Hyperammonemia after heart-lung transplantation

Yoshida, E; Ostrow, DN; Erb, SR; Fradet, Guy

doi:10.1053/gast.1997.v112.agast972162

Cited by 14 publications

(11 citation statements)

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“…Adult-onset noncirrhotic hyperammonemia (NCH) is a rare clinical condition that is distinct from hepatic encephalopathy. The condition is associated with a very high morbidity and mortality 1,2 and has been described in a variety of settings, including post-solid organ transplantations, most commonly post-lung transplantion, 3 but rarely in post-heart 4 or post-kidney transplantation. [5][6][7][8] Four prior case reports exist for post-kidney transplantation NCH, 3 of which were associated with patient mortality.…”

Section: Discussionmentioning

confidence: 99%

Noncirrhotic hyperammonemia after deceased donor kidney transplantation: A case report

Tio

Pak

et al. 2019

American Journal of Transplantation

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A 72-year-old woman with end-stage kidney disease related to recurrent urinary tract infections, history of recurrent nephrolithiasis, and obstructive uropathy of a solitary kidney presented to our hospital for renal transplantation. Her past medical history was notable for a prior cerebrovascular accident without residual deficits, and oligometastatic colon cancer over 30 years ago, for which she underwent chemotherapy and extensive surgical resection, including a right colectomy, right nephrectomy, and partial hepatectomy.Subsequent to this surgery, she developed recurrent urinary tract infections and renal calculi requiring multiple procedural interventions. She had progressive deterioration of her remaining left kidney function and she eventually initiated hemodialysis 18 months prior to presentation. She had normal baseline functional status and was cleared by the transplantation committee at our institution to be listed as active on the United Network for Organ Sharing kidney waiting list. On the day of admission, a deceased donor organ with a Kidney Donor Profile Index of 85% had become available from a 55-year-old man with a 5-year history of hypertension who died of a hemorrhagic stroke. There was a 3 out of 6 human leukocyte antigen mismatch between donor and recipient. Pretransplant workups are as follows. Preoperative laboratory tests, including liver function tests, were normal with the exception of a creatinine of 4.7 mg/dL, blood urea nitrogen (BUN) of 15 mg/ A 72-year-old woman with end-stage kidney disease due to recurrent urinary tract infections and obstructive uropathy of a solitary kidney presented to our hospital for renal transplantation. She underwent successful transplantation of a deceased donor allograft, but developed acute mental status deterioration on the fifth postoperative day. Her serum ammonia was found to be markedly elevated to 447 μmol/L in the setting of normal hepatic function. She was treated with emergent dialysis and empiric antibiotics targeting urea-splitting organisms, and ultimately made a full neurologic recovery with stable renal allograft function. Noncirrhotic hyperammonemia (NCH)is an exceedingly rare clinical entity but seems to have a predilection for patients who have undergone solid organ transplantation. This report emphasizes the importance of rapid diagnosis and initiation of treatment for NCH, which is associated with a high rate of mortality and irreversible neurological morbidity. We outline the successful workup and management approach for this patient. K E Y W O R D Sclinical research/practice, encephalopathy, genetics, genetics, infection and infectious agents -bacterial, infectious disease, kidney disease, kidney transplantation/nephrology, metabolism/metabolite

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Section: Discussionmentioning

confidence: 99%

Noncirrhotic hyperammonemia after deceased donor kidney transplantation: A case report

Tio

Pak

et al. 2019

American Journal of Transplantation

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“…This syndrome is characterized by elevated serum ammonia levels associated with worsening sensorium (i.e., lethargy, confusion, and agitation), seizures, and normal liver enzymes. Cerebral edema may develop, leading to death in some cases 8‐10 . Previous studies have demonstrated a relationship between Ureaplasma urealyticum , Ureaplasma parvum , and Mycoplasma hominis identification, mostly but not limited to airway specimens, and the development of HS 4‐6,8,11,12,13 .…”

Section: Introductionmentioning

confidence: 99%

Association between Mycoplasma and Ureaplasma airway positivity, ammonia levels, and outcomes post–lung transplantation: A prospective surveillance study

