital, Sunderland, SR4 7TP, UK
| | - Brijesh Madhok
- Bariatric Unit, Department of General Surgery, Sunderland Royal Hospital, Sunderland, SR4 7TP, UK
| | - Nimantha De Alwis
- Bariatric Unit, Department of General Surgery, Sunderland Royal Hospital, Sunderland, SR4 7TP, UK
| | - Manisha Sharma
- Department of Chemical Pathology, Homerton University Hospital NHS Trust, London, UK
| | | | - Kamal K Mahawar
- Bariatric Unit, Department of General Surgery, Sunderland Royal Hospital, Sunderland, SR4 7TP, UK.
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Abstract
A 47-year-old woman developed severe bilateral visual loss 4 years after a Roux-en-Y gastric bypass and 24 years after vertical banded gastroplasty. Her serum copper level was 35 μg/dL (normal, 80-155 μg/dL). She was prescribed elemental copper tablets. Because her methylmalonic acid was slightly elevated, she received vitamin B12 injections as well. Five weeks later, she reported that her vision had improved and, at 10 months, her vision had recovered from 20/400 bilaterally to 20/25 in each eye. This case highlights the importance of checking copper levels in addition to the "more routine" vitamin levels, such as B1, B6, B12, E, and serum folate in patients with suspected nutritional optic neuropathy after bariatric surgery, particularly if it involved a bypass procedure.
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Coyle L, Entezaralmahdi M, Adeola M, De Hoyos P, Mehed A, Varon J. The perfect storm: copper deficiency presenting as progressive peripheral neuropathy. Am J Emerg Med 2015; 34:340.e5-6. [PMID: 26162620 DOI: 10.1016/j.ajem.2015.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 06/13/2015] [Indexed: 11/19/2022] Open
Affiliation(s)
- Laura Coyle
- Weill Cornell Medical College, New York City, NY
| | | | - Mobolaji Adeola
- Department of Medicine, Houston Methodist Hospital, Houston, TX
| | | | - Ali Mehed
- Department of Medicine, Houston Methodist Hospital, Houston, TX
| | - Joseph Varon
- Department of Medicine, Houston Methodist Hospital, Houston, TX; Department of Critical Care, University General Hospital, Houston, TX.
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Optic neuropathy, myelopathy, anemia, and neutropenia caused by acquired copper deficiency after gastric bypass surgery. J Clin Gastroenterol 2014; 48:862-5. [PMID: 24583748 DOI: 10.1097/mcg.0000000000000092] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Malabsorptive bariatric surgery is rapidly becoming a major cause of copper deficiency given the increasing prevalence of these procedures for morbid obesity. Acquired copper deficiency can present with clinically significant hematologic and neurological manifestations. Although hematologic manifestations of copper deficiency are rapidly reversible, significant neurological improvement after copper supplementation therapy is unusual and many patients remain debilitated and may only experience, at best, stabilization of the neurological manifestations. Here we present a case of an undiagnosed copper deficiency several years after bariatric gastric bypass surgery, in a patient who concomitantly used zinc-containing denture cream for several years, associated with anemia, neutropenia, myelopathy, respiratory failure, and bilateral optic neuropathy, which caused major vision loss. This patient was also a heterozygote carrier of the 5,10-methylenetetrahydrofolate reductase A1298C gene polymorphism, which may affect copper metabolism. Intravenous copper repletion resulted in rapid correction of hematologic indices. However, neurological manifestations, including vision loss responded only modestly to copper supplementation, despite achieving normal blood copper concentrations. Clinicians should consider copper deficiency in patients at risk, as in this case, as a delayed diagnosis can lead to irreversible disability due to neurological manifestations.
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Isom KA, Andromalos L, Ariagno M, Hartman K, Mogensen KM, Stephanides K, Shikora S. Nutrition and metabolic support recommendations for the bariatric patient. Nutr Clin Pract 2014; 29:718-39. [PMID: 25288251 DOI: 10.1177/0884533614552850] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Managing the metabolic needs of the patient with obesity is a challenge unto itself without the added demands of accounting for an altered gastrointestinal tract. Nevertheless, with about 200,000 bariatric procedures being performed annually in the United States, clinicians must be prepared to manage the critically ill bariatric surgery patient. This article reviews the recent literature relating to nutrient needs and metabolic support for the bariatric patient. Bariatric patients are at risk for several micronutrient deficiencies, including vitamins D and B₁₂, calcium, and iron; some bariatric procedures affect macronutrient needs as well. Literature on nutrition support guidelines for the bariatric population is limited. However, with an understanding of the anatomical and physiological effects of bariatric surgery, recent guidelines for critically ill patients with obesity can be applied to the bariatric surgery population. The unique needs of the bariatric population, such as susceptibility to micronutrient deficiencies and specialized access routes, must be considered to provide safe and efficacious nutrition support. Further research is necessary to develop specific nutrition support recommendations for the bariatric population.
