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Anand AC, Acharya SK. The Story of Ammonia in Liver Disease: An Unraveling Continuum. J Clin Exp Hepatol 2024; 14:101361. [PMID: 38444405 PMCID: PMC10910335 DOI: 10.1016/j.jceh.2024.101361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/03/2024] [Indexed: 03/07/2024] Open
Abstract
Hyperammonemia and liver disease are closely linked. Most of the ammonia in our body is produced by transamination and deamination activities involving amino acid, purine, pyrimidines, and biogenic amines, and from the intestine by bacterial splitting of urea. The only way of excretion from the body is by hepatic conversion of ammonia to urea. Hyperammonemia is associated with widespread toxicities such as cerebral edema, hepatic encephalopathy, immune dysfunction, promoting fibrosis, and carcinogenesis. Over the past two decades, it has been increasingly utilized for prognostication of cirrhosis, acute liver failure as well as acute on chronic liver failure. The laboratory assessment of hyperammonemia has certain limitations, despite which its value in the assessment of various forms of liver disease cannot be negated. It may soon become an important tool to make therapeutic decisions about the use of prophylactic and definitive treatment in various forms of liver disease.
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Aggarwal A, Biswas S, Arora U, Vaishnav M, Shenoy A, Swaroop S, Agarwal A, Elhence A, Kumar R, Goel A, Shalimar. Definitions, Etiologies, and Outcomes of Acute on Chronic Liver Failure: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00425-7. [PMID: 38750869 DOI: 10.1016/j.cgh.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND & AIMS Acute-on-chronic liver failure (ACLF) is a major public health concern. We aimed to assess the definitions, etiologic spectrum, organ failure (OF), and outcomes of ACLF globally. METHODS Three databases were searched for studies on ACLF from 1990 until September 2022. Information regarding definitions, acute precipitants, underlying chronic liver disease (CLD), OF, and mortality were extracted. Meta-analyses were performed for pooled prevalence rates (95% confidence interval [CI]) using random-effects model for each definition of ACLF. RESULTS Of the 11,451 studies identified, 114 articles (142 cohorts encompassing 210,239 patients) met the eligibility criteria. Most studies (53.2%) used the European Association for the Study of the Liver (EASL) definition, followed by Asia-Pacific Association for the Study of the Liver (APASL) (33.3%). Systemic infection was the major acute precipitant, and alcohol use was the major cause of CLD in EASL-defined studies, whereas alcohol was both the major acute precipitant and cause of CLD in APASL-defined studies. Liver failure was the major OF in APASL-based studies, whereas renal failure was predominant in EASL-based studies. Thirty-day mortality varied across definitions: APASL: 38.9%, 95% CI, 31.2%-46.9%; EASL: 47.9%, 95% CI, 42.2%-53.5%; and NACSELD: 52.2%, 95% CI, 51.9%-52.5%. Diagnostic overlap between definitions ranged from 7.7% to 80.2%. Meta-regression suggested that the World Health Organization region influenced 30-day mortality in studies using EASL definition. CONCLUSIONS Heterogeneity in the definition of ACLF proposed by different expert societies and regional preferences in its use result in differences in clinical phenotype and outcomes. A uniform definition would enhance the comparability and interpretation of global data.
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Affiliation(s)
- Arnav Aggarwal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Sagnik Biswas
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Umang Arora
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Manas Vaishnav
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Abhishek Shenoy
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Shekhar Swaroop
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Ayush Agarwal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Amit Goel
- Department of Hepatology, Sanjay Gandhi Institute of Medical Sciences, Lucknow, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India.