Buzo

Preiksaitis

Halloran

et al. 2021

American Journal of Transplantation

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Hyperammonemia syndrome (HS) is a rare complication with high mortality described after lung transplantation. Its pathophysiology is still unclear, but previous studies, including murine models, have linked the identification of Mycoplasmataceae in airway specimens with HS occurrence. This study explores the association between Mycoplasmataceae polymerase chain reaction (PCR) positivity, ammonia levels, HS, and mortality post–lung transplant. Adults who underwent lung transplantation between July 2017 and August 2019 had prospective surveillance testing for Mycoplasma and Ureaplasma using PCR on post‐operative bronchoscopy samples. One hundred and fifty‐nine patients underwent lung transplantation during the study period. Mean age was 54 (±13) years; baseline diseases were predominantly pulmonary fibrosis (37.7%) and chronic obstructive pulmonary disease (35.8%). Mycoplasma and/or Ureaplasma airway positivity was found in 42 (26.4%) of tested patients, represented mostly by M. salivarium (26/43; 60.4%), U. parvum (7/43; 16.2%), and U. urealyticum (5/43; 11.6%). Median peak ammonia levels were higher in those with Ureaplasma colonization compared to uncolonized patients (p = .04), however, only three patients developed HS. Recipient airway Ureaplasma positivity was independently associated with younger (aOR 0.94, 95% CI 0.88–0.99, p = .04) and female donors (aOR 4.29; 95% CI 1.01–18.2, p = .05).

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“…following lung transplantation typically progresses from early identification of elevated blood NH 3 levels or hyperammonemia (HA), as a cause of altered mental status resulting in confusion, lethargy, obtundation, and agitation, to eventual cerebral edema, resulting in seizure, coma, and often death (3)(4)(5)(6)(7). HS that presents in LTRs and, at lesser frequencies in other solid-organ transplant recipients (SOTRs), is atypical in that these patients do not have underlying liver disease or urea cycle disorders.…”

Section: Hsmentioning

confidence: 99%

Contribution of Uremia to Ureaplasma-Induced Hyperammonemia

Fleming¹,

Patel

2021

Preprint

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Lung transplant recipients (LTRs) are vulnerable to unexplained hyperammonemia syndrome (HS) in the early post-operative period, a condition typically unresponsive to non-antibiotic interventions. Recently, we showed that HS in LTRs is strongly correlated with Ureaplasma infection of the respiratory tract. It is not well-understood what makes LTRs preferentially susceptible to this phenomenon, compared to other immunocompromised hosts. Ureaplasma species harbor highly active ureases that convert urea to ammonia and CO2, utilizing the generated transmembrane potential to synthesize ATP. Post-operative LTRs commonly experience renal failure, resulting in uremia. We hypothesized that uremia could be a potentiating comorbidity to the development of HS secondary to Ureaplasma infection in LTRs by providing increased substrate for ureaplasmal ureases. We designed a novel dialyzed flow system to test the ammonia producing capacity of four isolates of Ureaplasma parvum and six isolates of Ureaplasma urealyticum in media formulations relating to normal and uremic host conditions. For all isolates, growth under uremic conditions resulted in significantly increased ammonia production over 24 hours, despite similar end-point bacterial quantities. Specifically, the isolates produced, on average, 1776.52 [standard deviation=263.98] μmol/L more ammonia when grown under uremic compared to normal conditions. This suggests that uremia, common in early post-operative LTRs, is a plausible contributing factor to the phenomenon of Ureaplasma-induced HS in this patient population.

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Hyperammonemia after heart-lung transplantation

Cited by 14 publications

References 0 publications

Noncirrhotic hyperammonemia after deceased donor kidney transplantation: A case report

Noncirrhotic hyperammonemia after deceased donor kidney transplantation: A case report

Association between Mycoplasma and Ureaplasma airway positivity, ammonia levels, and outcomes post–lung transplantation: A prospective surveillance study

Contribution of Uremia to Ureaplasma-Induced Hyperammonemia

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