Free radicals involvement in neurological porphyrias and lead poisoning

RNA interference therapy in acute hepatic porphyrias

The acute hepatic porphyrias (AHPs) are inherited disorders of heme biosynthesis characterized by life-threatening acute neurovisceral attacks precipitated by factors that upregulate hepatic 5-aminolevulinic acid synthase 1 (ALAS1) activity. Induction of hepatic ALAS1 leads to the accumulation of porphyrin precursors, in particular 5-aminolevulinic acid (ALA), which is thought to be the neurotoxic mediator leading to acute attack symptoms such as severe abdominal pain and autonomic dysfunction. Patients may also develop debilitating chronic symptoms and long-term medical complications, including kidney disease and an increased risk of hepatocellular carcinoma. Exogenous heme is the historical treatment for attacks and exerts its therapeutic effect by inhibiting hepatic ALAS1 activity. The pathophysiology of acute attacks provided the rationale to develop an RNA interference therapeutic that suppresses hepatic ALAS1 expression. Givosiran is a subcutaneously administered N-acetylgalactosamine-conjugated small interfering RNA against ALAS1 that is taken up nearly exclusively by hepatocytes via the asialoglycoprotein receptor. Clinical trials established that the continuous suppression of hepatic ALAS1 mRNA via monthly givosiran administration effectively reduced urinary ALA and porphobilinogen levels and acute attack rates and improved quality of life. Common side effects include injection site reactions and increases in liver enzymes and creatinine. Givosiran was approved by the US Food and Drug Administration and European Medicines Agency in 2019 and 2020, respectively, for the treatment of patients with AHP. Although givosiran has the potential to decrease the risk of chronic complications, long-term data on the safety and effects of sustained ALAS1 suppression in patients with AHP are lacking.

Regulation of three subtypes of SOD gene in Aleuroglyphus ovatus (Acari:Acaridae) under lead stress

Superoxide dismutase (SOD) is an important enzyme that acts as the first line of protection in the mite antioxidant defense system, involved in eliminating reactive oxygen species (ROS) under harsh environmental conditions. Nevertheless, the SOD gene family was yet to be reported in stored grain pest mite (Aleuroglyphus ovatus). In this study, A. ovatus was used to evaluate the response of SOD gene during lead stress. A. ovatus were separately exposed to different concentration lead (12.5, 25, 50, and 100 mg/kg), which induce the dynamic trend of SOD enzyme activity initially increased and then reduced with an increase in lead concentration, whereas they were still substantially higher than the control group. Moreover, after lead stress, it was found that all of the three SOD genes showed enhanced relative messenger RNA expression at high concentrations and decreased relative expression at low concentrations, which indicated that lead stress induces the expression of AoSODs. The present work implies that AoSODs play an important role in resisting oxidative damage caused by lead stress.

Pain in acute hepatic porphyrias: Updates on pathophysiology and management

Acute hepatic porphyrias (AHPs) typically present with recurrent acute attacks of severe abdominal pain and acute autonomic dysfunction. While chronic symptoms were historically overlooked in the literature, recent studies have reported increased prevalence of chronic, mainly neuropathic, pain between the attacks. Here we characterize acute and chronic pain as prominent manifestations of the AHPs and discuss their pathophysiology and updated management. In addition to the severe abdominal pain, patients could experience low back pain, limb pain, and headache during acute attacks. Chronic pain between the attacks is typically neuropathic and reported mainly by patients who undergo recurrent attacks. While the acute abdominal pain during attacks is likely mediated by autonomic neuropathy, chronic pain likely represents delayed recovery of the acute neuropathy with ongoing small fiber neuropathy in addition to peripheral and/or central sensitization. δ-aminolaevulinic acid (ALA) plays a major role in acute and chronic pain via its neurotoxic effect, especially where the blood-nerve barrier is less restrictive or absent i.e., the autonomic ganglia, nerve roots, and free nerve endings. For earlier diagnosis, we recommend testing a spot urine porphobilinogen (PBG) analysis in any patient with recurrent severe acute abdominal pain with no obvious explanation, especially if associated with neuropathic pain, hyponatremia, autonomic dysfunction, or encephalopathy. Of note, it is mandatory to exclude AHPs in any acute painful neuropathy. Between the attacks, diagnostic testing for AHPs should be considered for patients with a past medical history of acute/subacute neuropathy, frequent emergency room visits with abdominal pain, and behavioral changes. Pain during the attacks should be treated with opiates combined with hemin infusions. Symptomatic treatment of chronic pain should start with gabapentinoids and certain antidepressants before opiates. Givosiran reduces levels of ALA and PBG and likely has long-term benefits for chronic pain, especially if started early during the course of the disease.

Glycine Betaine Relieves Lead-Induced Hepatic and Renal Toxicity in Albino Rats

Lead (Pb) is a widespread and nondegradable environmental pollutant and affects several organs through oxidative mechanisms. This study was conducted to investigate the antioxidant protective effect of glycine betaine (GB) against Pb-induced renal and hepatic injury. Male albino rats (n = 45) were divided into three groups: G1 untreated control, G2 Pb-acetate (50 mg/kg/day), and G3 Pb-acetate (50 mg/kg/day) plus GB (250 mg/kg/day) administered for 6 weeks. For G3, Pb-acetate was administered first and followed by GB at least 4 h after. Pb-acetate treatment (G2) resulted in a significant decrease in renal function, including elevated creatinine and urea levels by 17.4% and 23.7%, respectively, and nonsignificant changes in serum uric acid levels. Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphates (ALP) activities were significantly increased with Pb treatment by 37.6%, 59.3%, and 55.1%, respectively. Lipid peroxidation level was significantly increased by 7.8 times after 6 weeks of Pb-acetate treatment. The level of reduced glutathione (GSH-R) significantly declined after Pb-acetate treatment. Pb-acetate treatment also reduced the activities of superoxide dismutase (SOD), glutathione-S-transferase (GST), and glutathione peroxidase (GSH-PX) by 74.1%, 85.0%, and 40.8%, respectively. Treatment of Pb-intoxicated rats with GB resulted in a significant reduction in creatinine, urea, ALT, AST, and lipid peroxidation, as well as a significant increase in the level of GSH-R and in the activities of ALP, SOD, GST, and GSH-PX. The molecular interaction between GB and GSH-PX indicated that the activation of GSH-PX in Pb-intoxicated rats was not the result of GB binding to the catalytic site of GSH-PX. The affinity of GB to bind to the catalytic site of GSH-PX is lower than that of H₂O₂. Thus, GB significantly mitigates Pb-induced renal and liver injury through the activation of antioxidant enzymes and the prevention of Pb-induced oxidative damage in the kidney and liver.