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Affiliation(s)
- Kellene A Isom
- Brigham and Women's Hospital Center for Metabolic and Bariatric Surgery Boston, Massachusetts
| | - Laura Andromalos
- Brigham and Women's Hospital Center for Metabolic and Bariatric Surgery Boston, Massachusetts
| | - Meghan Ariagno
- Brigham and Women's Hospital Center for Metabolic and Bariatric Surgery Boston, Massachusetts
| | - Katy Hartman
- Brigham and Women's Hospital Center for Metabolic and Bariatric Surgery Boston, Massachusetts
| | - Kris M Mogensen
- Brigham and Women's Hospital Department of Nutrition, Boston, Massachusetts
| | - Katrina Stephanides
- Brigham and Women's Hospital Center for Metabolic and Bariatric Surgery Boston, Massachusetts
| | - Scott Shikora
- Brigham and Women's Hospital Center for Metabolic and Bariatric Surgery Boston, Massachusetts
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Stein J, Stier C, Raab H, Weiner R. Review article: The nutritional and pharmacological consequences of obesity surgery. Aliment Pharmacol Ther 2014; 40:582-609. [PMID: 25078533 DOI: 10.1111/apt.12872] [Citation(s) in RCA: 145] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 11/22/2013] [Accepted: 06/21/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Obesity surgery is acknowledged as a highly effective therapy for morbidly obese patients. Beneficial short-term effects on common comorbidities are practically undisputed, but a growing data pool from long-term follow-up reveals increasing evidence of potentially severe nutritional and pharmacological consequences. AIMS To assess the prevalence, causes and symptoms of complications after obesity surgery, to elucidate and compare therapy recommendations for macro- and micronutrient deficiencies, and to explore surgically-induced effects on drug absorption and bioavailability, discussing ramifications for long-term therapy and prophylaxis. METHODS PubMed, Embase and MEDLINE were searched using terms including, but not limited to, bariatric surgery, gastric bypass, obesity surgery and Roux-en-Y, coupled with secondary search terms, e.g. anaemia, micronutrients, vitamin deficiency, bacterial overgrowth, drug absorption, pharmacokinetics, undernutrition. All studies in English, French or German published January 1980 through March 2014 were included. RESULTS Macro- and micronutrient deficiencies are common after obesity surgery. The most critical, depending on surgical technique, are hypoalbuminemia (3-18%) and deficiencies of vitamins B1 (≤49%), B12 (19-35%) and D (25-73%), iron (17-45%) and zinc (12-91%). Many drugs commonly administered to obese patients (e.g. anti-depressants, anti-microbials, metformin) are subject to post-operative and/or PPI-associated changes affecting bioavailability and absorption. CONCLUSIONS Complications are associated with pre-operative and/or post-operative malnutrition or procedure-related changes in intake, absorption and drug bioavailability. The high prevalence of nutrient deficiencies after obesity surgery makes life-long nutritional monitoring and supplementation essential. Post-operative changes to drug absorption and bioavailability in bariatric patients cast doubt on the validity of standard drug dosage and administration recommendations.
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Affiliation(s)
- J Stein
- Department of Gastroenterology and Clinical Nutrition, Sachsenhausen Hospital, Frankfurt/Main, Germany; German Obesity Center (GOC), Frankfurt-Sachsenhausen, Frankfurt/Main, Germany
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Zeng B, Chen GL, Xu SZ. Divalent copper is a potent extracellular blocker for TRPM2 channel. Biochem Biophys Res Commun 2012; 424:279-84. [PMID: 22750002 DOI: 10.1016/j.bbrc.2012.06.107] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 06/20/2012] [Indexed: 10/28/2022]
Abstract
Transient receptor potential melastatin 2 (TRPM2) is a Ca(2+)-permeable cationic channel in the TRP channel family. The channel activity can be regulated by reactive oxygen species (ROS) and cellular acidification, which has been implicated to the pathogenesis of diabetes and some neuronal disorders. However, little is known about the effect of redox-active metal ions, such as copper, on TRPM2 channels. Here we investigated the effect of divalent copper on TRPM2. TRPM2 channel was over-expressed in HEK-293 cells and the whole-cell current was recorded by patch clamp. We found the whole-cell current evoked by intracellular ADP-ribose was potently inhibited by Cu(2+) with a half maximal inhibitory concentration (IC(50)) of 2.59 μM. The inhibitory effect was irreversible. The single channel activity was abolished in the outside-out patches, and intracellular application of Cu(2+) did not prevent the channel activation, suggesting that the action site of Cu(2+) is located in the extracellular domains of the channel. TRPM2 current was also blocked by Hg(2+), Pb(2+), Fe(2+) and Se(2+). We concluded that Cu(2+) is a potent TRPM2 channel blocker. The sensitivity of TRPM2 channel to heavy metal ions could be a new mechanism for the pathogenesis of some metal ion-related diseases.
