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Sheppard S, Herrick H, Ahrens-Nicklas RC, Cohen JL, Flibbotte J, Pyle LC. Case 2: Severe Hyperammonemia in a Neonate: An Alternate Ending. Neoreviews 2019; 20:e90-e92. [PMID: 31261090 DOI: 10.1542/neo.20-2-e90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Sarah Sheppard
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.,Divisions of Human Genetics and
| | - Heidi Herrick
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.,Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Rebecca C Ahrens-Nicklas
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.,Divisions of Human Genetics and
| | - Jennifer L Cohen
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.,Divisions of Human Genetics and
| | - John Flibbotte
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.,Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Louise C Pyle
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.,Divisions of Human Genetics and
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2
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Pizarro MD, Mamprin ME, Daurelio LD, Rodriguez JV, Mediavilla MG. Experimental bio-artificial liver: Importance of the architectural design on ammonia detoxification performance. World J Hepatol 2018; 10:719-730. [PMID: 30386465 PMCID: PMC6206149 DOI: 10.4254/wjh.v10.i10.719] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 07/12/2018] [Accepted: 08/07/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the influence of the construction design over the biological component’s performance in an experimental bio-artificial liver (BAL) device.
METHODS Two BAL models for liver microorgans (LMOs) were constructed. First, we constructed a cylindrical BAL and tested it without the biological component to establish its correct functioning. Samples of blood and biological compartment (BC) fluid were taken after 0, 60, and 120 min of perfusion. Osmolality, hematocrit, ammonia and glucose concentrations, lactate dehydrogenase (LDH) release (as a LMO viability parameter), and oxygen consumption and ammonia metabolizing capacity (as LMO functionality parameters) were determined. CPSI and OTC gene expression and function were measured. The second BAL, a “flat bottom” model, was constructed using a 25 cm2 culture flask while maintaining all other components between the models. The BC of both BALs had the same capacity (approximately 50 cm3) and both were manipulated with the same perfusion system. The performances of the two BALs were compared to show the influence of architecture.
RESULTS The cylindrical BAL showed a good exchange of fluids and metabolites between blood and the BC, reflected by the matching of osmolalities, and glucose and ammonia concentration ratios after 120 min of perfusion. No hemoconcentration was detected, the hematocrit levels remained stable during the whole study, and the minimal percentage of hemolysis (0.65% ± 0.10%) observed was due to the action of the peristaltic pump. When LMOs were used as biological component of this BAL they showed similar values to the ones obtained in a Normothermic Reoxygenation System (NRS) for almost all the parameters assayed. After 120 min, the results obtained were: LDH release (%): 14.7 ± 3.1 in the BAL and 15.5 ± 3.2 in the NRS (n = 6); oxygen consumption (μmol/min·g wet tissue): 1.16 ± 0.21 in the BAL and 0.84 ± 0.15 in the NRS (n = 6); relative expression of Cps1 and Otc: 0.63 ± 0.12 and 0.67 ± 0.20, respectively, in the BAL, and 0.86 ± 0.10 and 0.82 ± 0.07, respectively, in the NRS (n = 3); enzymatic activity of CPSI and OTC (U/g wet tissue): 3.03 ± 0.86 and 222.0 ± 23.5, respectively, in the BAL, and 3.12 ± 0.73 and 228.8 ± 32.8, respectively, in the NRS (n = 3). In spite of these similarities, LMOs as a biological component of the cylindrical BAL were not able to detoxify ammonia at a significant level (not detected vs 35.1% ± 7.0% of the initial 1 mM NH4+ dose in NRS, n = 6). Therefore, we built a second BAL with an entirely different design that offers a flat base BC. When LMOs were placed in this “flat bottom” device they were able to detoxify 49.3% ± 8.8% of the initial ammonia overload after 120 min of perfusion (n = 6), with a detoxification capacity of 13.2 ± 2.2 μmol/g wet tissue.
CONCLUSION In this work, we demonstrate the importance of adapting the BAL architecture to the biological component characteristics to obtain an adequate BAL performance.
