Successful management of hyperammonemia with hemodialysis on day 2 during 5-fluorouracil treatment in a patient with gastric cancer: a case report with 5-fluorouracil metabolite analyses.

PURPOSE: Hyperammonemia is an important adverse event associated with 5-fluorouracil (5FU) from 5FU metabolite accumulation. We present a case of an advanced gastric cancer patient with chronic renal failure, who was treated with 5FU/leucovorin (LV) infusion chemotherapy (2-h infusion of LV and 5FU bolus followed by 46-h 5FU continuous infusion on day 1; repeated every 2 weeks) and developed hyperammonemia, with the aim of exploring an appropriate hemodialysis (HD) schedule to resolve its symptoms. METHODS: The blood concentrations of 5FU and its metabolites, α-fluoro-ß-alanine (FBAL), and monofluoroacetate (FA) of a patient who had hyperammonemia from seven courses of palliative 5FU/LV therapy for gastric cancer were measured by liquid chromatography-mass spectrometry. RESULTS: On the third day of the first cycle, the patient presented with symptomatic hyperammonemia relieved by emergency HD. Thereafter, the 5FU dose was reduced; however, in cycles 2-4, the patient developed symptomatic hyperammonemia and underwent HD on day 3 for hyperammonemia management. In cycles 5-7, the timing of scheduled HD administration was changed from day 3 to day 2, preventing symptomatic hyperammonemia. The maximum ammonia and 5FU metabolite levels were significantly lower in cycles 5-7 than in cycles 2-4 (NH3 75 ± 38 vs 303 ± 119 µg/dL, FBAL 13.7 ± 2.5 vs 19.7 ± 2.0 µg/mL, FA 204.0 ± 91.6 vs 395.9 ± 12.6 ng/mL, mean ± standard deviation, all p < 0.05). After seven cycles, partial response was confirmed. CONCLUSION: HD on day 2 instead of 3 may prevent hyperammonemia in 5FU/LV therapy.

Plasma fluoroacetic acid concentrations: Symptoms, hematological, and biochemical characteristics in patients with fluoroacetic acid poisoning in the emergency department.

Fluoroacetic acid (FAcOH) was once a highly toxic rodenticide widely used in the world. In the past, studies on the toxicity of FAcOH have focused on animal experiments. The toxicity of FAcOH to humans and the changes of FAcOH in plasma have not been studied. Therefore, the present study aimed to describe the changes of plasma FAcOH concentrations, hematological, and biochemical characteristics in patients with FAcOH intoxication. According to clinical symptoms, 68 patients from the emergency department were divided into different groups: convulsion group, unconsciousness group, death group, and control groups. Plasma FAcOH concentrations, hematological, and biochemical parameters were investigated. Results demonstrated that patients in the convulsion group and the unconsciousness group had a significant increase (p < 0.01) in the level of neuron-specific enolase (NSE), creatine kinase MB (CKMB), glucose (GLU), and white blood cell count (WBC) and a significant decrease (p < 0.01) in serum potassium compared with the control group, respectively. Moreover, patients in the death group had a significant increase (p < 0.01) in the level of NSE, CKMB, N-terminal pro-brain natriuretic peptide, GLU, and WBC and a significant decrease (p < 0.01) in serum potassium and total calcium compared with the survival group. The concentrations of FAcOH in plasma in the convulsion group, the unconsciousness group, and the death group were 72.31 ± 42.29, 118.33 ± 55.41, and 163.78 ± 43.32 µg/mL, respectively. These changes and the plasma FAcOH concentrations may increase our understanding of the toxicity of FAcOH to humans and may help doctors to judge the clinical prognosis of patients with FAcOH intoxication.

[Determination of monofluoroacetic acid in plasma and urine by stable isotope dilution ion chromatography-triple quadrupole mass spectrometry].