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Thanapirom K, Treeprasertsuk S, Choudhury A, Verma N, Dhiman RK, Al Mahtab M, Devarbhavi H, Shukla A, Hamid SS, Jafri W, Tan SS, Lee GH, Ghazinyan H, Sood A, Kim DJ, Eapen CE, Tao H, Yuemin N, Dokmeci AK, Sahu M, Arora A, Kumar A, Kumar R, Prasad VGM, Shresta A, Sollano J, Payawal DA, Lau G, Sarin SK. Ammonia is associated with liver-related complications and predicts mortality in acute-on-chronic liver failure patients. Sci Rep 2024; 14:5796. [PMID: 38461166 PMCID: PMC10924893 DOI: 10.1038/s41598-024-56401-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/06/2024] [Indexed: 03/11/2024] Open
Abstract
The relationship between ammonia and liver-related complications (LRCs) in acute-on-chronic liver failure (ACLF) patients is not clearly established. This study aimed to evaluate the association between ammonia levels and LRCs in patients with ACLF. The study also evaluated the ability of ammonia in predicting mortality and progression of LRCs. The study prospectively recruited ACLF patients based on the APASL definition from the ACLF Research Consortium (AARC) from 2009 to 2019. LRCs were a composite endpoint of bacterial infection, overt hepatic encephalopathy (HE), and ascites. A total of 3871 cases were screened. Of these, 701 ACLF patients were enrolled. Patients with LRCs had significantly higher ammonia levels than those without. Ammonia was significantly higher in patients with overt HE and ascites, but not in those with bacterial infection. Multivariate analysis found that ammonia was associated with LRCs. Additionally, baseline arterial ammonia was an independent predictor of 30-day mortality, but it was not associated with the development of new LRCs within 30 days. In summary, baseline arterial ammonia levels are associated with 30-day mortality and LRCs, mainly overt HE and ascites in ACLF patients.
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Affiliation(s)
- Kessarin Thanapirom
- Division of Gastroenterology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
- Center of Excellence in Hepatic Fibrosis and Cirrhosis, Chulalongkorn University, Bangkok, Thailand.
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.
| | - Sombat Treeprasertsuk
- Division of Gastroenterology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Nipun Verma
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Radha Krishan Dhiman
- Department of Hepatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | | | - Akash Shukla
- Department of Gastroenterology, Lokmanya Tilak Municipal General Hospital, and Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India
| | - Saeed Sadiq Hamid
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Wasim Jafri
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Soek Siam Tan
- Department of Hepatology, Hospital Selayang, Bata Caves, Selangor, Malaysia
| | - Guan H Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hasmik Ghazinyan
- Department of Hepatology, Nork Clinical Hospital of Infectious Disease, Yerevan, Armenia
| | - Ajit Sood
- Department of Gastroenterology, DMC, Ludhiana, India
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, South Korea
| | - C E Eapen
- Department of Hepatology, CMC, Vellore, India
| | - Han Tao
- Department of Hepatology and Gastroenterology, The Third Central Clinical College of Tianjin Medical University, No. 83, Jintang Road, Hedong District, Tianjin, 300170, China
| | - Nan Yuemin
- Department of Traditional and Western Medical Hepatology, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - A Kadir Dokmeci
- Department of Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Manoj Sahu
- Department of Gastroenterology and Hepatology Sciences, IMS and SUM Hospital, Bhubaneswar, Odisha, India
| | - Anil Arora
- Institute of Liver Gastroenterology and Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Ashish Kumar
- Institute of Liver Gastroenterology and Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, Bihar, India
| | | | - Ananta Shresta
- Department of Hepatology, Alka Hospital Pvt Ltd, Jawalakhel, Lalitpur, Nepal
| | - Jose Sollano
- Department of Medicine, Cardinal Santos Medical Center, Manila, Philippines
| | | | - George Lau
- Department of Medicine, Humanity, and Health Medical Group, Hong Kong, People's Republic of China
- Senior Department of Hepatology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Cai YJ, Dong JJ, Chen RC, Xiao QQ, Li XM, Chen DY, Cai C, Lin XL, Shi KQ, Lu MQ. Serum ammonia variation predicts mortality in patients with hepatitis B virus-related acute-on-chronic liver failure. Front Microbiol 2023; 14:1282106. [PMID: 38111648 PMCID: PMC10725913 DOI: 10.3389/fmicb.2023.1282106] [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: 08/23/2023] [Accepted: 11/15/2023] [Indexed: 12/20/2023] Open
Abstract
