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Gallego-Durán R, Hadjihambi A, Ampuero J, Rose CF, Jalan R, Romero-Gómez M. Ammonia-induced stress response in liver disease progression and hepatic encephalopathy. Nat Rev Gastroenterol Hepatol 2024:10.1038/s41575-024-00970-9. [PMID: 39251708 DOI: 10.1038/s41575-024-00970-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2024] [Indexed: 09/11/2024]
Abstract
Ammonia levels are orchestrated by a series of complex interrelated pathways in which the urea cycle has a central role. Liver dysfunction leads to an accumulation of ammonia, which is toxic and is strongly associated with disruption of potassium homeostasis, mitochondrial dysfunction, oxidative stress, inflammation, hypoxaemia and dysregulation of neurotransmission. Hyperammonaemia is a hallmark of hepatic encephalopathy and has been strongly associated with liver-related outcomes in patients with cirrhosis and liver failure. In addition to the established role of ammonia as a neurotoxin in the pathogenesis of hepatic encephalopathy, an increasing number of studies suggest that it can lead to hepatic fibrosis progression, sarcopenia, immune dysfunction and cancer. However, elevated systemic ammonia levels are uncommon in patients with metabolic dysfunction-associated steatotic liver disease. A clear causal relationship between ammonia-induced immune dysfunction and risk of infection has not yet been definitively proven. In this Review, we discuss the mechanisms by which ammonia produces its diverse deleterious effects and their clinical relevance in liver diseases, the importance of measuring ammonia levels for the diagnosis of hepatic encephalopathy, the prognosis of patients with cirrhosis and liver failure, and how our knowledge of inter-organ ammonia metabolism is leading to the development of novel therapeutic approaches.
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Affiliation(s)
- Rocío Gallego-Durán
- UCM Digestive Diseases, Virgen del Rocío University Hospital. Instituto de Biomedicina de Sevilla (HUVR/CSIC/US), Department of Medicine, University of Seville, Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Anna Hadjihambi
- The Roger Williams Institute of Hepatology, Foundation for Liver Research, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Javier Ampuero
- UCM Digestive Diseases, Virgen del Rocío University Hospital. Instituto de Biomedicina de Sevilla (HUVR/CSIC/US), Department of Medicine, University of Seville, Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Christopher F Rose
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montreal, Canada
| | - Rajiv Jalan
- Institute for Liver and Digestive Health, Division of Medicine, UCL Medical School, Royal Free Hospital, London, UK
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Manuel Romero-Gómez
- UCM Digestive Diseases, Virgen del Rocío University Hospital. Instituto de Biomedicina de Sevilla (HUVR/CSIC/US), Department of Medicine, University of Seville, Seville, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.
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Li Y, Yao Z, Li Y, Yang Z, Li M, Chen Z, Liu S, Gong J, Huang L, Xu P, Li Y, Li H, Liu X, Zhang L, Zhang G, Wang H. Prognostic value of serum ammonia in critical patients with non-hepatic disease: A prospective, observational, multicenter study. J Transl Int Med 2023; 11:401-409. [PMID: 38130646 PMCID: PMC10732347 DOI: 10.2478/jtim-2022-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background and Objectives Non-hepatic hyperammonemia can damage the central nervous system (CNS), and possible prognostic factors are lacking. This study aimed to investigate the prognostic and risk factors for patients admitted to the intensive care unit (ICU). Materials and Methods This prospective, observational, multicenter study was conducted between November and December 2019 at 11 ICUs in the Chinese Heilongjiang province. Changes in blood ammonia level during and after ICU admission were continuously monitored and expressed as the high level (H-), mean level (M-), and initial level (I-) of ammonia. The risk factors of poor prognosis were investigated by conducting univariate and multivariate logistic regression analyses. Receiver operating characteristic (ROC) curve analysis was conducted to compare the predictive ability of Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE-II) score, lactic acid, total bilirubin (TBil), and M-ammonia. Results A total of 1060 patients were included in this study, of which 707 (67%) had a favorable prognosis and 353 (33%) had a poor prognosis. As shown by univariate models, a poor prognosis was associated with elevated serum levels of lactic acid, TBil, and ammonia (P < 0.05) and pathologic scores from three assessments: APACHE-II, Glasgow Coma Scale (GCS), and Sequential Organ Failure Assessment (SOFA). Multivariate analysis revealed that circulating mean ammonia levels in ICU patients were independently associated with a poor prognosis (odds ratio [OR] = 1.73, 95% confidence interval [CI]: 1.07-2.80, P = 0.02). However, the APACHE-II score (area under the curve [AUC]: 0.714, sensitivity: 0.86, specificity: 0.68, P < 0.001) remained the most predictive factor for patient prognosis by ROC analysis. Conclusion Elevated serum levels of ammonia in the blood were independently prognostic for ICU patients without liver disease.