Porphyric Neuropathy: Pathophysiology, Diagnosis, and Updated Management

PURPOSE OF REVIEW

To review the peripheral neurological complications of the acute hepatic porphyrias, as well as the latest advances in their pathophysiology and management.

RECENT FINDINGS

The diagnosis of porphyric neuropathy remains challenging as varying neuropathic patterns are encountered depending on disease stage, including a non-length-dependent distribution pattern. The major pathophysiologic mechanism is δ-aminolevulinic acid (ALA)-induced neurotoxicity. The less restrictive blood-nerve barrier in the autonomic ganglia and myenteric plexus may explain the frequency of dysautonomic manifestations. Recently, a prophylactic small interfering RNA (siRNA)-based therapy that reduces hepatic ALA Synthase-1 mRNA was approved for patients with recurrent neuro-visceral attacks. Neurologists should appreciate the varying patterns of porphyric neuropathy. As with most toxin-induced axonopathies, long-term outcomes depend on early diagnosis and treatment. While the short-term clinical and biochemical benefits of siRNA-based therapy are known, its long-term effects on motor recovery, chronic pain, and dysautonomic manifestations are yet to be determined.

Porphyria-induced posterior reversible encephalopathy syndrome and central nervous system dysfunction

BACKGROUND AND AIM

An association between neuropsychiatric manifestations and neuroimaging suggestive of posterior reversible encephalopathy syndrome (PRES) during porphyric attacks has been described in numerous case reports. We aimed to systematically review clinical-radiological features and likely pathogenic mechanisms of PRES in patients with acute hepatic porphyrias (AHP) and porphyric attacks.

METHODS

PubMed, Scopus, Ovid MEDLINE, and Google Scholar were searched (July 30, 2019). We included articles describing patients with convincing evidence of an AHP, confirmed porphyric attacks, and PRES in neuroimaging.

RESULTS

Forty-three out of 269 articles were included, which reported on 46 patients. Thirty-nine (84.8%) patients were women. The median age was 24 ± 13.8 years. 52.2% had unspecified AHP, 41.3% acute intermittent porphyria, 4.3% hereditary coproporphyria, and 2.2% variegate porphyria. 70.2% had systemic arterial hypertension. Seizures, mental changes, arterial hypertension, and hyponatremia occurred more frequently than expected for porphyric attacks (p < .001). Seizures and hyponatremia were also more frequent than expected for PRES. The most common distributions of brain lesions were occipital (81.4%), parietal (65.1%), frontal (60.5%), subcortical (40%), and cortical (32.5%). Cerebral vasoconstriction was demonstrated in 41.7% of the patients who underwent angiography. 19.6% of the patients had ischemic lesions, and 4.3% developed long-term sequelae (cognitive decline and focal neurological deficits).

CONCLUSIONS

Brain edema, vasoconstriction, and ischemia in the context of PRES likely account for central nervous symptoms in some porphyric attacks.

Effect of sub-chronic exposure to lead (Pb) and Bacillus subtilis on Carassius auratus gibelio: Bioaccumulation, antioxidant responses and immune responses

Lead (Pb) poisoning in humans and fish represents a significant global problem. Bacillus subtilis (B. subtilis) is a widely used probiotic in aquaculture. Carassius auratus gibelio (C. gibelio) is one of the most important aquaculture species with great commercial value. The objective of this study was to evaluate the potential of B. subtilis in ameliorating lead-induced toxicity in C. gibelio. The fish were exposed for 60 days to waterborne Pb at 0, 0.05, 0.5 and 1 mg/L and/or dietary B. subtilis at 10⁹ cfu/g. After 30 and 60 days, the fish were sampled and bioaccumulation, antioxidant activity and immune responses were assessed. The results revealed that B. subtilis confers significant protective effects against lead toxicity by preventing alterations in the levels of bioaccumulation, superoxide dismutase, catalase and glutathione. B. subtilis also assists in the recovery of blood δ-aminolevulinic acid dehydratase, lysozyme, and IgM levels while regulating the expression of immune-related genes including IL-10, lysozyme, TNF-α, IgM and Hsp70 after 60 days of lead exposure. Our results suggest that administration of B. subtilis (10⁹ cfu/g) has the potential to combat lead toxicity in C. gibelio.

Systemic inflammation in acute intermittent porphyria: a case-control study

This study aimed to examine whether acute intermittent porphyria (AIP) is associated with systemic inflammation and whether the inflammation correlates with disease activity. A case-control study with 50 AIP cases and age-, sex- and place of residence-matched controls was performed. Plasma cytokines, insulin and C-peptide were analysed after an overnight fast using multiplex assay. Long pentraxin-3 (PTX3) and complement activation products (C3bc and TCC) were analysed using enzyme-linked immunosorbent assay (ELISA). Urine porphobilinogen ratio (U-PBG, µmol/mmol creatinine), haematological and biochemical tests were performed using routine methods. Questionnaires were used to register AIP symptoms, medication and other diseases. All 27 cytokines, chemokines and growth factors investigated were increased significantly in symptomatic AIP cases compared with controls (P < 0·0004). Hierarchical cluster analyses revealed a cluster with high visfatin levels and several highly expressed cytokines including interleukin (IL)-17, suggesting a T helper type 17 (Th17) inflammatory response in a group of AIP cases. C3bc (P = 0·002) and serum immunoglobulin (Ig)G levels (P = 0·03) were increased significantly in cases with AIP. The U-PBG ratio correlated positively with PTX3 (r = 0·38, P = 0·006), and with terminal complement complex (TCC) levels (r = 0·33, P = 0·02). PTX3 was a significant predictor of the biochemical disease activity marker U-PBG in AIP cases after adjustment for potential confounders in multiple linear regression analyses (P = 0·032). Prealbumin, C-peptide, insulin and kidney function were all decreased in the symptomatic AIP cases, but not in the asymptomatic cases. These results indicate that AIP is associated with systemic inflammation. Decreased C-peptide levels in symptomatic AIP cases indicate that reduced insulin release is associated with enhanced disease activity and reduced kidney function.