A method was developed for the determination of monofluoroacetic acid (MFA) in plasma and urine by ion chromatography-triple quadrupole mass spectrometry (IC-MS/MS). A plasma sample was extracted with 3% (v/v) perchloric acid aqueous solution, and the extract was centrifuged to remove the protein and lipids. A urine sample was acidulated with 3% (v/v) perchloric acid aqueous solution. The target analyte was extracted with methyl tert-butyl ether (MTBE) at a pH between 0.5 and 1.0. After the MTBE was removed by blowing with nitrogen, the MFA in the residues was dissolved into 0.1% (v/v) ammonia solution. The separation of MFA was carried out on a Dionex Ionpac AS 19 analytical column (250 mm×2 mm, 7.5 µm) with gradient elution using KOH solution electrolytically generated from an on-line eluent generation cartridge. Before the eluent flow entered the mass spectrometer, an in-line suppressor was used to remove potassium ions. The MFA was detected with a negative electrospray ionization source in the multiple reaction monitoring (MRM) mode, and quantified with the stable isotope internal standard method. The correlation coefficient of the linear calibration curve of MFA was greater than 0.999 at the corresponding ranges of 0.1-1000 µg/L. The average recoveries were 96.2%-120% of MFA in plasma and urine samples with relative standard deviations of 1.1%-13.1% (n=6). The limits of detection of MFA in plasma and urine samples were 0.03 µg/L and 0.1 µg/L, respectively. The method is simple, sensitive and accurate, and can be applied for the determination of MFA in plasma and urine samples.

Analysis of monofluoroacetic acid in human plasma by UFLC-MS/MS and its application in patients with sodium monofluoroacetate or monofluoroacetamide poisoning.

Monofluoroacetic acid (FAcOH), was once widely used in baits as a rodenticide in agriculture. For intentional and unintentional misuses, the incidence of FAcOH poisoning has increased in recent years. Organic fluorine rodenticides such as sodium monofluoroacetate and monofluoroacetamide, the analogs of FAcOH, can easily be converted to FAcOH in vivo and cause injury. It is urgent to establish a simple and sensitive analytical method of FAcOH in human plasma and applied to clinical poison analysis. In this paper, an ultra-fast liquid chromatography-tandem mass spectrometry (UFLC-MS/MS) method was developed for determination of FAcOH in patient plasma. We used isotopic labelled FAcOH-13C2, D2 as the internal standard (IS). Plasma samples were simply precipitated with acetonitrile and the supernatant was injected directly for analysis. The chromatographic column was Phenomenex Luna® Silica column (100 × 2 mm, 3 µm), FAcOH was eluted by isocratic elution with a mobile phase of acetonitrile-water contains 5 mM ammonium formate with 0.2% formic acid. The retention time of FAcOH was 2.31 min A good linear response was from 0.25 to 200 µg/mL, with a correlation coefficient of r = 0.9980. The limit of detection was 0.05 µg/mL. The recoveries at three spiking levers were 89.51-93.03% with relative standard deviations ranged between 2.55-3.61%. This new method has been successfully applied to monitor 31 cases of patients suspected with sodium monofluoroacetate or monofluoroacetamide poisoning.

Accumulation of alpha-fluoro-beta-alanine and fluoro mono acetate in a patient with 5-fluorouracil-associated hyperammonemia.

PURPOSE: High-dose 5-fluorouracil (5-FU) containing chemotherapy occasionally causes hyperammonemia and can be lethal. However, the mechanism of 5FU-associated hyperammonemia has not been known. The aim of this study was to reveal the pharmacokinetics of 5-FU-associated hyperammonemia in a recurrent colorectal cancer patient with end-stage renal disease (ESRD). METHODS: We experienced a case of hyperammonemia during mFOLFOX6 plus bevacizumab therapy for recurrent colorectal cancer. He was a dialyzed patient due to diabetic nephropathy and was registered to prospective blood sampling for pharmacokinetics analysis during chemotherapy. Blood concentrations of 5-FU and its catabolites were determined by inductively coupled plasma-mass spectrometry. RESULTS: The patient developed hyperammonemia encephalopathy 41 h after the initiation of continuous 5-FU infusion (on the third day). Before onset of hyperammonemia encephalopathy, serum alpha-fluoro-beta-alanine (FBAL, 59.2 µg/ml) and fluoro mono acetate (FMA, 905.8 ng/ml) were gradually increased. After hemodialysis for hyperammonemia, FBAL and FMA were collaterally decreased and his symptom was improved. Other intermediate catabolites of 5-FU, dihydrofluorouracil, and alpha-fluoro-beta-ureidopropionic acid were not changed. CONCLUSION: We found increases of serum FBAL and FMA under the condition of hyperammonemia in the patient with ESRD during mFOLFOX6 plus bevacizumab therapy. This research supported the hypothesis that impairment of tricarboxylic acid (TCA) cycle by FMA would cause 5-FU-associated hyperammonemia.