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Affiliation(s)
- María Dolores Pizarro
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Rosario S2002 LRK, Argentina
- Laboratorio de Investigaciones en Fisiología y Biología Molecular Vegetal (LIFiBVe), Facultad de Ciencias Agrarias, Universidad Nacional del Litoral, Esperanza 3080, Argentina
| | - María Eugenia Mamprin
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Rosario S2002 LRK, Argentina
- Farmacología, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Rosario S2002 LRK, Argentina
| | - Lucas Damián Daurelio
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Rosario S2002 LRK, Argentina
- Laboratorio de Investigaciones en Fisiología y Biología Molecular Vegetal (LIFiBVe), Facultad de Ciencias Agrarias, Universidad Nacional del Litoral, Esperanza 3080, Argentina
| | - Joaquín Valentín Rodriguez
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Rosario S2002 LRK, Argentina
- Centro Binacional de Criobiología Clínica y Aplicada (CAIC), Universidad Nacional de Rosario, Rosario S2011 BXN, Argentina
| | - María Gabriela Mediavilla
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Rosario S2002 LRK, Argentina
- Instituto de Biología Molecular y Celular de Rosario (IBR, CONICET-UNR), Consejo Nacional de Investigaciones Científicas y Tecnológicas, y Universidad Nacional de Rosario, Rosario S2002 LRK, Argentina
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3
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Mouat S, Bishop J, Glamuzina E, Chin S, Best EJ, Evans HM. Fatal hyperammonemia associated with disseminated Serratia marcescens infection in a pediatric liver transplant recipient. Pediatr Transplant 2018; 22:e13180. [PMID: 29624817 DOI: 10.1111/petr.13180] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/23/2018] [Indexed: 12/22/2022]
Abstract
Hyperammonemia is a rare and important complication post-liver transplantation. We review a case of a 5-month-old boy with biliary atresia who received a split liver transplant following a variceal bleed. The transplant was complicated by recurrent portal vein thrombosis. Colonized with Serratia marcescens pretransplant, he developed disseminated infection associated with very high levels of ammonia that led to his death. It is important to be aware of serum ammonia levels in patients with portal vein thrombosis, particularly in the setting of gastrointestinal bleeding and sepsis.
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Affiliation(s)
- Stephen Mouat
- Department of Paediatric Gastroenterology, Starship Children's Health, Auckland, New Zealand
| | - Jonathan Bishop
- Department of Paediatric Gastroenterology, Starship Children's Health, Auckland, New Zealand
| | - Emma Glamuzina
- Starship Children's Health, Adult and Paediatric National Metabolic Service, Auckland, New Zealand
| | - Simon Chin
- Department of Paediatric Gastroenterology, Starship Children's Health, Auckland, New Zealand
| | - Emma J Best
- Starship Children's Health, Infectious Diseases, Auckland, New Zealand.,Department of Paediatrics; Child and Youth Health Auckland, University of Auckland, Auckland, New Zealand
| | - Helen M Evans
- Department of Paediatric Gastroenterology, Starship Children's Health, Auckland, New Zealand
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4
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Clericetti CM, Milani GP, Lava SAG, Bianchetti MG, Simonetti GD, Giannini O. Hyperammonemia associated with distal renal tubular acidosis or urinary tract infection: a systematic review. Pediatr Nephrol 2018; 33:485-491. [PMID: 29134448 DOI: 10.1007/s00467-017-3829-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/13/2017] [Accepted: 10/16/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND Hyperammonemia usually results from an inborn error of metabolism or from an advanced liver disease. Individual case reports suggest that both distal renal tubular acidosis and urinary tract infection may also result in hyperammonemia. METHODS A systematic review of the literature on hyperammonemia secondary to distal renal tubular acidosis and urinary tract infection was conducted. RESULTS We identified 39 reports on distal renal tubular acidosis or urinary tract infections in association with hyperammonemia published between 1980 and 2017. Hyperammonemia was detected in 13 children with distal renal tubular acidosis and in one adult patient with distal renal tubular acidosis secondary to primary hyperparathyroidism. In these patients a negative relationship was observed between circulating ammonia and bicarbonate levels (P < 0.05). In 31 patients (19 children, 12 adults), an acute urinary tract infection was complicated by acute hyperammonemia and symptoms and signs of acute neuronal dysfunction, such as an altered level of consciousness, convulsions and asterixis, often associated with signs of brain edema, such as anorexia and vomiting. Urea-splitting bacteria were isolated in 28 of the 31 cases. The urinary tract was anatomically or functionally abnormal in 30 of these patients. CONCLUSIONS This study reveals that both altered distal renal tubular acidification and urinary tract infection may be associated with relevant hyperammonemia in both children and adults.
