Abstract
A controlled study was carried out in two groups of 20 patients with cirrhosis of the liver and deep coma in order to compare the efficacy of intravenous branched-chain amino acid solutions in 20% glucose (group A) vs lactulose plus glucose in isocaloric amount (group B). There were 3 drop-outs from each group. Plasma amino acids and ammonia were assayed at fixed intervals throughout the 10-day observation period. Routine tests were assayed daily. Complete mental recovery was obtained in 70% of patients in group A and in 47% in group B. The difference was not significant, likely due to the lack of placebo group. With the exception of free tryptophan/all competing amino acids ratio, the modifications in plasma amino acid levels showed no correlation with the clinical course under either treatment. Ammonia, like free tryptophan, decreased significantly upon mental recovery, paralleling the clinical course throughout the study. In conclusion, branched-chain amino acids are at least as effective as lactulose in deep hepatic coma. It is suggested that branched-chain amino acids may reverse coma either by competing with brain entry of the aromatic amino acid or by metabolically decreasing free tryptophan and ammonia.
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Fischer JE, Funovics JM, Aguirre A, James JH, Keane JM, Wesdrop RIC, Yoshimura N, Westman T: The role of plasma amino acids in hepatic encephalopathy. Surgery 78:276–290, 1975
Cascino A, Cangiano C, Calcaterra V, Rossi-Fanelli F, Capocaccia L: Plasma amino acids imbalance in patients with liver disease. Am J Dig Dis 23:591–598, 1978
Fischer JE, Rosen HM, Ebeid AM, James JH, Keane J, Soeters PB. The effect of normalization of plasma amino acids on hepatic encephalopathy in man. Surgery 80:77–91, 1976
Zieve L: Amino acids in liver failure. Gastroenterology 76:219–221, 1979
Rossi-Fanelli F, Cangiano C, Cascino A, Fiaccadori F, Ghinelli F, Riggio O, Capocaccia L: The therapeutic effect of branched chain amino acids in hepatic encephalopathy. Clin Res 27:579A, 1979
Capocaccia L, Calcaterra V, Cangiano C, Cascino A, Fiaccadori F, Gentile S, Ghinelli F, Pelosi G, Riggio O, Rossi-Fanelli F, Sacchini D, Giunchi G: Therapeutic effect of branched-chain amino acids in hepatic encephalopathy: a preliminary study.In Medical and Surgical Problems of Portal Hypertension. MJ Orloff, S Stipa, V Ziparo (eds). London, Academic Press, 1980, pp 239–249
O'Keefe SJD, Whyte W, Trey C, Blackburn GL: The therapeutic use of branched-chain amino acids in hepatic encephalopathy. Clin Res 26:324A, 1978
Conn HO and Lieberthal MM: The Hepatic Coma Syndromes and Lactulose, Baltimore, Williams & Wilkins, 1979
Adams RD, Foley JM: The neurological disorder associated with liver disease. Res Publ Assoc Res Nerv Ment Dis 32:198–237, 1953
Earley LE: Conclusive remarks and presentation of diagnostic criteria of the hepato-renal syndrome.In Hepato-renal Syndrome. E Bartoli, L Chiandussi (eds), Padova, Piccin Medical Books, 1980, pp 494–499
Attili AF, Autizi D, Capocaccia L, Constantini S, Cotta-Ramusino F: Rapid determination of plasma ammonia using an ion specific electrode. Biochem Med 14:109–116, 1975
Perry TL, Hansen S: Technical pitfalls leading to errors in the quantitation of plasma amino acids. Clin Chim Acta 25:53–58, 1969
Cangiano C, Calcaterra V, Cascino A, Capocaccia L: Bound and free tryptophan plasma levels in hepatic encephalopathy. Rend Gastroenterol 8:186–189, 1976
Fischer JE, Baldessarini RJ: Pathogenesis and therapy of hepatic coma.In Progress in Liver Disease. H Popper, F Schaffner (eds), New York, Grune and Stratton, 1976, pp 363–397