Determination of plasma dibasic amino acids following trimethylsilyl-trifluoroacyl derivatization using gas chromatography-mass spectrometry.

A rapid analytical method was developed to quantify dibasic amino acids (ornithine, lysine and arginine) after two-step derivatization procedure with good sensitivity and specificity on human plasma. If early diagnosis has not been made, patients with inborn metabolic disorders such as HHH syndrome, Hyperornithinemia and dibasic aminoaciduria rapidly progress to sudden death, physical defect or mental retardation resulting in storage of the toxic material into the brain. Therefore, it is necessary to develop the analytical method for rapid screening and/or correct confirmation diagnosis. The formation of trimethylsilyl derivative of the carboxylic (COO-) functional group was performed by adding MSTFA. Five µL of methyl orange was added to the residue until the color changed into yellow. Consecutively, the trifluoroacyl derivative of the amino (-NH2) functional group was produced by adding MBTFA. Specific ions was chosen for quantification with following ions; m/z 166 and m/z 212 for ornithine, m/z 180 and m/z 395 for lysine, and m/z 292 and, m/z 519 for arginine. A calibration curve showed a linear relationship for the dibasic amino acids spiked to pooled normal plasma showing R(2) of 0.9955-0.9979 in the range of 0.1-600 ng investigated. The utility of the method for screening and diagnosis was demonstrated by recovery 80-125 % and reproducibility with RSD (9-17 %) at low, medium and high concentration fortified to pooled plasma. Collectively, the present study suggest that this method could be useful for diagnosis, screening, therapeutic monitoring of metabolic disorders on dietary therapy with excellent sensitivity and rapidity.

Determination of fluoroacetate and fluoride in blood serum by capillary zone electrophoresis using capacitively coupled contactless conductivity detection.

Fluoroacetate is a highly toxic species naturally found in plants and in commercial products (compound 1080) for population control of several undesirable animal species. However, it is non-selective and toxic to many other animals including humans, and thus its detection is very important for forensic purposes. This paper presents a sensitive and fast method for the determination of fluoroacetate in blood serum using capillary electrophoresis with capacitively coupled contactless conductivity detection. Serum blood samples were treated with ethanol to remove proteins. The samples were analyzed in BGE containing 15 mmol/L histidine and 30 mmol/L gluconic acid (pH 3.85). The calibration curve was linear up to 75 µmol/L (R² =0.9995 for N=12). The detection limit in the blood serum was 0.15 mg/kg, which is smaller than the lethal dose for humans and other animals. Fluoride, a metabolite of the fluoroacetate defluorination, could also be detected for levels greater than 20 µmol/L, when polybrene was used for reversion of the EOF. CTAB and didecyldimethylammonium bromide are not useful for this task because of the severe reduction of the fluoride level. However, no interference was observed for fluoroacetate.

Evaluation of 6-([(18)F]fluoroacetamido)-1-hexanoicanilide for PET imaging of histone deacetylase in the baboon brain.

