Safety analysis of ketogenic diet in refractory status epilepticus: a small-sample prospective study and systematic review_Journal of Epilepsy

Authors：

REN Yishu ,  CHEN Weibi

Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing 100053, China;

Corresponding?author：

CHEN Weibi, Email: chenweibi@126.com

Keywords：

Ketogenic diet; Super refractory status epilepticus; Intensive care unit; Adverse reactions

DOI：

10.7507/2096-0247.202504005

Video：

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Abstract Full text Figures/Tables Video References Cited by

Objective Ketogenic diet (KD) has shown promising efficacy in the treatment of super-refractory status epilepticus (SRSE); however, its adverse effects have not been systematically evaluated. This study aimed to analyze the safety profile of adjunctive KD therapy for SRSE and explore potential risk factors. Methods Prospective data from 13 SRSE patients (3 adolescents, 10 adults; mean age 34.6±18.4 years) at Xuanwu Hospital, Capital Medical University (July 2020–December 2024) who received KD adjunctive therapy after failing conventional treatments were collected. Adverse reactions were observed, and a systematic literature review (up to March 2025) was conducted for meta-analysis. Results In the single-center cohort of 13 patients, common adverse events included gastrointestinal intolerance (53.8%), hematologic and metabolic abnormalities such as thrombocytosis (84.6%), hyperammonemia (76.9%), dyslipidemia (69.2%), and hypocalcemia (69.2%), as well as nutritional deficits including hypoalbuminemia (61.5%), anemia (53.8%), and transient weight loss (61.5%). Most adverse events were transient and reversible with timely adjustments to the KD regimen. The meta-analysis (25 studies, 251 cases; mean age 16.1±19.0 years) revealed a spectrum of major adverse events, including gastrointestinal intolerance (26.7%), hypoglycemia (19.1%), acidosis (17.5%), and hyperlipidemia (12.0%). Conclusions The ketogenic diet as adjunctive therapy for super-refractory status epilepticus demonstrates a manageable safety profile. Reported adverse events are primarily confined to gastrointestinal intolerance, metabolic derangements, and nutritional deficits, with notable occurrences of thrombocytosis and hyperammonemia requiring timely clinical management. This study provides critical evidence-based support for KD implementation in SRSE treatment protocols.

Citation： REN Yishu, CHEN Weibi. Safety analysis of ketogenic diet in refractory status epilepticus: a small-sample prospective study and systematic review. Journal of Epilepsy, 2025, 11(4): 301-309. doi: 10.7507/2096-0247.202504005 Copy