Fiaccadori F, Ghinelli F, Pelosi G, Sacchini D, Vaona GL, Zeneroli ML, Rocchi E, Santunione V, Gibertini P, Ventura E: Selective amino acid solutions in hepatic encephalopathy treatment. La Ricerca 10:411–422, 1980
Striebel JP, Holm E, Lutz H, Storz LW: Parenteral nutrition and coma therapy with amino acids in hepatic failure. JPEN 3:240–246, 1979
Fischer JE, Yoshimura N, Aguirre A, James JH, Cummings MG, Abel RM, Deindoefer F: Plasma amino acids in patients with hepatic encephalopathy. Effect of amino acid infusions. Am J Surg 127:40–47, 1974
Watanabe A, Takeane A, Higashi T, Nagashima N: Serum amino acids in hepatic encephalopathy. Effect of branched chain amino acid infusion on serum aminogram. Acta Hepato-Gastroenterol 26:346–357, 1979
Sato Y, Eriksson S, Hagenfeld L, Wahren J: Inhibition of brain uptake of aromatic amino acids in hepatic cirrhosis by branched chain amino acid infusion. JPEN 3:390, 1979 (abstract)
Knott PJ, Curzon G: Free tryptophan in plasma and brain tryptophan metabolism. Nature 239:452–453, 1972
Rossi-Fanelli F, Angelico M, Cangiano C, Cascino A, Capocaccia R, De Conciliis D, Riggio O, Capocaccia L: Effect of glucose and/or branched chain amino acid infusions on plasma amino acid imbalance in chronic liver failure. JPEN 5:414–419, 1981
Cangiano C, Rossi-Fanelli F, Cascino A, Capocaccia L: Tryptophan and hepatic encephalopathy. Gastroenterology 77:203–205, 1979 (letter)
Ono J, Hutson DG, Dombro RS, Levi JU, Livingstone A, Zeppa R: Tryptophan and hepatic coma. Gastroenterology 74:196–200, 1978
Salerno F, Dioguardi SD, Abbiati R: Tryptophan and hepatic coma. Gastroenterology 75:769–779, 1978 (letter)
Hutson DG, Ono J, Dombro RS, Levi JV, Livingstone A, Zeppa R: A longitudinal study of tryptophan involvement in hepatic coma. Am J Surg 137:235–239, 1979
Goldberg AL, Odessey R: Oxidation of amino acids by diaphragms from fed and fasted rats. Am J Physiol 223:1384–1391, 1972
Freund H, Yoshimura N, Lunetta L, Fischer JE: The role of the branched chain amino acids in decreasing muscle catabolismin vivo. Surgery 83:611–618, 1978
Adibi SA: Roles of branched chain amino acids in metabolic regulation. J Lab Clin Med 95:475–484, 1980
Lockwood AH, McDonald JM, Reiman RE, Gelbard AS, Laughlin SJ, Duffy TE, Plum F: The dynamics of ammonia metabolism in man. J Clin Invest 63:449–460, 1979
James JH, Ziparo V, Jeppson B, Fischer JE: Hyperammonemia plasma AA imbalance and blood brain amino acid transport: A unified theory of portal systemic encephalopathy. Lancet 2:772–775, 1979
Cardelli-Cangiano P, Cangiano C, James JH, Jeppsson B, Brenner W, Fischer JE: Uptake of amino acids by brain microvessels isolated from rats after portocaval anastomosis. J Neurochem 36:627–632, 1981
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Participants in the study included: V. Petroni Albertini (Ente Ospedaliero Centro, Rome), F. Alegiani (Ospedale Fatebenefratelli, Rome), R. Bernardi (Boehringer Biochemia Robin, Milan), P. Guarascio (Ente Ospedaliero Monteverde, Rome), M. Luminari (Ente Ospedaliero Monteverde, Rome), U. Naim (Ente Ospedaliero Monteverde, Rome), M. Sposito (Ente Ospedaliero Centro, Rome), G. Visco (Ente Ospedaliero Monteverde, Rome), and S. Vulterini (Ospedale Fatebenefratelli, Rome).
This work was supported by grant 500.6/Contr. 70/1743, Ministry of Health, Rome, Italy.
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Rossi-Fanelli, F., Riggio, O., Cangiano, C. et al. Branched-chain amino acids vs lactulose in the treatment of hepatic coma. Digest Dis Sci 27, 929–935 (1982). https://doi.org/10.1007/BF01316578
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DOI: https://doi.org/10.1007/BF01316578