Biochemical effects of lead exposure on oxidative stress and antioxidant status of battery manufacturing workers of Western Maharashtra, India

BACKGROUND

Lead induces oxidative stress and alters the antioxidant status of population exposed to high lead levels, i.e. battery manufacturing workers. The aim of this study was to know the current scenario of blood lead (PbB) levels and their effect on the oxidative stress parameter, i.e. serum lipid peroxide (LP), and antioxidant parameters, such as red blood cell (RBC)-superoxide dismutase (SOD), RBC-catalase (CAT), plasma ceruloplasmin (CP), and serum nitrite, of battery manufacturing workers.

METHODS

Forty-three battery manufacturing workers from Western Maharashtra, India, with ages between 19 and 42 years, were selected as study group and compared with 38 age-matched, healthy male subjects (control group). From both group subjects, 10 mL of blood sample was drawn by puncturing the antecubital vein, and PbB, serum LP, RBC-SOD, RBC-CAT, plasma CP, and serum nitrite were estimated using standard methods.

RESULTS

The PbB levels of the battery manufacturing workers were significantly higher (p<0.001, 1050%) as compared with the control subjects. The serum LP levels were significantly increased (p<0.001, 96.86%); all antioxidant status parameters such as RBC-SOD (p<0.001, -26.32%), RBC-CAT (p<0.001, -51.57%), and plasma CP (p<0.001, -35.13%) were significantly decreased; and serum nitrite levels (p<0.001, 154%) were significantly increased in the battery manufacturing workers as compared with the control subjects.

CONCLUSIONS

Despite modern techniques used to reduce lead exposure in battery manufacturing workers, PbB levels remain high, inducing oxidative stress and altering the antioxidant status of battery manufacturing workers.

The Level of Selenium and Oxidative Stress in Workers Chronically Exposed to Lead

The possible beneficial role of selenium (Se) on the oxidative stress induced by lead (Pb) is still unclear in humans. Therefore, the aim of the present study was to explore the associations among the Se levels, chronic Pb exposure, oxidative stress parameters, and parameters characterizing the function of the antioxidant defense system in men who are occupationally exposed to Pb. Based on the median serum Se concentrations, the 324 study subjects were divided into two subgroups: a subgroup with a low Se level (L-Se) and a subgroup with a high Se level (H-Se). The levels of lead (PbB) and zinc protoporphyrin (ZPP) in the blood and the delta-aminolevulinic acid (ALA) level in the urine served as indices of Pb exposure. The PbB level was significantly lower in the H-Se group compared to that in the L-Se group by 6 %. The levels of 8-hydroxyguanosine and lipofuscin (LPS) and the activity of superoxide dismutase were significantly lower in the H-Se group compared to that in the L-Se group by 17, 19, and 11 %, respectively. However, the glutathione level (GSH) and the activities of glutathione peroxidase (GPx) and catalase were significantly higher by 9, 23, and 3 %. Spearman correlations showed positive associations between the Se level and GPx activity and GSH level. A lower serum Se level in chronically Pb-exposed subjects is associated with higher Pb blood levels and an elevated erythrocyte LPS level, which reflects the intensity of oxidative stress. Besides, in a group of Pb-exposed subjects with lower serum Se level, depleted GSH pool and decreased activity of GPx in erythrocytes were reported. However, the present results are inadequate to recommend Se supplementation for chronic lead exposure at higher doses than would be included in a normal diet except for selenium deficiency.

Cross-species coherence in effects and modes of action in support of causality determinations in the U.S. Environmental Protection Agency's Integrated Science Assessment for Lead

The peer-reviewed literature on the health and ecological effects of lead (Pb) indicates common effects and underlying modes of action across multiple organisms for several endpoints. Based on such observations, the United States (U.S.) Environmental Protection Agency (EPA) applied a cross-species approach in the 2013 Integrated Science Assessment (ISA) for Lead for evaluating the causality of relationships between Pb exposure and specific endpoints that are shared by humans, laboratory animals, and ecological receptors (i.e., hematological effects, reproductive and developmental effects, and nervous system effects). Other effects of Pb (i.e., cardiovascular, renal, and inflammatory responses) are less commonly assessed in aquatic and terrestrial wildlife limiting the application of cross-species comparisons. Determinations of causality in ISAs are guided by a framework for classifying the weight of evidence across scientific disciplines and across related effects by considering aspects such as biological plausibility and coherence. As illustrated for effects of Pb where evidence across species exists, the integration of coherent effects and common underlying modes of action can serve as a means to substantiate conclusions regarding the causal nature of the health and ecological effects of environmental toxicants.

Porphyric neuropathy

Porphyric neuropathy often poses a diagnostic dilemma; it is typically associated with the hepatic porphyrias, characterized by acute life-threatening attacks of neurovisceral symptoms that mimic a range of acute medical and psychiatric conditions. The development of acute neurovisceral attacks is responsive to environmental factors, including drugs, hormones, and diet. This chapter reviews the clinical manifestations, genetics, pathophysiology, and mechanisms of neurotoxicity of the acute hepatic porphyrias. While the etiology of the neurological manifestations in the acute porphyrias remains undefined, the main hypotheses include toxicity of porphyrin precursors and deficiency of heme synthesis. These hypotheses will be discussed with reference to novel experimental models of porphyric neuropathy.

Lactobacillus plantarum CCFM8661 alleviates lead toxicity in mice

Lead causes a broad range of adverse effects in humans and animals. The objective was to evaluate the potency of lactobacilli to bind lead in vitro and the protective effects of a selected Lactobacillus plantarum CCFM8661 against lead-induced toxicity in mice. Nine strains of bacteria were used to investigate their binding abilities of lead in vitro, and L. plantarum CCFM8661 was selected for animal experiments because of its excellent lead binding capacity. Both living and dead L. plantarum CCFM8661 were used to treat 90 male Kunming mice during or after the exposure to 1 g/L lead acetate in drinking water. The results showed oral administration of both living and dead L. plantarum CCFM8661 offered a significant protective effect against lead toxicity by recovering blood δ-aminolevulinic acid dehydratase activity, decreasing the lead levels in blood and tissues, and preventing alterations in the levels of glutathione, glutathione peroxidase, malondialdehyde, superoxide dismutase, and reactive oxygen species caused by lead exposure. Moreover, L. plantarum CCFM8661 was more effective when administered consistently during the entire lead exposure, not after the exposure. Our results suggest that L. plantarum CCFM8661 has the potency to provide a dietary strategy against lead toxicity.