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Affiliation(s)
- Caterina M Clericetti
- Pediatric Department of Southern Switzerland, Bellinzona, Switzerland.,Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gregorio P Milani
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Sebastiano A G Lava
- University Children's Hospital, Inselspital - University of Bern, Bern, Switzerland
| | - Mario G Bianchetti
- Pediatric Department of Southern Switzerland, Bellinzona, Switzerland. .,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland.
| | - Giacomo D Simonetti
- Pediatric Department of Southern Switzerland, Bellinzona, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Olivier Giannini
- Department of Internal Medicine, Ente Ospedaliero Cantonale, Mendrisio, Switzerland
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Cordano C, Traverso E, Calabrò V, Borzone C, Stara S, Marchese R, Marinelli L. Recurring hyperammonemic encephalopathy induced by bacteria usually not producing urease. BMC Res Notes 2014; 7:324. [PMID: 24884855 PMCID: PMC4057615 DOI: 10.1186/1756-0500-7-324] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 05/26/2014] [Indexed: 11/21/2022] Open
Abstract
Background Hyperammonemic encephalopathy may occur when urease-positive bacteria in the urinary tract produce ammonium which directly enters systemic circulation. Predisposing conditions such as a neurogenic bladder can increase both urinary tract infection and urine stagnation. Case presentation We describe the case of a 66 years old woman with a neurogenic bladder who twice developed hyperammonemic encephalopathy following urinary tract infection. During the second episode Escherichia coli and Enterococcus faecalis have been isolated in the urine. The neurologic examination showed psychomotor slowing, weak photomotor reflex, nystagmus in the lateral gaze and asterixis. The EEG showed triphasic waves which disappeared along with clinical recovery. Conclusion Escherichia coli and Enterococcus faecalis are commonly considered urease-negative bacteria. Although frequently involved in urinary tract infections, their role in causing hyperammonemic encephalopathy have not been previously reported. Moreover, despite only one case with a neurogenic bladder have been described so far, our is the first patient with reoccurring hyperammonemic encephalopathy secondary to urinary tract infections.
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Affiliation(s)
| | | | | | | | | | | | - Lucio Marinelli
- Institute of Neurology, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Largo Daneo 3, 16132 Genova, Italy.
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Abstract
Hyperammonaemia is well reported in animals with advanced hepatic disease and portosystemic shunts, but is unreported in cats with renal disease. This case series describes four cats with severe renal azotaemia in which elevated ammonia levels were detected during the course of treatment. In two cases hyperammonaemia was detected at a time when neurological signs consistent with encephalopathy had developed. This raises the possibility that hyperammonaemia may play a role in the development of encephalopathy in cats with renal azotaemia.
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Affiliation(s)
- Carl Adagra
- School of Veterinary and Biomedical Sciences, James Cook University, Townsville, QLD, Australia
| | - Darren J Foster
- Eastside Vet Emergency and Specialists, Rose Bay, Sydney, NSW, Australia
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Häberle J. Clinical and biochemical aspects of primary and secondary hyperammonemic disorders. Arch Biochem Biophys 2013; 536:101-8. [PMID: 23628343 DOI: 10.1016/j.abb.2013.04.009] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 04/16/2013] [Accepted: 04/17/2013] [Indexed: 02/08/2023]
Abstract
An increased concentration of ammonia is a non-specific laboratory sign indicating the presence of potentially toxic free ammonia that is not normally removed. This does occur in many different conditions for which hyperammonemia is a surrogate marker. Hyperammonemia can occur due to increased production or impaired detoxification of ammonia and should, if associated with clinical symptoms, be regarded as an emergency. The conditions can be classified into primary or secondary hyperammonemias depending on the underlying pathophysiology. If the urea cycle is directly affected by a defect of any of the involved enzymes or transporters, this results in primary hyperammonemia. If however the function of the urea cycle is inhibited by toxic metabolites or by substrate deficiencies, the situation is described as secondary hyperammonemia. For removal of ammonia, mammals require the action of glutamine synthetase in addition to the urea cycle, in order to ensure lowering of plasma ammonia concentrations to the normal range. Independent of its etiology, hyperammonemia may result in irreversible brain damage if not treated early and thoroughly. Thus, early recognition of a hyperammonemic state and immediate initiation of the specific management are of utmost importance. The main prognostic factors are, irrespective of the underlying cause, the duration of the hyperammonemic coma and the extent of ammonia accumulation. This paper will discuss the biochemical background of primary and secondary hyperammonemia and will give an overview of the various underlying conditions including a brief clinical outline and information on the genetic backgrounds.