1.	Claassen J, Silbergleit R, Weingart SD, et al. Emergency neurological life support: status epilepticus. Neurocrit Care, 2012, 17(Suppl 1): 73-78.
2.	Li Y, Tian L, Zeng T, et al. Clinical features and outcome of super-refractory status epilepticus: a retrospective analysis in West China. Seizure, 2014, 23(9): 722-727.
3.	Gofton TE, Gaspard N, Hocker SE, et al. New onset refractory status epilepticus research: What is on the horizon? Neurology, 2019, 92(17): 802-810.
4.	Shorvon S, Ferlisi M, et al. The treatment of super-refractory status epilepticus: a critical review of available therapies and a clinical treatment protocol. Brain, 2011, 134(10): 2802-2818.
5.	Kantanen AM, Reinikainen M, Parviainen I, et al. Incidence and mortality of super-refractory status epilepticus in adults. Epilepsy Behav, 2015, 49: 131-134.
6.	Trinka E, K?lvi?inen R, et al. 25 years of advances in the definition, classification and treatment of status epilepticus. Seizure, 2017, 44: 65-73.
7.	Cervenka MC, Hocker S, Koenig M, et al. Phase I/II multicenter ketogenic diet study for adult superrefractory status epilepticus. Neurology, 2017, 88(10): 938-943.
8.	Masino SA, Rho JM. Mechanisms of ketogenic diet action. In: Noebels JL, Avoli M, Rogawski MA, editors. Jasper's basic mechanisms of the epilepsies. Bethesda (MD): National Center for Biotechnology Information (US) Copyright ? 2012, Michael A Rogawski, Antonio V Delgado-Escueta, Jeffrey L Noebels, Massimo Avoli and Richard W Olsen, 2012.Masino SA, Rho JM. Mechanisms of ketogenic diet action. In: Noebels JL, Avoli M, Rogawski MA, editors. Jasper's basic mechanisms of the epilepsies. Bethesda (MD): National Center for Biotechnology Information (US) Copyright ? 2012, Michael A Rogawski, Antonio V Delgado-Escueta, Jeffrey L Noebels, Massimo Avoli and Richard W Olsen, 2012.
9.	Lindefeldt M, Eng A, Darban H, et al. The ketogenic diet influences taxonomic and functional composition of the gut microbiota in children with severe epilepsy. NPJ Biofilms Microbiomes, 2019, 5(1): 5.
10.	Dahlin M, Hjelte L, Nilsson S, et al. Plasma phospholipid fatty acids are influenced by a ketogenic diet enriched with n-3 fatty acids in children with epilepsy. Epilepsy Res, 2007, 73(2): 199-207.
11.	Martin-McGill KJ, Bresnahan R, Levy RG, et al. Ketogenic diets for drug-resistant epilepsy. Cochrane Database Syst Rev, 2020, 6(6): Cd001903.
12.	Abdallah DM, et al. Anticonvulsant potential of the peroxisome proliferator-activated receptor γ agonist pioglitazone in pentylenetetrazole-induced acute seizures and kindling in mice. Brain Res, 2010, 1351: 246-253.
13.	Bromfield E, Dworetzky B, Hurwitz S, et al. A randomized trial of polyunsaturated fatty acids for refractory epilepsy. Epilepsy Behav, 2008, 12(1): 187-190.
14.	Zhang Y, Zhou S, Zhou Y, et al. Altered gut microbiome composition in children with refractory epilepsy after ketogenic diet. Epilepsy Res, 2018, 145: 163-168.
15.	Tagliabue A, Ferraris C, Uggeri F, et al. Short-term impact of a classical ketogenic diet on gut microbiota in GLUT1 deficiency syndrome: a 3-month prospective observational study. Clin Nutr ESPEN, 2017, 17: 33-37.
16.	Goswami JN, Sharma S, et al. Current perspectives on the role of the ketogenic diet in epilepsy management. Neuropsychiatr Dis Treat, 2019, 15: 3273-3285.
17.	Neal EG, Chaffe H, Schwartz RH, et al. The ketogenic diet for the treatment of childhood epilepsy: a randomised controlled trial. Lancet Neurol, 2008, 7(6): 500-506.