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Affiliation(s)
- Bo Zeng
- Centre for Cardiovascular and Metabolic Research, Hull York Medical School, University Hull, Hull, HU6 7RX, UK
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Gastric bypass and copper deficiency: a possible overlooked consequence. Obes Surg 2012; 21:1482-3; author reply 1484-5. [PMID: 21671052 DOI: 10.1007/s11695-011-0465-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Deep brain stimulation for obesity--from theoretical foundations to designing the first human pilot study. Neurosurg Rev 2011; 35:37-42; discussion 42-3. [PMID: 21996938 DOI: 10.1007/s10143-011-0359-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 06/08/2011] [Accepted: 07/31/2011] [Indexed: 10/17/2022]
Abstract
Obesity is perhaps an evolutionary consequence of a species reared with intermittent caloric reward. Humans are hardwired to enjoy food, and our bodies voraciously extract and store energy from food as if each meal was the last. As an amalgam of behavioral and metabolic disturbance, obesity is an attractive target for deep brain stimulation (DBS) since neuromodulation may be able to influence both eating behavior and metabolism. The current pandemic proportions of obesity combined with the failures and morbidity of modern treatments remain the impetus behind the application of DBS to this complex disease. We review the rationale and scientific foundations for obesity DBS and explain how this preclinical evidence has helped sculpt the design of the first human pilot study.
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Btaiche IF, Yeh AY, Wu IJ, Khalidi N. Neurologic Dysfunction and Pancytopenia Secondary to Acquired Copper Deficiency Following Duodenal Switch. Nutr Clin Pract 2011; 26:583-92. [DOI: 10.1177/0884533611416127] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Imad F. Btaiche
- Department of Pharmacy Services, University of Michigan Hospitals and Health Centers, Ann Arbor, Michigan
- University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | - Alice Y. Yeh
- Department of Pharmacy Services, University of Michigan Hospitals and Health Centers, Ann Arbor, Michigan
| | | | - Nabil Khalidi
- University of Michigan College of Pharmacy, Ann Arbor, Michigan
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O'Donnell KB, Simmons M. Early-onset copper deficiency following Roux-en-Y gastric bypass. Nutr Clin Pract 2011; 26:66-9. [PMID: 21266700 DOI: 10.1177/0884533610392921] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Weight loss surgery can provide many health benefits to those suffering from morbid obesity. The surgery, however, is not without potential complications. This clinical observation describes a patient who experienced gait disturbances, lower extremity weakness, and neuropathy which led to a diagnosis of copper deficiency less than 2 years following a Roux-en-Y gastric bypass. Neurological symptoms were improved within 2 months of copper supplementation. The need to monitor patients for less common micronutrient deficiencies such as copper following Roux-en-Y gastric bypass is reinforced by this case.
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Affiliation(s)
- Kelly B O'Donnell
- University of Virginia Health System, PO Box 800673, Charlottesville, VA 22908, USA.
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Rudnicki SA. Prevention and Treatment of Peripheral Neuropathy after Bariatric Surgery. Curr Treat Options Neurol 2010; 12:29-36. [DOI: 10.1007/s11940-009-0052-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Optimal functioning of the central and peripheral nervous system is dependent on a constant supply of appropriate nutrients. The first section of this review discusses neurologic manifestations related to deficiency of key nutrients such as vitamin B(12), folate, copper, vitamin E, thiamine, and others. The second section addresses neurologic complications related to bariatric surgery. The third sections includes neurologic presentations caused by nutrient deficiencies in the setting of alcoholism. The concluding section addresses neurologic deficiency diseases that have a geographic predilection.
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Affiliation(s)
- Neeraj Kumar
- Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA.
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