Heme and heme biosynthesis intermediates induce heme oxygenase-1 and cytochrome P450 2A5, enzymes with putative sequential roles in heme and bilirubin metabolism: different requirement for transcription factor nuclear factor erythroid- derived 2-like 2

Cytochrome P450 2A5 (CYP2A5) oxidizes bilirubin to biliverdin and represents a putative candidate for maintaining bilirubin at safe but adequate antioxidant levels. Curiously, CYP2A5 is induced by both excessive heme and chemicals that inhibit heme synthesis. We hypothesized that heme homeostasis is a key modifier of Cyp2a5 expression via transcription factor nuclear factor erythroid-derived 2-like 2 (Nrf2) and characterized the coordination of CYP2A5 and heme oxygenase-1 (HMOX1) responses using wild-type and Nrf2(-/-) primary mouse hepatocytes. HMOX1 was rapidly elevated by exogenous hemin, thereby limiting the transactivation of Cyp2a5 until high heme (> 5µM) exposure. Nrf2 was mandatory for CYP2A5 but not for HMOX1 induction by heme. CYP2A5 was intensively and HMOX1 moderately elevated in heme synthesis blockades by succinylacetone and N-methyl protoporphyrin IX, and Nrf2 partially mediated the induction of CYP2A5. Immunoelectron microscopy revealed that CYP2A5 is targeted Nrf2 dependently both to the endoplasmic reticulum (ER) and mitochondria. However, excessive heme increased CYP2A5 predominantly in the ER. Phenobarbital, dibutyryl-cAMP, and peroxisome proliferator-activated receptor-γ coactivator-1α (PGC-1α) overexpression stimulate heme biosynthesis and induce CYP2A5. Acute but not chronic CYP2A5 induction by phenobarbital required Nrf2, whereas CYP2A5 induction by dibutyryl-cAMP and PGC-1α was potentiated by Nrf2 knockout. Collectively, heme homeostasis is established as a crucial regulator of hepatic Cyp2a5 expression mediated via Nrf2 activation, whereas Nrf2 is redundant for Hmox1 induction by heme. Similar subcellular targeting and coordination of CYP2A5 and HMOX1 responses suggest favorable conditions for enhanced CYP2A5-mediated bilirubin maintenance in altered heme homeostasis that predisposes to oxidative stress.

Oxidative stress and antioxidant defense

Reactive oxygen species (ROS) are produced by living organisms as a result of normal cellular metabolism and environmental factors, such as air pollutants or cigarette smoke. ROS are highly reactive molecules and can damage cell structures such as carbohydrates, nucleic acids, lipids, and proteins and alter their functions. The shift in the balance between oxidants and antioxidants in favor of oxidants is termed “oxidative stress.” Regulation of reducing and oxidizing (redox) state is critical for cell viability, activation, proliferation, and organ function. Aerobic organisms have integrated antioxidant systems, which include enzymatic and nonenzymatic antioxidants that are usually effective in blocking harmful effects of ROS. However, in pathological conditions, the antioxidant systems can be overwhelmed. Oxidative stress contributes to many pathological conditions and diseases, including cancer, neurological disorders, atherosclerosis, hypertension, ischemia/perfusion, diabetes, acute respiratory distress syndrome, idiopathic pulmonary fibrosis, chronic obstructive pulmonary disease, and asthma. In this review, we summarize the cellular oxidant and antioxidant systems and discuss the cellular effects and mechanisms of the oxidative stress.

Purple pigments: the pathophysiology of acute porphyric neuropathy

The porphyrias are inherited metabolic disorders arising from disturbance in the haem biosynthesis pathway. The neuropathy associated with acute intermittent porphyria (AIP) occurs due to mutation involving the enzyme porphobilinogen deaminase (PBGD) and is characterised by motor-predominant features. Definitive diagnosis often encompasses a combination of biochemical, enzyme analysis and genetic testing, with clinical neurophysiological findings of a predominantly motor axonal neuropathy. Symptomatic and supportive treatment are the mainstays during an acute attack. If administered early, intravenous haemin may prevent progression of neuropathy. While the pathophysiology of AIP neuropathy remains unclear, axonal dysfunction appears intrinsically linked to the effects of neural energy deficits acquired through haem deficiency coupled to the neurotoxic effects of porphyrin precursors. The present review will provide an overview of AIP neuropathy, including discussion of recent advances in understanding developed through neurophysiological approaches that have further delineated the pathophysiology of axonal degeneration.

Surface dental enamel lead levels and antisocial behavior in Brazilian adolescents

Lead poisoning has been reportedly linked to a high risk of learning disabilities, aggression and criminal offenses. To study the association between lead exposure and antisocial/delinquent behavior, a cross-sectional study was conducted with 173 Brazilian youths aged 14-18 and their parents (n=93), living in impoverished neighborhoods of Bauru-SP, with high criminality indices. Self-Reported Delinquency (SRD) and Child Behavior Checklist (CBCL) questionnaires were used to evaluate delinquent/antisocial behavior. Body lead burdens were evaluated in surface dental enamel acid microbiopsies. The dental enamel lead levels (DELL) were quantified by graphite furnace atomic absorption spectrometry (GFAAS) and phosphorus content was measured using inductively coupled plasma optical emission spectrometry (ICP-OES). Logistic regression was used to identify associations between DELL and each scale defined by CBCL and SRD scores. Odd ratios adjusted for familial and social covariates, considering a group of youths exposed to high lead levels (>or=75 percentile), indicated that high DELL is associated with increased risk of exceeding the clinical score for somatic complaints, social problems, rule-breaking behavior and externalizing problems (CI 95%). High DELL was not found to be associated with elevated SRD scores. In conclusion, our data support the hypothesis that high-level lead exposure can trigger antisocial behavior, which calls for public policies to prevent lead poisoning.