18.	Levy RG, Cooper PN, Giri P, et al. Ketogenic diet and other dietary treatments for epilepsy. Cochrane Database Syst Rev, 2012(3): Cd001903.
19.	Ren Y, Zhang M, Fu X, et al. Ketogenic diet treatment for super-refractory status epilepticus in the intensive care unit: feasibility, safety and effectiveness. Front Neurol, 2024, 15: 1517850.
20.	Worden LT, Abend NS, Bergqvist AGC, et al. Ketogenic diet treatment of children in the intensive care unit: Safety, tolerability, and effectiveness. Seizure, 2020, 80: 242-248.
21.	Koh S, Kim TJ, Shin HB, et al. Expanding indications for a ketogenic diet as an adjuvant therapy in adult refractory status epilepticus: an exploratory study using moderation analysis. Neurotherapeutics, 2022, 19(5): 1526-1534.
22.	Breu M, H?fele C, Glatter S, et al. Ketogenic diet in the treatment of super-refractory status epilepticus at a pediatric intensive care unit: a single-center experience. Front Neurol, 2021, 12: 669296.
23.	Nam SH, Lee BL, Lee CG, et al. The role of ketogenic diet in the treatment of refractory status epilepticus. Epilepsia, 2011, 52(11): 181-184.
24.	Schoeler NE, Simpson Z, Zhou R, et al. Dietary management of children with super-refractory status epilepticus: a systematic review and experience in a single UK tertiary centre. Front Neurol, 2021, 12: 643105.
25.	Thakur KT, Probasco JC, Hocker SE, et al. Ketogenic diet for adults in super-refractory status epilepticus. Neurology, 2014, 82(8): 665-670.
26.	Cobo NH, Sankar R, Murata KK, et al. The ketogenic diet as broad-spectrum treatment for super-refractory pediatric status epilepticus: challenges in implementation in the pediatric and neonatal intensive care units. J Child Neurol, 2015, 30(2): 259-266.
27.	Farias-Moeller R, Bartolini L, Pasupuleti A, et al. A practical approach to ketogenic diet in the pediatric intensive care unit for super-refractory status epilepticus. Neurocrit Care, 2017, 26(2): 267-272.
28.	Park EG, Lee J, Lee J, et al. The ketogenic diet for super-refractory status epilepticus patients in intensive care units. Brain Dev, 2019, 41(5): 420-427.
29.	Li WJ, Xue CL, Zhang Y, et al. Ketogenic diet (KD) therapy in the acute phase of febrile infection-related epilepsy syndrome (FIRES): a case report. Transl Pediatr, 2021, 10(9): 2392-2397.
30.	Cam?es J, Reis AH, Sousa L, et al. Super-refractory status epilepticus and ketogenic diet in intensive care: a series report. Rev Bras Ter Intensiva, 2021, 33(4): 635-639.
31.	Kaul N, Nation J, Laing J, et al. Modified low ratio ketogenic therapy in the treatment of adults with super-refractory status epilepticus. JPEN J Parenter Enteral Nutr, 2022, 46(8): 1819-1827.
32.	Nabbout R, Matricardi S, De Liso P, et al. Ketogenic diet for super-refractory status epilepticus (SRSE) with NORSE and FIRES: single tertiary center experience and literature data. Front Neurol, 2023, 14: 1134827.
33.	Peng P, Peng J, Yin F, et al. Ketogenic diet as a treatment for super-refractory status epilepticus in febrile infection-related epilepsy syndrome. Front Neurol, 2019, 10: 423.
34.	Francis BA, Fillenworth J, Gorelick P, et al. The feasibility, safety and effectiveness of a ketogenic diet for refractory status epilepticus in adults in the intensive care unit. Neurocrit Care, 2019, 30(3): 652-657.