INTRODUCTION: Histone deacetylases (HDACs) are enzymes involved in epigenetic modifications that shift the balance toward chromatin condensation and silencing of gene expression. Here, we evaluate the utility of 6-([(18)F]fluoroacetamido)-1-hexanoicanilide ([(18)F]FAHA) for positron emission tomography imaging of HDAC activity in the baboon brain. For this purpose, we assessed its in vivo biodistribution, sensitivity to HDAC inhibition, metabolic stability and the distribution of the putative metabolite [(18)F]fluoroacetate ([(18)F]FAC). METHODS: [(18)F]FAHA and its metabolite [(18)F]FAC were prepared, and their in vivo biodistribution and pharmacokinetics were determined in baboons. [(18)F]FAHA metabolism and its sensitivity to HDAC inhibition using suberanilohydroxamic acid (SAHA) were assessed in arterial plasma and by in vitro incubation studies. The chemical form of F-18 in rodent brain was assessed by ex vivo studies. Distribution volumes for [(18)F]FAHA in the brain were derived. RESULTS: [(18)F]FAHA was rapidly metabolized to [(18)F]FAC, and both labeled compounds entered the brain. [(18)F]FAHA exhibited regional differences in brain uptake and kinetics. In contrast, [(18)F]FAC showed little variation in regional brain uptake and kinetics. A kinetic analysis that takes into account the uptake of peripherally produced [(18)F]FAC indicated that SAHA inhibited binding of [(18)F]FAHA in the baboon brain dose-dependently. In vitro studies demonstrated SAHA-sensitive metabolism of [(18)F]FAHA to [(18)F]FAC within the cell and diffusion of [(18)F]FAC out of the cell. All radioactivity in brain homogenate from rodents was [(18)F]FAC at 7 min postinjection of [(18)F]FAHA. CONCLUSION: The rapid metabolism of [(18)F]FAHA to [(18)F]FAC in the periphery complicates the quantitative analysis of HDAC in the brain. However, dose-dependent blocking studies with SAHA and kinetic modeling indicated that a specific interaction of [(18)F]FAHA in the brain was observed. Validating the nature of this interaction as HDAC specific will require additional studies.

Simultaneous determination of two acute poisoning rodenticides tetramine and fluoroacetamide with a coupled column in poisoning cases.

A coupled column system was developed for the simultaneous determination of both rodenticides fluoroacetamide and tetramine in this paper by gas chromatography/mass spectrometry (GC/MS). A short length of strong polar column (1.5 m of Innowax) was coupled to the top of a 30 m of DB-5 ms with a quartz capillary column connector. Peak width at half height (W(h)) was used to evaluate the band broadening of the coupled column system. The length of the short couple column and oven temperature program were discussed according to W(h). The precisions of the coupled column were analyzed with peak area and retention time. Good linear correlations were found for both rodenticides. Typical samples were discussed for each rodenticide and some poisoning cases were presented.

Quantitative analysis of monofluoroacetate in biological samples by high-performance liquid chromatography using fluorescence labeling with 9-chloromethylanthracene.

A rapid and sensitive RP-HPLC method with fluorescence detection has been developed for the quantitative analysis of trace amounts of monofluoroacetate (MFA) in biological samples as serum, food and meat. 9-Chloromethylanthracene (9-CMA) is used as the fluorescence labeling reagent. Samples were extracted and reacted with 9-chloromethylanthracene together with tetrabutylammonium bromide as catalyst at 80 degrees C for 50 min to give a new fluorescent derivative as 9-methyleneanthracene monofluoroacetate (MA-MFA). The resulting MA-MFA was characterized with IR, (1)H NMR, (13)C NMR and MS. Chromatography separation is performed on an Agilent Hypersil ODS column with a fluorescent detector employed with the excitation and emission wavelengths as 256 nm and 412 nm, respectively. Optimal conditions for derivatization, fluorescence detection and chromatographic separation have been established. The novel method yields a good linear relationship when the MFA concentration in serum within 1 and 250 ng/mL (r=0.9988). The detection limit (signal-to-noise ratio=3 with 2 microL injected) was 0.25 ng/mL. The practical applicability of this method was demonstrated by quantitative determination of MFA-Na in a blood sample from a person who had ingested the poison.

[Determination of sodium monofluoroacetate in human blood and food samples by ion chromatography].