Challenges associated with metal chelation therapy in Alzheimer's disease

A close association between brain metal dishomeostasis and the onset and/or progression of Alzheimer's disease (AD) has been clearly established in a number of studies, although the underlying biochemical mechanisms remain obscure. This observation renders chelation therapy an attractive pharmacological option for the treatment of this disease. However, a number of requirements must be fulfilled in order to adapt chelation therapy to AD so that the term "metal targeted strategies" seems now more appropriate. Indeed, brain metal redistribution rather than brain metal scavenging and removal is the major goal of this type of intervention. The most recent developments in metal targeted strategies for AD will be discussed using, as useful examples, clioquinol, curcumin, and epigallocatechin, and the future perspectives will also be outlined.

Structural, chemical and biological aspects of antioxidants for strategies against metal and metalloid exposure

Oxidative stress contributes to the pathophysiology of exposure to heavy metals/metalloid. Beneficial renal effects of some medications, such as chelation therapy depend at least partially on the ability to alleviate oxidative stress. The administration of various natural or synthetic antioxidants has been shown to be of benefit in the prevention and attenuation of metal induced biochemical alterations. These include vitamins, N-acetylcysteine, alpha-lipoic acid, melatonin, dietary flavonoids and many others. Human studies are limited in this regard. Under certain conditions, surprisingly, the antioxidant supplements may exhibit pro-oxidant properties and even worsen metal induced toxic damage. To date, the evidence is insufficient to recommend antioxidant supplements in subject with exposure to metals. Prospective, controlled clinical trials on safety and effectiveness of different therapeutic antioxidant strategies either individually or in combination with chelating agent are indispensable. The present review focuses on structural, chemical and biological aspects of antioxidants particularly related to their chelating properties.

Vitamin-E reduces the oxidative damage on delta-aminolevulinic dehydratase induced by lead intoxication in rat erythrocytes

Lead intoxication induces oxidative damage on lipids and proteins. In the present paper we study in vivo and in vitro the antioxidant effect of vitamin-E and trolox, on the oxidative effects of lead intoxication in rat erythrocytes. Vitamin-E simultaneously administered to erythrocytes treated with lead was capable to prevent the inhibition of delta-aminolevulinic dehydratase activity and lipid oxidation. Partial but important protective effects were found when vitamin-E was administered either after or before lead exposure in rats. In vitro, the antioxidant trolox protected delta-ALA-D activity against damage induced by lead or menadione. These results indicate that vitamin-E could be useful in order to protect membrane-lipids and, notably, to prevent protein oxidation produced by lead intoxication.

Neuropsychiatric porphyria in patients with refractory epilepsy: report of three cases

OBJECTIVES

Although epileptic seizures are an infrequent feature of acute attacks of the neuropsychiatric porphyrias, there are no significant reports of porphyria in chronic epilepsy. This paper attempts to redress the balance.

METHODS

Three case reports, including detailed laboratory and molecular diagnostics.

RESULTS

Two patients with variegate porphyria and one with acute intermittent porphyria, referred within 1 year to a specialist porphyria service, with a long history of chronic refractory epileptic seizures, are described.

CONCLUSIONS

Porphyria may be an aetiological factor in some cases of chronic refractory partial or generalised epilepsy. Porphyria should also be considered if addition of a new anti-epileptic medication causes a major deterioration in the epilepsy.

Ebselen and diphenyl diselenide do not change the inhibitory effect of lead acetate on delta-aminolevulinate dehidratase

It is known that lead is toxic to several species of animals, and growing data support the participation of oxidative in lead toxicity. Selenium compounds, like diphenyl diselenide and Ebselen have a thiol-peroxidase like and other antioxidant properties. In this work, we determine whether these non-thiol-containing compounds with antioxidant properties could reverse the toxicity produced by Pb(2+). Lead acetate injection followed by injection with Ebselen or diphenyl diselenide did not change the levels of non-protein thiol groups (NPSH), whereas simultaneous treatment with lead plus Ebselen reduced NPSH levels in liver. Lead and Ebselen caused a marked reduction in TBARS level in kidney, whereas lead or selenium compounds did not change TBARS levels in brain or liver. Lead acetate inhibited, δ-aminolevulinate dehydratase (ALA-D) activity in blood, liver, kidney and brain. Selenium compounds did not change enzyme activity nor the inhibitory effect of lead acetate in kidney and liver. Ebselen reversed brain ALA-D inhibition caused by Pb(2+). Reactivation index for ALA-D by DTT was higher in lead-treated groups than control groups in all tissues. Lead acetate or selenium compounds did not demonstrate alteration on [(3)H]-glutamate uptake by synaptosomes, whereas lead acetate plus Ebselen showed an increase on [(3)H]-glutamate uptake. The results of the present study indicate that ALA-D inhibition antecedes the overproduction of reactive oxygen species, which is becoming well documented in the literature.

Acute lead exposure induces renal haeme oxygenase-1 and decreases urinary Na+ excretion

The effects of acute lead exposure on renal function, lipid peroxidation and the expression of haeme oxygenase (HO) in rat kidney were determined. A single injection of lead acetate (50 mg Pb/kg) was given to rats. Changes in renal function, characterized by a significant reduction in the Na+ excretion was observed six hours after Pb exposure; this effect persisted for 24 hours. TBARS levels increased in kidney cortex 24 hours after Pb administration. In kidney cortex, Pb exposure affected the expression of HO-1, a renal protein associated with oxidative stress. HO-1 mRNA increased 2.3-fold, three hours after Pb administration and remained increased for six, 12 and 24 hours. HO enzymatic activity and HO-1 protein increased six and three hours after Pb administration, respectively, and remained increased at 24 hours. HO inhibition by tin-protoporphyrin, potentiated Pb-induced increase in TBARS and prevented the Pb-induced reduction in Na+ excretion. Our data suggest that Pb may be acting through the generation of oxidant products and induction of HO.