35.	Appavu B, Vanatta L, Condie J, et al. Ketogenic diet treatment for pediatric super-refractory status epilepticus. Seizure, 2016, 41: 62-65.
36.	Caraballo RH, Flesler S, Armeno M, et al. Ketogenic diet in pediatric patients with refractory focal status epilepticus. Epilepsy Res, 2014, 108(10): 1912-1916.
37.	Cervenka MC, Hartman AL, Venkatesan A, et al. The ketogenic diet for medically and surgically refractory status epilepticus in the neurocritical care unit. Neurocrit Care, 2011, 15(3): 519-524.
38.	Thompson L, Fecske E, Salim M, et al. Use of the ketogenic diet in the neonatal intensive care unit-Safety and tolerability. Epilepsia, 2017, 58(2): 36-39.
39.	Arya R, Peariso K, Gaínza-Lein M, et al. Efficacy and safety of ketogenic diet for treatment of pediatric convulsive refractory status epilepticus. Epilepsy Res, 2018, 144: 1-6.
40.	Strzelczyk A, Reif PS, Bauer S, et al. Intravenous initiation and maintenance of ketogenic diet: proof of concept in super-refractory status epilepticus. Seizure, 2013, 22(7): 581-583.
41.	Martikainen MH, P?iv?rinta M, J??skel?inen S, et al. Successful treatment of POLG-related mitochondrial epilepsy with antiepileptic drugs and low glycaemic index diet. Epileptic Disord, 2012, 14(4): 438-441.
42.	鄧瑤, 喻韜, 陳小璐, 等. 生酮飲食治療熱性感染相關性癲癇綜合征5例并文獻復習. 癲癇雜志, 2021, 7(4): 281-287.
43.	楊炯賢, 樊超男, 劉珺, 等. 生酮飲食治療超難治性癲癇持續狀態PICU病兒短期療效探討. 腸外與腸內營養, 2023, 30(3): 129-134.
44.	Paoli A, Mancin L, Bianco A, et al. Ketogenic diet and microbiota: friends or enemies? Genes (Basel), 2019, 10(7): 534.
45.	Ross FC, Patangia D, Grimaud G, et al. The interplay between diet and the gut microbiome: implications for health and disease. Nat Rev Microbiol, 2024, 22(11): 671-686.
46.	Santangelo A, Corsello A, Spolidoro GCI, et al. The influence of ketogenic diet on gut microbiota: potential benefits, risks and indications. Nutrients, 2023, 15(17): 3680.
47.	Olson CA, Vuong HE, Yano JM, et al. The gut microbiota mediates the anti-seizure effects of the ketogenic diet. Cell, 2018, 173(7): 1728-1741.
48.	Ramirez J, Guarner F, Bustos Fernandez L, et al. Antibiotics as major disruptors of gut microbiota. Front Cell Infect Microbiol, 2020, 10: 572912.
49.	Bachmann C, et al. Mechanisms of hyperammonemia. Clin Chem Lab Med, 2002, 40(7): 653-662.
50.	Zhu R, Liu L, Zhang G, et al. The pathogenesis of gut microbiota in hepatic encephalopathy by the gut-liver-brain axis. Biosci Rep, 2023, 43(6): BSR20222524.
51.	Adeva-Andany MM, Pérez-Felpete N, Fernández-Fernández C, et al. Liver glucose metabolism in humans. Biosci Rep, 2016, 36(6): e00416.
52.	Li Y, Yang X, Zhang J, et al. Ketogenic diets induced glucose intolerance and lipid accumulation in mice with alterations in gut microbiota and metabolites. mBio, 2021, 12(2): 03601-03620.
53.	Yancy WS, Jr. , Olsen MK, Dudley T, et al. Acid-base analysis of individuals following two weight loss diets. Eur J Clin Nutr, 2007, 61(12): 1416-1422.
54.	Carnauba RA, Baptistella AB, Paschoal V, et al. Diet-induced low-grade metabolic acidosis and clinical outcomes: a review. Nutrients, 2017, 9(6): 538.
55.	Bjurulf B, Magnus P, Hallb??k T, et al. Potassium citrate and metabolic acidosis in children with epilepsy on the ketogenic diet: a prospective controlled study. Dev Med Child Neurol, 2020, 62(1): 57-61.
56.	Kaser A, Brandacher G, Steurer W, et al. Interleukin-6 stimulates thrombopoiesis through thrombopoietin: role in inflammatory thrombocytosis. Blood, 2001, 98(9): 2720-2725.