A method was developed for the determination of sodium monofluoroacetate in human blood by ion chromatography. The analysis was performed on a Dionex Ion Pac AS11 column (250 mm x 4 mm i.d.) with an AG11 guard column (50 mm x 4 mm i.d.). A conductivity detector, an SRS suppressor and a 25 microL sample loop were used. The eluent was 2.0 mmol/L Na2B4O7 with a flow rate of 1.0 mL/min. A blood sample of 0.2 mL was pipetted into a test tube followed by adding 1.0 mL of pure water. And then acetonitrile was used to dilute it to 3.0 mL. After the protein was settled down from the blood sample, the supernatant layer was filtered through a 0.45 microm filter before injected into the ion chromatographic system. Good linear relationship between the peak area and the concentration of sodium monofluoroacetate was found with correlation coefficient (r2) of 0.9978 within the range from 0.10 to 10.0 mg/L. The detection limit for blood was 2.5 mg/L. This method also can be used for the determination of sodium monofluoroacetate in food samples.

Headspace solid-phase microextraction with 1-pyrenyldiazomethane on-fibre derivatisation for analysis of fluoroacetic acid in biological samples.

A new and in part automated headspace solid-phase microextraction method for quantitative determination of the highly toxic rodenticide fluoroacetic acid (FAA) in serum and other biological samples has been developed. FAA and deuterated acetic acid (internal standard) were extracted from acidified samples by a StableFlex divinylbenzene-Carboxen on polydimethylsiloxane fibre. The acids were derivatised on the fibre in-situ with 1-pyrenyldiazomethane and detected using gas chromatography-mass spectrometry with electron impact ionisation and selected ion monitoring. The calibration curve for FAA in serum was linear over the range from 0.02 to 5 microg/ml, with limits of detection and quantification of 0.02 and 0.07 microg/ml, respectively. The method was also tested with spiked whole blood, urine, stomach contents and kidney samples. It was sufficiently reliable, reproducible and sensitive for use in routine forensic toxicology applications.

Sorption of fluoroacetate (compound 1080) by Colestipol, activated charcoal and anion-exchange in resins in vitro and gastrointestinal decontamination in rats.

The sorption of sodium fluoroacetate (FA) by activated charcoal (AC) and 5 anion exchange resins (AERs) was tested in 2 simulated gastrointestinal (GI) fluids. Each sorbent was incubated with FA in a shaker-water-bath at 37 C for 24 h. Supernatant was removed and filtered, and the concentration of FA was determined by gas chromatographic detection of the dichloroaniline derivative. Under simulated gastric conditions (0.1 M HCl at approximately pH 1.5), the sorbents removed the following proportions of FA from solution: Carbosorb AC, 87 +/- 2%; cholestyramine, 28 +/- 7%; colestipol, 96 +/- 0%; Amberlite IRA-96, 70 +/- 2%; DEAE-Sephadex, 7 +/- 4%; Chitosan, 66 +/- 2%. Under simulated intestinal conditions (0.05 M sodium phosphate at approximately pH 7.4), binding was as follows: Carbosorb AC, 68 +/- 4%; cholestyramine, 53 +/- 5%; colestipol, 46 +/- 2%; AmberliteIRA-96, 10 +/- 20%; DEAE-Sephadex, 64 +/- 7%; Chitosan, 5 +/- 2%. All findings differed significantly from control, with the exception of Amberlite IRA-96 and Chitosan in phosphate buffer, and DEAE-Sephadex in HCI. In a second study, rats were given 5 mg FA/kg, and then gavaged with 2 g/kg Carbosorb AC, colestipol or bentonite. Over 4 h, the area under the curve of serum FA versus time (AUC) decreased by 39% in the rats treated with colestipol and 42% in those treated with bentonite. In contrast, Carbosorb AC did not affect the AUC,yet increased Tmax In another study, mortality was assessed 96 h after rats were orally dosed with 5 mg FA/kg followed by gavage with 2 g/kg Carbosorb AC, colestipol or water immediatey or 30 min after dosing. When the sorbents were given immediately, mortality was the same as control (75%). Surprisingiy, the 30-min delay resulted in lower mortality in colestipol-treated rats, (approximately 38%) compared to 100% in the group treated with Carbosorb AC. Before any recommendation can be made regarding the use of colestipol as a GI decontaminant, the latter findings require confirmation in an intensive care setting. The potential for synergistic effects with 2 or more sorbents also warrant investigating.