Effects of delta-aminolevulinic acid and melatonin in the harderian gland of female Syrian hamsters

Effects of delta-aminolevulinic acid (ALA) and melatonin were investigated in the female Syrian hamster Harderian gland. This is an organ physiologically exposed to strong oxidative stress due to the highest porphyrinogenic rates known in nature. Enzyme activities of porphyrin biosynthesis and of antioxidative protection, oxidative protein modification, and histological integrity were studied. In the porphyrin biosynthetic pathway, ALA and melatonin acted synergistically by downregulating ALA synthase (ALA-S) and stimulating product formation from ALA; the combination of ALA and melatonin suppressed ALA-S activity, down to about 1% of that in controls. While ALA effects on porphyrinogenesis can be interpreted in terms of homeostasis, melatonin's actions may be seen in relation to seasonality and/or reduction of oxidative stress. Among antioxidant enzymes, superoxide dismutase (SOD) and glutathione reductase (GR) activities were diminished by ALA, presumably due to the vulnerability of their active centers to free radicals, whereas melatonin moderately increased SOD. Both ALA and melatonin strongly stimulated catalase (CAT), thereby counteracting the oxidative stress induced by ALA and its metabolites. Nevertheless, exogenous ALA caused a strong net rise in protein carbonyl and considerable damage of tissue. When given together with ALA, melatonin antagonized these effects and largely protected the integrity of glandular structures.

Alterations of heme metabolism in lymphocytes and metal content in blood plasma as markers of diesel fuels effects on human organism

Workers in the diesel fuel distribution trade are intensively exposed to fuel vapours. Diesel fuel presents the main source of air pollution by benzene at a marine diesel fuel terminal. Levels of benzene are used to evaluate the external exposure to diesel fuel. Since benzene causes alterations in porphyrin metabolism, and some of these may lead to the generation of tumours, heme synthesis is proposed as a biomarker of early health effects of diesel fuel. A group of 20 workers exposed to diesel fuel and a group of 20 unexposed persons were examined and interviewed using structured questionnaires. The levels of 5-aminolevulinic acid (ALA) and protoporphyrin (PP), activities of ALA synthase and ferrochelatase, as well as levels of PP associated with DNA were determined in lymphocytes spectrophotometrically. Amounts of the metals Cd, Mn, Zn, Cu and Ca were measured in blood plasma by flame atomic absorption spectrometry method. Both ALA and PP levels were significantly increased in marine terminal workers: 3.0 +/- 0.4 vs. 0.8 +/- 0.2 nmol/10(6) lymphocytes: and 511 +/- 164 vs. 389 +/- 77 pmol/10(6) lymphocytes in exposed and control individuals, respectively. ALA-synthase activity was 2.5 fold higher in lymphocytes of workers exposed to diesel fuels (P < 0.01). At the same time ferrochelatase activity was decreased and protoporphyrin level was accordingly elevated. The amount of porphyrin associated with DNA increased 1.4 fold in exposed workers (P = 0.05). Among all investigated metals in blood plasma of exposed workers only zinc levels were statistically significantly increased (P < 0.05). The disturbances of heme metabolism in lymphocytes and zinc level in blood plasma caused by diesel fuel exposure seems to be a useful biomarkers for carcinogenic risk assessment.

Pitfalls in preparation of (3)H-unconjugated bilirubin by biosynthetic labeling from precursor (3)H-5-aminolevulinic acid in the dog

We report problems encountered during preparation of tritium-labeled unconjugated bilirubin ((3)H-UCB) from precursor (3)H-5-aminolevulinic acid ((3)H-ALA) in 2 dogs with external biliary drainage installed into the animals under general anesthesia. Under prolonged sedation, 12.9 or 14.0 mCi of (3)H-ALA was administered intravenously in two divided doses, and bile was collected for 9 hours. In one animal, taurocholate (TC) infusion was needed to maintain bile flow. (3)H-UCB was isolated from the bile and recrystallized with the improved method of Webster et al (Webster CC, Tiribelli C, Ostrow JD. J Lab Clin Med 2001;137:370-3). Based on radioactivity and pigment content, hourly bile collections were pooled to optimize specific activities. Surprisingly, in the first dog, only 2.9% of injected radioactivity was recovered in bile and only 14.1% in urine, and the specific activities of the crystalline (3)H-UCB from the two pools were only 39.5 and 30.0 x 10(3) dpm/microg. High-performance liquid chromatography analysis revealed that only 4% of ALA degraded during 5 minutes in injection solution at pH 6.8. The low incorporation of (3)H-ALA and low specific activity of (3)H-UCB was apparently caused mainly by prior degradation and exchange of labile tritium of the (3)H-ALA and probably by enhanced endogenous ALA synthesis caused by the anesthetic/sedative agents. Revised procedures in the second dog improved the incorporation of (3)H-ALA to 11.9% excreted in bile and the specific activity of the crystalline (3)H-UCB to 122.0 and 50.8 x 10(3) dpm/microg, while urinary excretion of tritium increased to 28.5%. These experiences emphasize possible pitfalls in preparing (3)H-UCB by biosynthetic labeling from (3)H-ALA administered to dogs.

Melatonin prevents delta-aminolevulinic acid-induced oxidative DNA damage in the presence of Fe2+

Delta-aminolevulinic acid (ALA), a heme precursor which accumulates during lead poisoning and acute intermittent porphyria, is reported to cause liver cancer. The carcinogenic mechanisms of ALA may relate to its ability to generate free radicals through metal-catalyzed oxidation which cause oxidative DNA damage. The aim of this study was to compare the efficacy of melatonin, trolox (vitamin E) and mannitol in altering DNA damage induced by ALA. Herein, we found, in the presence of Fe2+, that ALA-induced formation of 8-hydroxydeoxyguanosine in calf thymus DNA was dose and time-dependent. Melatonin, mannitol and trolox, all of which are free radical scavengers, inhibited the formation of 8-hydroxydeoxyguanosine in a concentration-dependent manner. The concentration of each (melatonin, mannitol and trolox) required to reduce DNA damage by 50%, i.e., the IC50, was 0.52, 0.84 and 0.90 mM, respectively.

Can antioxidants be beneficial in the treatment of lead poisoning?