1. Claassen J, Silbergleit R, Weingart SD, et al. Emergency neurological life support: status epilepticus. Neurocrit Care, 2012, 17(Suppl 1): 73-78.
2. Li Y, Tian L, Zeng T, et al. Clinical features and outcome of super-refractory status epilepticus: a retrospective analysis in West China. Seizure, 2014, 23(9): 722-727.
3. Gofton TE, Gaspard N, Hocker SE, et al. New onset refractory status epilepticus research: What is on the horizon? Neurology, 2019, 92(17): 802-810.
4. Shorvon S, Ferlisi M, et al. The treatment of super-refractory status epilepticus: a critical review of available therapies and a clinical treatment protocol. Brain, 2011, 134(10): 2802-2818.
5. Kantanen AM, Reinikainen M, Parviainen I, et al. Incidence and mortality of super-refractory status epilepticus in adults. Epilepsy Behav, 2015, 49: 131-134.
6. Trinka E, K?lvi?inen R, et al. 25 years of advances in the definition, classification and treatment of status epilepticus. Seizure, 2017, 44: 65-73.
7. Cervenka MC, Hocker S, Koenig M, et al. Phase I/II multicenter ketogenic diet study for adult superrefractory status epilepticus. Neurology, 2017, 88(10): 938-943.
8. Masino SA, Rho JM. Mechanisms of ketogenic diet action. In: Noebels JL, Avoli M, Rogawski MA, editors. Jasper's basic mechanisms of the epilepsies. Bethesda (MD): National Center for Biotechnology Information (US) Copyright ? 2012, Michael A Rogawski, Antonio V Delgado-Escueta, Jeffrey L Noebels, Massimo Avoli and Richard W Olsen, 2012.Masino SA, Rho JM. Mechanisms of ketogenic diet action. In: Noebels JL, Avoli M, Rogawski MA, editors. Jasper's basic mechanisms of the epilepsies. Bethesda (MD): National Center for Biotechnology Information (US) Copyright ? 2012, Michael A Rogawski, Antonio V Delgado-Escueta, Jeffrey L Noebels, Massimo Avoli and Richard W Olsen, 2012.
9. Lindefeldt M, Eng A, Darban H, et al. The ketogenic diet influences taxonomic and functional composition of the gut microbiota in children with severe epilepsy. NPJ Biofilms Microbiomes, 2019, 5(1): 5.
10. Dahlin M, Hjelte L, Nilsson S, et al. Plasma phospholipid fatty acids are influenced by a ketogenic diet enriched with n-3 fatty acids in children with epilepsy. Epilepsy Res, 2007, 73(2): 199-207.
11. Martin-McGill KJ, Bresnahan R, Levy RG, et al. Ketogenic diets for drug-resistant epilepsy. Cochrane Database Syst Rev, 2020, 6(6): Cd001903.
12. Abdallah DM, et al. Anticonvulsant potential of the peroxisome proliferator-activated receptor γ agonist pioglitazone in pentylenetetrazole-induced acute seizures and kindling in mice. Brain Res, 2010, 1351: 246-253.
13. Bromfield E, Dworetzky B, Hurwitz S, et al. A randomized trial of polyunsaturated fatty acids for refractory epilepsy. Epilepsy Behav, 2008, 12(1): 187-190.
14. Zhang Y, Zhou S, Zhou Y, et al. Altered gut microbiome composition in children with refractory epilepsy after ketogenic diet. Epilepsy Res, 2018, 145: 163-168.
15. Tagliabue A, Ferraris C, Uggeri F, et al. Short-term impact of a classical ketogenic diet on gut microbiota in GLUT1 deficiency syndrome: a 3-month prospective observational study. Clin Nutr ESPEN, 2017, 17: 33-37.
16. Goswami JN, Sharma S, et al. Current perspectives on the role of the ketogenic diet in epilepsy management. Neuropsychiatr Dis Treat, 2019, 15: 3273-3285.
17. Neal EG, Chaffe H, Schwartz RH, et al. The ketogenic diet for the treatment of childhood epilepsy: a randomised controlled trial. Lancet Neurol, 2008, 7(6): 500-506.