Persistence of sodium monofluoroacetate in livestock animals and risk to humans.

1. Sodium monofluoroacetate (1080), a vertebrate pesticide widely used in New Zealand, was administered orally to sheep and goats at a dose level of 0.1 mg kg-1 body weight to assess risk to humans of secondary poisoning from meat. Blood, muscle, liver, and kidney were analysed for 1080 residues. 2. The plasma elimination half-life was 10.8 h in sheep and 5.4 h in goats. Concentrations of 1080 in muscle (0.042 microgram g-1), kidney (0.057 microgram g-1), and liver (0.021 microgram g-1) were substantially lower than those in plasma (0.098 microgram ml-1) at 2.5 h after dosing. 3. Only traces of 1080 (< 0.002 to 0.008 microgram g-1) were found in sheep tissues after 96 hours. 4. Livestock are normally excluded from areas where 1080 is being used for pest control, reducing the risk of secondary poisoning. Even with accidental exposure to a sublethal dose 1080 would not persist in tissues for more than a few days because it is cleared rapidly from the body. Therefore the occurrence of 1080 in meat intended for human consumption is highly unlikely.

Determination of membrane potential and cell volume by 19F NMR using trifluoroacetate and trifluoroacetamide probes.

The distribution of ionic species between intra- and extracellular compartments forms one basis for the determination of cell membrane potential. It is shown that fluorine-19 NMR studies of erythrocytes in the presence of trifluoroacetate, a stable, relatively nontoxic anion with pK = -0.3, provide a sensitive probe of membrane potential. Since such measurements are based on ion concentrations, the parallel use of the neutral analogue trifluoroacetamide to provide information on intra/extracellular volume ratios was also explored. In both cases, separate 19F resonances corresponding to intra- and extracellular ions were observed, with the intracellular resonance shifted downfield by approximately 0.2 ppm and the intracellular peak typically somewhat broader than the extracellular resonance. Studies with the band 3 anion-exchange inhibitor 4-acetamido-4'-isothiocyanatostilbene-2,2'-disulfonic acid (SITS) indicate that both transmembrane diffusion and flux involving the band 3 anion exchanger contribute to the observed transport of the trifluoroacetate anion. Intra/extracellular volume ratios determined on the basis of trifluoroacetamide intensity ratios were in good agreement with determinations based on measured hematocrits. On the basis of the high sensitivity of 19F NMR and the capability of monitoring volume changes simultaneously, the time resolution for these measurements can approach the lifetime of intracellular trifluoroacetate ions and hence be limited by the trifluoroacetate flux rate.

Inorganic and organic fluoride concentrations in tissues after the oral administration of sodium monofluoroacetate (Compound 1080) to rats.

Male rats were used to study the inorganic (ionic) and organic fluoride concentrations in plasma, liver, kidneys and stomach content after oral doses of 0, 2.2, 3.5, 4.0, 5.0 and 7.0 mg sodium monofluoroacetate (SMFA, Compound 1080)/kg body weight. Tissue and plasma ionic fluoride concentrations were observed to be higher in all rats given SMFA as compared to rats in the control group. This observation suggests in vivo defluorination of SMFA. Homogenates of liver obtained from SMFA poisoned rats showed significant increases in ionic fluoride concentration during a 6-day storage period at +4 degrees C, with the total fluoride concentration (ionic and organic) remaining constant. The average percentages of distribution of SMFA (organic fluoride) in plasma, liver, and kidneys were 7.05, 5.07 and 1.68, respectively. Plasma and tissue SMFA concentrations were generally lower than the corresponding stomach fluid SMFA concentrations for all dosage groups. Lethal concentration of SMFA in the liquid stomach content was in the range 84.9--189 micrograms/ml, corresponding to total (ionic and organic) fluoride concentrations in the range of 16.1--36 micrograms/ml.