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Affiliation(s)
- Johannes Häberle
- Division of Metabolism, University Children's Hospital Zurich, Steinwiesstr. 75, 8032 Zurich, Switzerland.
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Colletti JE, Homme JL, Woodridge DP. Unsuspected neonatal killers in emergency medicine. Emerg Med Clin North Am 2004; 22:929-60. [PMID: 15474777 DOI: 10.1016/j.emc.2004.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A neonate presenting to the emergency department can present a challenge to even the most experienced clinician. This article has focused on four deceiving and potentially devastating neonatal diseases. 1. Neonatal herpes is a potentially devastating illness without pathognomonic signs or symptoms. Early recognition and therapy can reduce mortality markedly. Although no specific sign or symptom is diagnostic,the diagnosis should be strongly considered in the presence of HSV risk factors, atypical sepsis, unexplained acute hepatitis, or focal seizure activity. Acyclovir therapy should be initiated before viral dissemination or significant CNS replication occurs. 2. Pertussis is a disease in which infants are at greatest risk of death or severe complication. Neonatal pertussis often presents in an atypical manner, lacking the classic signs and symptoms such as the "whoop."More common signs and symptoms include cough, feeding difficulty,low-grade fever, emesis, increasing respiratory distress, apnea, cyanosis,and seizures. Management should include hospitalization, supportive care, and antibiotics. 3. Congenital heart defects, particularly ductal-dependent lesions, may have an initial asymptomatic period that culminates in a rapidly progressive and fatal course. A neonate with CHD presents with shock refractory to volume resuscitation or pressor support. Resuscitative efforts are ineffective unless PGE, is administered. 4. Inborn errors of metabolism often are unsuspected because of their protean and heterogeneous nature. Signs and symptoms are subtle,are nonspecific, and often mimic other, more common diseases.An elevated index of suspicion, along with application and correct interpretation of a select few laboratory tests, is the key to making a diagnosis. Therapy is relatively straightforward and focused on resuscitation followed by prevention of catabolism and correction of specifically identified abnormalities. Although these disorders are relatively uncommon, prompt diagnosis and therapy can lead to a decrease in morbidity and mortality. The key is to maintain a high index of suspicion.
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MESH Headings
- Diagnosis, Differential
- Electrocardiography
- Electroencephalography
- Emergency Medicine/methods
- Emergency Treatment/methods
- Fluorescent Antibody Technique, Direct
- Heart Defects, Congenital/diagnosis
- Heart Defects, Congenital/epidemiology
- Heart Defects, Congenital/etiology
- Heart Defects, Congenital/therapy
- Herpes Simplex/diagnosis
- Herpes Simplex/epidemiology
- Herpes Simplex/etiology
- Herpes Simplex/therapy
- Humans
- Infant Mortality
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/epidemiology
- Infant, Newborn, Diseases/etiology
- Infant, Newborn, Diseases/therapy
- Intensive Care, Neonatal/methods
- Metabolism, Inborn Errors/diagnosis
- Metabolism, Inborn Errors/epidemiology
- Metabolism, Inborn Errors/etiology
- Metabolism, Inborn Errors/therapy
- Morbidity
- Neonatal Screening
- Oximetry
- Polymerase Chain Reaction
- Resuscitation/methods
- Risk Factors
- Time Factors
- United States/epidemiology
- Whooping Cough/diagnosis
- Whooping Cough/epidemiology
- Whooping Cough/etiology
- Whooping Cough/therapy
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Affiliation(s)
- James E Colletti
- Department of Pediatric and Adolescent Medicine, Mayo Medical School, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Abstract
Hyperammonemia has been reported rarely in the pediatric age group in systemically ill patients. All cases resulted from infections with urea splitting organisms, which are more common among patients who have undergone surgical procedures on the urinary tract. The authors report for the first time in the pediatric literature, one patient who presented with hyperammonemic encephalopathy that resulted from urinary tract infection with Staphylococcus epidermidis and Corynebacterium sp.
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Affiliation(s)
- H O S Gabra
- Paediatric Surgical Unit, Sheffield Children's Hospital NHS Trust, Western Bank, Sheffield, UK
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