18. Levy RG, Cooper PN, Giri P, et al. Ketogenic diet and other dietary treatments for epilepsy. Cochrane Database Syst Rev, 2012(3): Cd001903.
19. Ren Y, Zhang M, Fu X, et al. Ketogenic diet treatment for super-refractory status epilepticus in the intensive care unit: feasibility, safety and effectiveness. Front Neurol, 2024, 15: 1517850.
20. Worden LT, Abend NS, Bergqvist AGC, et al. Ketogenic diet treatment of children in the intensive care unit: Safety, tolerability, and effectiveness. Seizure, 2020, 80: 242-248.
21. Koh S, Kim TJ, Shin HB, et al. Expanding indications for a ketogenic diet as an adjuvant therapy in adult refractory status epilepticus: an exploratory study using moderation analysis. Neurotherapeutics, 2022, 19(5): 1526-1534.
22. Breu M, H?fele C, Glatter S, et al. Ketogenic diet in the treatment of super-refractory status epilepticus at a pediatric intensive care unit: a single-center experience. Front Neurol, 2021, 12: 669296.
23. Nam SH, Lee BL, Lee CG, et al. The role of ketogenic diet in the treatment of refractory status epilepticus. Epilepsia, 2011, 52(11): 181-184.
24. Schoeler NE, Simpson Z, Zhou R, et al. Dietary management of children with super-refractory status epilepticus: a systematic review and experience in a single UK tertiary centre. Front Neurol, 2021, 12: 643105.
25. Thakur KT, Probasco JC, Hocker SE, et al. Ketogenic diet for adults in super-refractory status epilepticus. Neurology, 2014, 82(8): 665-670.
26. Cobo NH, Sankar R, Murata KK, et al. The ketogenic diet as broad-spectrum treatment for super-refractory pediatric status epilepticus: challenges in implementation in the pediatric and neonatal intensive care units. J Child Neurol, 2015, 30(2): 259-266.
27. Farias-Moeller R, Bartolini L, Pasupuleti A, et al. A practical approach to ketogenic diet in the pediatric intensive care unit for super-refractory status epilepticus. Neurocrit Care, 2017, 26(2): 267-272.
28. Park EG, Lee J, Lee J, et al. The ketogenic diet for super-refractory status epilepticus patients in intensive care units. Brain Dev, 2019, 41(5): 420-427.
29. Li WJ, Xue CL, Zhang Y, et al. Ketogenic diet (KD) therapy in the acute phase of febrile infection-related epilepsy syndrome (FIRES): a case report. Transl Pediatr, 2021, 10(9): 2392-2397.
30. Cam?es J, Reis AH, Sousa L, et al. Super-refractory status epilepticus and ketogenic diet in intensive care: a series report. Rev Bras Ter Intensiva, 2021, 33(4): 635-639.
31. Kaul N, Nation J, Laing J, et al. Modified low ratio ketogenic therapy in the treatment of adults with super-refractory status epilepticus. JPEN J Parenter Enteral Nutr, 2022, 46(8): 1819-1827.
32. Nabbout R, Matricardi S, De Liso P, et al. Ketogenic diet for super-refractory status epilepticus (SRSE) with NORSE and FIRES: single tertiary center experience and literature data. Front Neurol, 2023, 14: 1134827.
33. Peng P, Peng J, Yin F, et al. Ketogenic diet as a treatment for super-refractory status epilepticus in febrile infection-related epilepsy syndrome. Front Neurol, 2019, 10: 423.
34. Francis BA, Fillenworth J, Gorelick P, et al. The feasibility, safety and effectiveness of a ketogenic diet for refractory status epilepticus in adults in the intensive care unit. Neurocrit Care, 2019, 30(3): 652-657.
35. Appavu B, Vanatta L, Condie J, et al. Ketogenic diet treatment for pediatric super-refractory status epilepticus. Seizure, 2016, 41: 62-65.