Background Hyperammonemia is critical to the development of hepatic encephalopathy (HE) and is associated with mortality in end-stage liver disease. This study investigated the clinical value of ammonia variation in hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) patients. Methods A total of 276 patients with HBV-ACLF were retrospectively recruited. Patients' ammonia levels were serially documented. Baseline ammonia, Peak ammonia (highest level), and Trough ammonia (lowest level) were particularly corrected to the upper limit of normal (AMM-ULN). The primary endpoint was 28-day mortality. Results The 28-day, 3-month, and 12-month mortality rates were 19.2, 25.7, and 28.2%, respectively. A total of 51 (18.4%) patients had overt HE (grade 2/3/4). Peak AMM-ULN was significantly higher in patients with overt HE and non-survivors compared with their counterparts (P < 0.001). Following adjustment for significant confounders, high Peak AMM-ULN was an independent predictor of overt HE (hazard ratio, 1.031, P < 0.001) and 28-day mortality (hazard ratio, 1.026, P < 0.001). The cut-off of Peak AMM-ULN was 1.8, determined by using the X-tile. Patients with Peak AMM-ULN appearing on days 1-3 after admission had a higher proportion of overt HE and mortality compared to other groups. Patients with decreased ammonia levels within 7 days had better clinical outcomes than those with increased ammonia. Conclusion Serum Peak ammonia was independently associated with overt HE and mortality in HBV-ACLF patients. Serial serum ammonia may have prognostic value.
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Affiliation(s)
- Yi-Jing Cai
- Department of Infectious Diseases, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Translational Medicine Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jia-Jia Dong
- Department of Ultrasonography, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Rui-Cong Chen
- Department of Infectious Diseases, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Qian-Qian Xiao
- Department of Infectious Diseases, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xu-Mei Li
- Translational Medicine Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - De-Yuan Chen
- Department of Pathology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Chao Cai
- Department of Infectious Diseases, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xiu-Li Lin
- Department of Infectious Diseases, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ke-Qing Shi
- Translational Medicine Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ming-Qin Lu
- Department of Infectious Diseases, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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Phinder-Puente ME, Pérez-Nieto OR, Hernández-Velázquez NN, Mondragón-Labelle TO, Deloya-Tomas E. Utility of serum ammonia in critically ill hospitalized patients with hepatic encephalopathy. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:455-456. [PMID: 37833135 DOI: 10.1016/j.rgmxen.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 04/26/2023] [Indexed: 10/15/2023]
Affiliation(s)
- M E Phinder-Puente
- Unidad de Cuidados Intensivos, Hospital General San Juan del Río, Querétaro, Mexico.
| | - O R Pérez-Nieto
- Unidad de Cuidados Intensivos, Hospital General San Juan del Río, Querétaro, Mexico
| | - N N Hernández-Velázquez
- Departamento de Gastroenterología y Endoscopía, Hospital General San Juan del Río, Querétaro, Mexico
| | | | - E Deloya-Tomas
- Unidad de Cuidados Intensivos, Hospital General San Juan del Río, Querétaro, Mexico
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Jalan R, Rose CF. Heretical thoughts into hepatic encephalopathy. J Hepatol 2022; 77:539-548. [PMID: 35358618 DOI: 10.1016/j.jhep.2022.03.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/03/2022] [Accepted: 03/11/2022] [Indexed: 02/06/2023]
Abstract
Clinical progress in the development of new diagnostic modalities and therapeutic strategies for the management of patients with hepatic encephalopathy has lagged behind the vast knowledge that has been generated from basic studies. In this article, we critically assess matters that should be revisited, such as definition, classification, diagnosis and grading of hepatic encephalopathy, which are difficult to apply reproducibly using the current criteria. Many lines of investigation have confirmed that hepatic encephalopathy is irreversible in many patients and suggest the need for further studies focussing on mechanisms of neuronal injury and death, to guide future drug development for these patients. The clinical evidence behind using lactulose for all severities of hepatic encephalopathy, which is currently considered the standard of care, is poor and placebo-controlled trials for hepatic encephalopathy should be considered ethically sound. This expert opinion identifies current challenges in hepatic encephalopathy and highlights areas which require further debate and investigation in order to help advance the field both scientifically and clinically.
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Affiliation(s)
- Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom.
| | - Christopher F Rose
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montreal, Canada.
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