Complication of Parenteral Nutrition Composed of Essential Amino Acids and Histidine in Adults With Renal Failure

Abstract

This is a case report on six patients with hyperammonemia that developed while they were receiving total parenteral nutrition (TPN) as a component of renal failure therapy. Clinically, the hyperammonemia presented as mental status changes in all six cases. Four of the six patients with renal failure initially received 400 mL Amiyu in 1400 mL 17% glucose (total = 1800 mL TPN-A) administered over each 24-hour period. Two patients had been placed on 400 mL complete amino acid in 1400 mL 17% glucose (total = 1800 mL TPN-C over each 24-hour period) prior to therapy with TPN-A. Approximately 3 weeks after initiation of TPN therapy with TPN-A, episodes of mental status changes of increasing duration and paroxysms were documented in five of the six patients. In one of the patients receiving TPN-C prior to TPN-A therapy, toxicity was clinically evident only 4 days after initiation of TPN-A. Serum ammonia levels were obtained and found to be elevated in the acute (ie, presenting) stage in all patients. With the discontinuance of TPN-A, ammonia levels normalized uniformly. Mental status also improved in all cases except for the patient with rapid clinical presentation who died 2 weeks after first evidence of clinical toxicity. In cases 1, 2, and 6, serum amino acid analysis in the acute phase showed reduced levels of ornithine and citrulline, the substrate and product, respectively, of condensation with carbamyl phosphate at its entry into the urea cycle. Moreover, levels of arginine, precursor to ornithine, were found to be elevated.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of a New Amino Acid Solution on Nutritional Status and Nitrogen Metabolism in Rats with Chronic Renal Failure Undergoing Hyperalimentation.

“…An increase in plasma orotic acid level has also been observed in patients with renal failure undergoing hyperalimentation containing EAA without arginine (25). In the present study, the plasma orotic acid was not determined, but the urinary excretion of orotic acid in each TPN group was low and the plasma Cr level as an index of renal function did not increase during the period of TPN.…”

The Principles and Practice of Nutritional Support

“…Further concern about the use of EAA was raised by the observation of mental status changes associated with metabolic side effects in children and adults with ARF treated with EAA. Investigation revealed hyperammonemia and hyperchloremic metabolic acidosis, elevated plasma methionine and ammonia, and depressed plasma citrulline, ornithine, arginine, and histidine levels [272,273]. The explanation for this appeared to be impairment of the capacity of key urea cycle intermediates (ornithine and citrulline) to accept ammonia from carbamoyl phosphate ( Fig.…”

Expert working group report on nutrition in adult patients with renal insuffciency (Part 2 of 2)

“…Protein intake might be gradually increased up to 0.8 g/kg/day if BUN levels are below *36 mmol/L; 0.6±1.0 range of protein or essential amino acids (EAA) and non essential amino acids (NEAA) has been also suggested in these patients (91). In ARF, besides EAA, also NEAA histidine, arginine, tyrosine, serine, and cysteine become indispensable, while others, such as phenylalanine and methionine, may accumulate (91,92). If more than 0.4±0.5 g/kg/day of amino acids are infused, non essential amino acids, and in particular those from the urea cycle (arginine, ornitine or citrulline) must also be given (91).…”