new_n_lost
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A. impaired excretion by kidney ??
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| hottie99
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i too am thinking impaird kidney function so the NH3 accumulates 
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| sigh
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no
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| new_n_lost
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D. elevated production of NH3 in GUT >> but that would be in relation to decreased secretion. right??? If that is the case then this should be the answer. Usually Ammonia production is by bacterial ureases and rest is produced by liver and kidneys. The one produced in liver is usually non toxic if all goes well and the kidney and the gut one is the toxic one. Now in RF the kidneys are shutdown so the only other place left is the gut. ??
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| Tiff
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???thought it was A.
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| GoodGirl
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B,
elevated production of NH4+ ( which turns into NH3+ ) by kidney adds HCO3 - to the blood, to compensate acidosis in renal failure.
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| GoodGirl
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Glutamine--> NH4 ( goes into urine ) and HCO3- goes into blood. But seems like the Qs is asking something else .  So now I don't know. It just this crossed my mind.
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| GoodGirl
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But in kidney failure it could be A.
So A.
Let's see what sigh will say .
Edited by GoodGirl on 04/08/08 - 05:32 PM
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| sigh
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D. is right answer. I don't have an explanation for the question. I am confused why is not A... Guess, new_lost did gave us explanation...
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| new_n_lost
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The only reason i chose D was that i remembered that the first Rx of Encephalopathy is diet protein restriction and giving loads and loads of Lactulose. Therefore it hit me there has to be some connection with the intestinal bacterial ureases. Cos till now i was thinking it was sort of driving out the ammonia from the circulation thru gut 
Inches covered and miles to go.
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| yarab99
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i got that exact Q on my exam......
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| hottie99
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yes but nnl, dont they give lactulose and protien restriction in diet to avoid more hepatic encephalopathy, didnt u mention that increased ammonia from liver isn't as toxic but kidney and gi is?? how is that so, we give lactulose for hepatic encephalopathy.. im confused now.. 
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| taipei817
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liver doesnt produce amonia, it converts ammonia to urea.
kidney secretes amonium mostly from its amoniogenesis function, which is impaired in renal failure.
the kidney would decrease excretion of urea, and may lead to urea cycle backing up, but still that doesnt mean the liver is producing excess amonia.
the only choices left are GI absorption and secretion.
to have hyperamonemia, GI absorption would be the choice.
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| hottie99
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so taipai, u think it is D as well, but choice D is about production not absorption, no??
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| Tiff
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From what I've read and now understand is that even though urea is excreted in the urine, a small amount will diffuse back into the intestine. The bacterial ureases in the intestines converts it back to ammonia. So it seems it would make sense that when there is kidney failure, the urea that had diffused to the blood to be filtered and excreted, would just diffuse back into the intestine.
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| hottie99
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so ok tiff, if that is the case, which makes total sense, then why isn't it impaired kidney excretion, ans A?? b/c if it's impaird there, then only will it back up to gut, rite??
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| Tiff
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Well when you think about it, the other causes of hyperammonemia are independent of kidney function. In cirrhosis or Reye's syndrome, the urea cycle (which takes place in the liver) is disrupted. Hereditary forms, like ornithine transcarbamoylase and CPS I deficiencies occur in the liver mitochondria. All independent of kidney function. The urea from the urea cycle is normally excreted in urine or reabsorbed by the intestines which use ureases to produce more ammonia. That ammonia gets excreted in the stool.
The ammonia in the kidney is transported there by glutamine from extrahepatic tissues to acidify the urine. So it makes sense that if there was kidney failure, any excess of that would undergo the urea cycle and then become urea in the end which would then be diffused back into the intestines instead of urine because of the kidney failure.
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| taipei817
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sorry, i meant production instead of absorption. still production must be absorbed into the blood. poor and hard twist.
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| hottie99
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okie, so we're all in agreement then that it has to be D rite?? that's wat im getting out of this now, thx so much tiff and taipei!!! 
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