36. Caraballo RH, Flesler S, Armeno M, et al. Ketogenic diet in pediatric patients with refractory focal status epilepticus. Epilepsy Res, 2014, 108(10): 1912-1916.
37. Cervenka MC, Hartman AL, Venkatesan A, et al. The ketogenic diet for medically and surgically refractory status epilepticus in the neurocritical care unit. Neurocrit Care, 2011, 15(3): 519-524.
38. Thompson L, Fecske E, Salim M, et al. Use of the ketogenic diet in the neonatal intensive care unit-Safety and tolerability. Epilepsia, 2017, 58(2): 36-39.
39. Arya R, Peariso K, Gaínza-Lein M, et al. Efficacy and safety of ketogenic diet for treatment of pediatric convulsive refractory status epilepticus. Epilepsy Res, 2018, 144: 1-6.
40. Strzelczyk A, Reif PS, Bauer S, et al. Intravenous initiation and maintenance of ketogenic diet: proof of concept in super-refractory status epilepticus. Seizure, 2013, 22(7): 581-583.
41. Martikainen MH, P?iv?rinta M, J??skel?inen S, et al. Successful treatment of POLG-related mitochondrial epilepsy with antiepileptic drugs and low glycaemic index diet. Epileptic Disord, 2012, 14(4): 438-441.
42. 鄧瑤, 喻韜, 陳小璐, 等. 生酮飲食治療熱性感染相關性癲癇綜合征5例并文獻復習. 癲癇雜志, 2021, 7(4): 281-287.
43. 楊炯賢, 樊超男, 劉珺, 等. 生酮飲食治療超難治性癲癇持續狀態PICU病兒短期療效探討. 腸外與腸內營養, 2023, 30(3): 129-134.
44. Paoli A, Mancin L, Bianco A, et al. Ketogenic diet and microbiota: friends or enemies? Genes (Basel), 2019, 10(7): 534.
45. Ross FC, Patangia D, Grimaud G, et al. The interplay between diet and the gut microbiome: implications for health and disease. Nat Rev Microbiol, 2024, 22(11): 671-686.
46. Santangelo A, Corsello A, Spolidoro GCI, et al. The influence of ketogenic diet on gut microbiota: potential benefits, risks and indications. Nutrients, 2023, 15(17): 3680.
47. Olson CA, Vuong HE, Yano JM, et al. The gut microbiota mediates the anti-seizure effects of the ketogenic diet. Cell, 2018, 173(7): 1728-1741.
48. Ramirez J, Guarner F, Bustos Fernandez L, et al. Antibiotics as major disruptors of gut microbiota. Front Cell Infect Microbiol, 2020, 10: 572912.
49. Bachmann C, et al. Mechanisms of hyperammonemia. Clin Chem Lab Med, 2002, 40(7): 653-662.
50. Zhu R, Liu L, Zhang G, et al. The pathogenesis of gut microbiota in hepatic encephalopathy by the gut-liver-brain axis. Biosci Rep, 2023, 43(6): BSR20222524.
51. Adeva-Andany MM, Pérez-Felpete N, Fernández-Fernández C, et al. Liver glucose metabolism in humans. Biosci Rep, 2016, 36(6): e00416.
52. Li Y, Yang X, Zhang J, et al. Ketogenic diets induced glucose intolerance and lipid accumulation in mice with alterations in gut microbiota and metabolites. mBio, 2021, 12(2): 03601-03620.
53. Yancy WS, Jr. , Olsen MK, Dudley T, et al. Acid-base analysis of individuals following two weight loss diets. Eur J Clin Nutr, 2007, 61(12): 1416-1422.
54. Carnauba RA, Baptistella AB, Paschoal V, et al. Diet-induced low-grade metabolic acidosis and clinical outcomes: a review. Nutrients, 2017, 9(6): 538.
55. Bjurulf B, Magnus P, Hallb??k T, et al. Potassium citrate and metabolic acidosis in children with epilepsy on the ketogenic diet: a prospective controlled study. Dev Med Child Neurol, 2020, 62(1): 57-61.
56. Kaser A, Brandacher G, Steurer W, et al. Interleukin-6 stimulates thrombopoiesis through thrombopoietin: role in inflammatory thrombocytosis. Blood, 2001, 98(9): 2720-2725.

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Safety analysis of ketogenic diet in refractory status epilepticus: a small-sample prospective study and systematic review

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