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As only nine trials were included, we could not create a funnel plot to detect bias or heterogeneity, and not all included trials reported similar outcomes

Ammonia is known to alter mitochondrial permeability, leading to mitochondrial swelling and dysfunction.6 In addition, hyperactivation of NMDA receptors activates neurotoxic pathways conducting to axonal degeneration and cellular death.5 Another hypothesis of brain impairment is the activation of the phosphatase calcineurin, which increases the ATP consumption by 80% through the Na/K ATPase dephosphorylation

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