Recent studies have shown that lead causes oxidative stress by inducing the generation of reactive oxygen species, reducing the antioxidant defense system of cells via depleting glutathione, inhibiting sulfhydryl-dependent enzymes, interfering with some essential metals needed for antioxidant enzyme activities, and/or increasing susceptibility of cells to oxidative attack by altering the membrane integrity and fatty acid composition. Consequently, it is plausible that impaired oxidant/antioxidant balance can be partially responsible for the toxic effects of lead. Where enhanced oxidative stress contributes to lead-induced toxicity, restoration of a cell's antioxidant capacity appears to provide a partial remedy. Several studies are underway to determine the effect of antioxidant supplementation following lead exposure. Data suggest that antioxidants may play an important role in abating some hazards of lead. To explain the importance of using antioxidants in treating lead poisoning the following topics are addressed: (i) Oxidative damage caused by lead poisoning; (ii) conventional treatment of lead poisoning and its side effects; and (iii) possible protective effects of antioxidants in lead toxicity.

Hepatocellular carcinoma in patients with acute hepatic porphyria: frequency of occurrence and related factors

BACKGROUND/AIMS

Previous retrospective studies have suggested an association between hepatocellular carcinoma and acute hepatic porphyrias. The incidence, the relative risk, the characteristics and the outcome of primary liver cancer were prospectively evaluated in patients with acute hepatic porphyrias; the molecular mechanism of carcinogenesis in these patients was also pointed out.

METHODS

A cohort of 650 patients with acute hepatic porphyria was followed over 7 years. Standardized rate ratio was used to measure the relative risk of primary liver cancer after indirect standardization. Morphological and clinical aspects of primary liver cancer were investigated, and survival rates were calculated using the Kaplan-Meier method. Common etiological factors involved in liver carcinogenesis were screened. Excretion rates of porphyrin precursors, serum melatonin levels and mutations in the genes encoding for heme biosynthetic enzymes were studied.

RESULTS

Hepatocellular carcinoma was found in four symptomatic and three asymptomatic patients (four female, three male). The overall standardized rate ratio was 36 (95% CI: 14-74). The 5-year disease-free survival was 43% in patients with hepatocellular carcinoma. Usual risk factors for primary liver cancer were not confounding factors. Hepatocellular carcinoma was not related to specific heme biosynthesis gene mutations. Heme precursors were significantly increased in porphyric patients with hepatocellular carcinoma, and serum melatonin levels were low.

CONCLUSIONS

Acute hepatic porphyrias are risk factors for hepatocellular carcinoma. Hepatic porphyrias should be sought in patients with hepatocellular cancer without obvious etiology, and a periodic screening for hepatocellular carcinoma should be evaluated in these patients. Genes encoding for heme biosynthetic pathway may not act as tumor suppressor genes. Chronic increased levels of delta aminolevulinic acid could lead to the generation of free radicals and subsequently to hepatic carcinogenesis.

The heme synthesis and degradation pathways: role in oxidant sensitivity. Heme oxygenase has both pro- and antioxidant properties

The heme biosynthetic and catabolic pathways generate pro- and antioxidant compounds, and consequently, influence cellular sensitivity to oxidants. Heme precursors (delta-aminolevulinic acid, porphyrins) generate reactive oxygen species (ROS), from autoxidation and photochemical reactions, respectively. Heme, an essential iron chelate, serves in respiration, oxygen transport, detoxification, and signal transduction processes. The potential toxicity of heme and hemoproteins points to a critical role for heme degradation in cellular metabolism. The heme oxygenases (HOs) provide this function and participate in cellular defense. This hypothesis emerges from the observation that the activation of HO-1 is an ubiquitous cellular response to oxidative stress. The reaction products of HO activity, biliverdin, and its subsequent metabolite bilirubin, have antioxidant properties. Furthermore, iron released from HO activity stimulates ferritin synthesis, which ultimately provides an iron detoxification mechanism that may account for long-term cytoprotection observed after HO induction. However, such models have overlooked potential pro-oxidant consequences of HO activity. The HO reaction releases iron, which could be involved in deleterious reactions that compete with iron reutilization and sequestration pathways. Indeed, the induction of HO activity may have both pro- and antioxidant sequelae depending on cellular redox potential, and the metabolic fate of the heme iron.

In vitro study of biosynthesis of protoporphyrin IX induced by delta-aminolevulinic acid in normal and cancerous cells of the human cervix

BACKGROUND

delta-Aminolevulinic acid (ALA) is recognized as the starter in the biosynthesis of the heme group, the structural basis of cytochromes, chlorophylls, biliary pigments, and other porphyrins. It is the first intermediary in the biosynthesis of protoporphyrin IX (PpIX), and of the heme group. PpIX is present in low concentration in normal cells, and in high concentration in tumor cells.

METHODS

The accumulation of protoporphyrin IX (PpIX) induced by delta-aminolevulinic acid (ALA) was tested in two cervico-uterine cancer cell lines (HeLa and CaLo), and in normal human cervical epithelial (NHCE) cells.

RESULTS

The optimal concentration of ALA that induced maximum levels of intra- and extracellular accumulation of PpIX in both HeLa and NHCE cells was 300 micrograms of ALA/mL, and for CaLo cells, 150 micrograms/mL. The viability of HeLa, CaLo, and NHCE cells exposed to ALA measured 81, 98, and 84%, respectively. The optimal time for accumulation of PpIX, both intra- and extracellular, was 4 h for HeLa and NHCE cells and 5 h for CaLo cells per 24 h of exposure to optimal concentrations of ALA. After the maximum level of PpIX accumulation was reached, there was a gradual decrease until there was only a small quantity. A statistically significant difference (p < 0.0001) was found in the accumulation of PpIX, depending on the concentrations of ALA used as well as between cervical cancer cell lines and NHCE cells (p < 0.0001). The concentration ratio of PpIX for NHCE and HeLa cells was 1:7, and for NHCE and CaLo cells, 1:5.

CONCLUSIONS

These results are important for determining the usefulness of the sensitizer (PpIX).