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Affiliation(s)
- Yue Li
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin150086, Heilongjiang Province, China
| | - Zhipeng Yao
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin150086, Heilongjiang Province, China
| | - Yunlong Li
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin150086, Heilongjiang Province, China
| | - Zhenyu Yang
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin150086, Heilongjiang Province, China
| | - Ming Li
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin150086, Heilongjiang Province, China
| | - Zhendong Chen
- Department of Intensive Care Medicine, The First Affiliated Hospital of Jiamusi University, Jiamusi154004, Heilongjiang Province, China
| | - Shujie Liu
- Department of Intensive Care Medicine, Mudanjiang City Second People’s Hospital, Mudanjiang157199, Heilongjiang Province, China
| | - Jianguo Gong
- Department of Intensive Care Medicine, The Fifth Affiliated Hospital of Harbin Medical University, Daqing163711, Heilongjiang Province, China
| | - Libin Huang
- Department of Intensive Care Medicine, Harbin Fifth Hospital, Harbin150001, Heilongjiang Province, China
| | - Ping Xu
- Department of Intensive Care Medicine, General Hospital of Heilongjiang Province Land Reclamation Bureau, Harbin150001, Heilongjiang Province, China
| | - Yan Li
- Department of Intensive Care Medicine, The First Hospital of Harbin, Harbin150001, Heilongjiang Province, China
| | - Haihong Li
- Department of Intensive Care Medicine, Hongqi Hospital Affiliated to Mudanjiang Medical University, Mudanjiang157000, Heilongjiang Province, China
| | - Xuan Liu
- Department of Intensive Care Medicine, Jiamusi Central Hospital, Jiamusi154003, Heilongjiang Province, China
| | - Li Zhang
- Department of Intensive Care Medicine, Daqing Oilfield General Hospital, Daqing163001, Heilongjiang Province, China
| | - Guixia Zhang
- Department of Intensive Care Medicine, The Longnan Hospital of Daqing, Daqing163458, Heilongjiang Province, China
| | - Hongliang Wang
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin150086, Heilongjiang Province, China
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A deep learning model for early risk prediction of heart failure with preserved ejection fraction by DNA methylation profiles combined with clinical features. Clin Epigenetics 2022; 14:11. [PMID: 35045866 PMCID: PMC8772140 DOI: 10.1186/s13148-022-01232-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/07/2022] [Indexed: 12/13/2022] Open
Abstract
Abstract
Background
Heart failure with preserved ejection fraction (HFpEF), affected collectively by genetic and environmental factors, is the common subtype of chronic heart failure. Although the available risk assessment methods for HFpEF have achieved some progress, they were based on clinical or genetic features alone. Here, we have developed a deep learning framework, HFmeRisk, using both 5 clinical features and 25 DNA methylation loci to predict the early risk of HFpEF in the Framingham Heart Study Cohort.
Results
The framework incorporates Least Absolute Shrinkage and Selection Operator and Extreme Gradient Boosting-based feature selection, as well as a Factorization-Machine based neural network-based recommender system. Model discrimination and calibration were assessed using the AUC and Hosmer–Lemeshow test. HFmeRisk, including 25 CpGs and 5 clinical features, have achieved the AUC of 0.90 (95% confidence interval 0.88–0.92) and Hosmer–Lemeshow statistic was 6.17 (P = 0.632), which outperformed models with clinical characteristics or DNA methylation levels alone, published chronic heart failure risk prediction models and other benchmark machine learning models. Out of them, the DNA methylation levels of two CpGs were significantly correlated with the paired transcriptome levels (R < −0.3, P < 0.05). Besides, DNA methylation locus in HFmeRisk were associated with intercellular signaling and interaction, amino acid metabolism, transport and activation and the clinical variables were all related with the mechanism of occurrence of HFpEF. Together, these findings give new evidence into the HFmeRisk model.
Conclusion
Our study proposes an early risk assessment framework for HFpEF integrating both clinical and epigenetic features, providing a promising path for clinical decision making.
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Yao ZP, Li Y, Liu Y, Wang HL. Relationship between the incidence of non-hepatic hyperammonemia and the prognosis of patients in the intensive care unit. World J Gastroenterol 2020; 26:7222-7231. [PMID: 33362378 PMCID: PMC7723668 DOI: 10.3748/wjg.v26.i45.7222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/14/2020] [Accepted: 10/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ammonia is a normal constituent of body fluids and is found mainly through the formation of urea in the liver. Blood levels of ammonia must remain low as even slightly elevated concentrations (hyperammonemia) are toxic to the central nervous system.