Motor neuropathy in porphobilinogen deaminase-deficient mice imitates the peripheral neuropathy of human acute porphyria

Acute porphyrias are inherited disorders caused by partial deficiency of specific heme biosynthesis enzymes. Clinically, porphyrias are manifested by a neuropsychiatric syndrome that includes peripheral neuropathy. Although much is known about the porphyrias' enzyme defects and their biochemical consequences, the cause of the neurological manifestations remains unresolved. We have studied porphyric neuropathy in mice with a partial deficiency of porphobilinogen deaminase (PBGD). PBGD-deficient mice (PBGD-/-) imitate acute porphyria through massive induction of hepatic delta-aminolevulinic acid synthase by drugs such as phenobarbital. Here we show that PBGD-/- mice develop impairment of motor coordination and muscle weakness. Histologically femoral nerves of PBGD-/- mice exhibit a marked decrease in large-caliber (>8 microm) axons and ultrastructural changes consistent with primary motor axon degeneration, secondary Schwann cell reactions, and axonal regeneration. These findings resemble those found in studies of affected nerves of patients with acute porphyria and thus provide strong evidence that PBGD deficiency causes degeneration of motor axons without signs of primary demyelination, thereby resolving a long-standing controversy. Interestingly, the neuropathy in PBGD-/- mice developed chronically and progressively and in the presence of normal or only slightly (twofold) increased plasma and urinary levels of the putative neurotoxic heme precursor delta-aminolevulinic acid. These data suggest that heme deficiency and consequent dysfunction of hemeproteins can cause porphyric neuropathy.

Delta-aminolevulinic acid-induced lipid peroxidation in rat kidney and liver is attenuated by melatonin: an in vitro and in vivo study

Acute intermittent porphyria (AIP) is a genetically inherited disease characterized by a partial block in liver heme biosynthesis and by increased urinary excretion of the delta-aminolevulinic acid (ALA). Recently, it has been proposed that the toxic effects of ALA are related to the generation of free radicals. In the present study the in vitro and in vivo effect of melatonin, a recently described antioxidative agent, on ALA-induced lipid peroxidation in rat liver and kidney was determined. The concentration of malonaldehyde (MDA) and 4-hydroxyalkenals (4-HDA) was assayed as an index of induced membrane oxidative damage. In vitro melatonin protected, in a concentration-dependent manner, against ALA-induced lipid peroxidation in liver and kidney homogenates. In in vivo experiments as well, it was demonstrated that ALA (40 mg/kg)-induced lipid peroxidation in liver and kidney was reduced by acute melatonin (10 mg/kg) treatment. The results support the involvement of free radicals in ALA toxicity and show that in vitro and in vivo melatonin confers protection against this toxicity, likely due to the antioxidative capability of the indole.

Melatonin protects against lipid peroxidation induced by delta-aminolevulinic acid in rat cerebellum, cortex and hippocampus

The in vitro and in vivo effect of melatonin on delta-aminolevulinic acid-induced lipid peroxidation in rat cerebellum, cortex and hippocampus was determined. The concentration of malonaldehyde and 4-hydroxyalkenals was assayed as an index of induced membrane oxidative damage. The rise in malonaldehyde+4-hydroxyalkenals concentrations induced by delta-aminolevulinic acid in cerebellar homogenates was concentration-dependent (P < 0.001) and also time-dependent in cerebellar, cortical and hippocampal homogenates (P < 0.01). In vitro melatonin and vitamin E protected, in a concentration-dependent manner, against delta-aminolevulinic acid-induced lipid peroxidation in cortical, cerebellar and hippocampal homogenates. In in vivo experiments it was demonstrated that delta-aminolevulinic acid-induced lipid peroxidation (40 mg/kg) in cerebellum and hippocampus was reduced by acute melatonin (10 mg/kg) treatment (P < 0.05). The results show that both in vitro and in vivo melatonin confers protection against delta-aminolevulinic acid-induced oxidative toxicity in brain regions. The findings suggest that melatonin may be useful in reducing neural damage in individuals suffering from acute intermittent porphyria.

Glutathione concentrations in the hard clam, Mercenaria mercenaria, following laboratory exposure to lead (a potential model system for evaluating exposure to carcinogens and toxins)

This study determined whether M. mercenaria retain Pb from sea water and whether endogenous GSH acts as an important primary response modulator of heavy metal detoxification. Lead accumulation in M. mercenaria may be related to the rate of endogenous formation of GSH. Glutathione concentrations decrease with increasing early exposure to Pb and increase after continued acute exposure. M. mercenaria do not accumulate Pb but appear to reach an equilibrium with their environment. GSH formation may protect the hard clam from accumulating excess Pb by forming insoluble sulfide adducts with Pb and excreting these complexes.

delta-Aminolevulinic acid effects on neuronal and glial tumor cell lines

Acute intermittent porphyria (AIP) or precursor syndrome is a well described neuropathic clinical entity with incompletely known etiology. The most prominent biological abnormalities associated with this syndrome are elevations in serum and hepatic delta-aminolevulinic acid (ALA) and porphobilinogen (PBG). We determined the impact of ALA and PBG on human neuroblastoma and glioblastoma tumor cell survival as measured by the MTT assay. ALA proved to be cytotoxic in neuroblastoma cells, while PBG lacked cytotoxic effects. This cytotoxic effect of ALA could be enhanced by deferoxamine and diminished by heme, presumably through modulation of ALA synthesis. In conclusion, ALA excess may prove to be associated with the development of neuropathy in AIP.

Biochemistry of porphyria

1. The porphyrias are a group of metabolic disorders arising from defects in the haem biosynthetic pathway. Most forms are inherited as Mendelian autosomal dominants, but some types are recessive and others acquired through exposure to porphyrinogenic drugs and chemicals. There is a linked group of diseases, which are not porphyrias, but have in common alterations of haem biosynthesis. 2. The processes of haem biosynthesis are now well understood and the molecular biology of the functions and dysfunctions in the porphyrias are currently an area of intensive investigation. 3. The acute porphyrias, Acute Intermittent Porphyria, Variegate Porphyria and Hereditary Coproporphyria are of most importance since attacks of these may be life-threatening. 4. These diseases that usually present with a neurovisceral attack are characterized by excess production of the porphyrin precursors, 5-aminolaevulinate and porphobilinogen because of lowered activity of Porphobilinogen deaminase. 5. A variety of factors may precipitate these attacks including various drugs, alcohol, smoking, dieting or fasting and variations in steroid hormone levels. 6. The non-acute porphyrias are largely dermatological conditions, which present clinically as cutaneous photosensitivity. The dermatological changes are caused by the photosensitizing properties of circulating porphyrins and are accompanied by systemic effects of these porphyrins.