AIM To examine the relationship between the incidence of non-hepatic hype-rammonemia (NHH) and the prognosis of patients who were admitted to the intensive care unit (ICU).
METHODS This is a prospective, observational and single-center study. A total of 364 patients who were admitted to the ICU from November 2019 to February 2020 were initially enrolled. Changes in the levels of blood ammonia at the time of ICU admission and after ICU admission were continuously monitored. In addition, factors influencing the prognosis of NHH patients were analyzed.
RESULTS A total of 204 patients who met the inclusion criteria were enrolled in this study, including 155 NHH patients and 44 severe-NHH patients. The incidence of NHH and severe-NHH was 75.98% and 21.57%, respectively. Patients with severe-NHH exhibited longer length of ICU stay and higher Acute Physiologic Assessment and Chronic Health Evaluation and Sequential Organ Failure Assessment scores compared to those with mild-NHH and non-NHH. Glasgow Coma Scale scores of patients with severe-NHH were than those of non-NHH patients. In addition, the mean and initial levels of ammonia in the blood might be helpful in predicting the prognosis of NHH.
CONCLUSION High blood ammonia level is frequent among NHH patients admitted to the ICU, which is related to the clinical characteristics of patients. Furthermore, the level of blood ammonia may be helpful for prognosis prediction.
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Affiliation(s)
- Zhi-Peng Yao
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province, China
| | - Yue Li
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province, China
| | - Yang Liu
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province, China
| | - Hong-Liang Wang
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province, China
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Mattke AC, Shikata F, McGill J, Justo R, Venugopal P. Successful management of a neonate with OTC deficiency presenting with hyperammonemia and severe cardiac dysfunction with extracorporeal membrane oxygenation support and continuous renal replacement therapy. JIMD Rep 2020; 55:12-14. [PMID: 32905004 PMCID: PMC7463050 DOI: 10.1002/jmd2.12135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 02/22/2020] [Accepted: 02/24/2020] [Indexed: 11/24/2022] Open
Abstract
Ornithine transcarbamylase (OTC) deficiency is an X-linked urea cycle disorder which-in severe form-results in rapid accumulation of ammonia and glutamine with subsequent irreversible brain injury. We present a case of severe left ventricular dysfunction with hyperammonemic crisis caused by OTC deficiency which was managed with veno-arterial extracorporeal membrane oxygenation support combined with continuous renal replacement therapy. Aggressive treatment led to normalization of ammonia and full left ventricular recovery.
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Affiliation(s)
- Adrian C. Mattke
- Paediatric Intensive Care Unit, Queensland Children's HospitalSouth BrisbaneQueenslandAustralia
- Queensland Pediatric Cardiac Service, Queensland Children's HospitalSouth BrisbaneQueenslandAustralia
- University of Queensland, Brisbane, School of MedicineSt LuciaQueenslandAustralia
- Paediatric Critical Care Research Group, CCHRUniversity of QueenslandSt LuciaQueenslandAustralia
| | - Fumiaki Shikata
- Queensland Pediatric Cardiac Service, Queensland Children's HospitalSouth BrisbaneQueenslandAustralia
| | - James McGill
- Metabolic Medicine, Queensland Children's HospitalSouth BrisbaneQueenslandAustralia
| | - Rob Justo
- Queensland Pediatric Cardiac Service, Queensland Children's HospitalSouth BrisbaneQueenslandAustralia
- University of Queensland, Brisbane, School of MedicineSt LuciaQueenslandAustralia
| | - Prem Venugopal
- Queensland Pediatric Cardiac Service, Queensland Children's HospitalSouth BrisbaneQueenslandAustralia
- University of Queensland, Brisbane, School of MedicineSt LuciaQueenslandAustralia
- Paediatric Critical Care Research Group, CCHRUniversity of QueenslandSt LuciaQueenslandAustralia
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The Efficacy of Lactulose for the Treatment of Hyperammonemic Encephalopathy Due to Severe Heart Failure. Diagnostics (Basel) 2020; 10:diagnostics10020070. [PMID: 32012742 PMCID: PMC7168910 DOI: 10.3390/diagnostics10020070] [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: 11/29/2019] [Revised: 01/23/2020] [Accepted: 01/26/2020] [Indexed: 11/29/2022] Open
Abstract
Hyperammonemic encephalopathy secondary to heart failure is rare and there had been little reports about effective treatment. Organ hypoperfusion or congestion by heart failure may lead to various organ dysfunctions, and liver and intestinal circulatory impairment might cause ammonia metabolic failure. Here, we report on the case of a patient with hyperammonemic encephalopathy that was secondary to heart failure, which was effectively treated by lactulose.
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