Cerebral GABA-ergic and glutamatergic function in hepatic encephalopathy

A glimpse into multimodal neuromonitoring in acute liver failure: a case report

Introduction

Acute liver failure (ALF) is a rapidly progressing, life-threatening syndrome characterized by liver-related coagulopathy and hepatic encephalopathy (HE). Given that higher HE grades correlate with poorer outcomes, clinical management of ALF necessitates close neurological monitoring. The primary objective of this case report is to highlight the diagnostic value of utilizing multimodal neuromonitoring (MNM) in a patient suffering from ALF.

Case report

A 56-year-old male patient with a history of chronic alcoholism, without prior chronic liver disease, and recent acetaminophen use was admitted to the hospital due to fatigue and presenting with a mild flapping tremor. The primary hypothesis was an acute hepatic injury caused by acetaminophen intoxication. In the following hours, the patient's condition deteriorated, accompanied by neurological decline and rising ammonia levels. The patient's neurological status was closely monitored using MNM. Bilaterally altered pupillary light reflex assessed by decreasing in the Neurological Pupil Index values, using automated pupillometry, initially suggested severe brain oedema. However, ultrasound measurements of the optic nerve sheath diameter showed normal values in both eyes, P2/P1 noninvasive intracranial pressure waveform assessment was within normal ranges and the cerebral computed tomography-scan revealed no signs of cerebral swelling. Increased middle cerebral artery velocities measured by Transcranial Doppler and the initiation of electroencephalography monitoring yielded the presence of status epilepticus.

Discussion

The utilization of MNM facilitated a more comprehensive understanding of the mechanisms underlying the patient's clinical deterioration in the setting of HE. Nonetheless, future studies are needed to show feasibility and to yield valuable insights that can enhance the outcomes for patients with HE using such an approach. Given the absence of specific guidelines in this particular context, it is advisable for physicians to give further consideration to the incorporation of MNM in the management of unconscious patients with ALF.

How important are brain banks for alcohol research?

This article contains the proceedings of a symposium at the 2002 RSA/ISBRA Meeting in San Francisco, organized and chaired by Clive Harper and co-chaired by Izuru Matsumoto. The presentations were (1) Introduction, by Clive Harper; (2) The quality of tissue-a critical issue, by Therese Garrick; (3) The first systematic brain tissue donor program in Japan, by Izuru Matsumoto; (4) Brain scans after death-really! by Adolf Pfefferbaum, Elfar Adalsteinsson, and Edith Sullivan; (5) Capture that (genial) expression, by Joanne Lewohl and Peter Dodd; and (6) Neurochemical/pharmacological studies: experimental design and limitations, by Roger Butterworth.

The role of inhibitory amino acidergic neurotransmission in hepatic encephalopathy: a critical overview

Gamma-Aminobutyric acid (GABA) is the main inhibitory amino acid in the central nervous system (CNS). Experiments with animal models of HE, and with brain slices or cultured CNS cells treated with ammonia, have documented changes in GABA distribution and transport, and modulation of the responses of both the GABA(A)-benzodiazepine receptor complex and GABA(B) receptors. Although many of the data point to an enhancement of GABAergic transmission probably contributing to HE, the evidence is not unequivocal. The major weaknesses of the GABA theory are (1) in a vast majority of HE models, there were no alterations of GABA content in the brain tissue and/or extracellular space, indicating that exposure of neurons to GABA may not have been altered, (2) changes in the affinity and capacity of GABA receptor binding were either absent or qualitatively different in HE models of comparable severity and duration, and (3) no sound changes in the GABAergic system parameters were noted in clinical cases of HE. Taurine (Tau) is an amino acid that is thought to mimic GABA function because of its agonistic properties towards GABA(A) receptors, and to contribute to neuroprotection and osmoregulation. These effects require Tau redistribution between the different cell compartments and the extracellular space. Acute treatment with ammonia evokes massive release of radiolabeled or endogenous Tau from CNS tissues in vivo and in vitro, and the underlying mechanism of Tau release differs from the release evoked by depolarizing conditions or hypoosmotic treatment. Subacute or chronic HE, and also long-term treatment of cultured CNS cells in vitro with ammonia, increase spontaneous Tau "leakage" from the tissue. This is accompanied by a decreased potassium- or hypoosmolarity-induced release of Tau and often by cell swelling, indicating impaired osmoregulation. In in vivo models of HE, Tau leakage is manifested by its increased accumulation in the extrasynaptic space, which may promote inhibitory neurotransmission and/or cell membrane protection. In chronic HE in humans, decreased Tau content in CNS is thought to be one of the causes of cerebral edema. However, understanding of the impact of the changes in Tau content and transport on the pathogenic mechanisms of HE is hampered by the lack of clear-cut evidence regarding the various roles of Tau in the normal CNS.

A case of fatal intoxication with ammonium sulfate and a toxicological study using rabbits

Agricultural fertilizers such as ammonium sulfate are widely used in house gardens as well as in agriculture, but few case reports or toxicological studies of ingested fertilizers have been reported. This paper investigates a fatal case of ammonium sulfate poisoning and demonstrates its clinical and biochemical findings in rabbits. An 85-year-old woman was found dead lying on the ground outside her house in the middle of March, but the autopsy could not determine the cause of her death. Examination at the police laboratory of the solution in the beer can found next to her showed that it was very likely ammonium sulfate. Our measurement showed a significant increase of ammonium and sulfate ions in serum and gastric contents. The cause of her death was determined as poisoning by ammonium sulfate. The total dose of 1500 mg/kg of ammonium sulfate was administered to three rabbits, all of which showed similar symptoms such as mydriasis, irregular respiratory rhythms, local and general convulsions, until they fell into respiratory failure with cardiac arrest. EEG showed slow, suppressive waves and high-amplitude slowing wave pattern, which is generally observed clinically in hyperammonemia in man and animal. There was a remarkable increase in the concentration of ammonium ion and inorganic sulfate ion in serum, and blood gas analysis showed severe metabolic acidosis. These results, mainly findings by EEG, have shown that a rapid increase in ammonium ions in blood can cause damaging the central nervous system without microscopic change. When the cause of death can not be determined, measurement of ammonium ion, inorganic ion and electrolytes in blood as well as in stomach contents at forensic autopsy is necessary.

Selective alterations of cerebrospinal fluid amino acids in dogs with congenital portosystemic shunts

Numerous studies suggest that modifications in concentrations of both excitatory and inhibitory amino acids are implicated in the pathophysiology of portal-systemic encephalopathy (PSE), a neuropsychiatric disorder associated with chronic liver disease in humans. In this study, amino acid levels were measured by High Performance Liquid Chromatography (HPLC) in Cerebrospinal Fluid (CSF) of 10 dogs (age range: 3 mo.- 3 yr 4 mo.) exhibiting a congenital portal-systemic shunt, either intra or extra-hepatic, and 8 age-matched control dogs who showed no signs of hepatic or neurologic disorders. Dogs with congenital shunts manifested signs of encephalopathy such as disorientation, head pressing, vocalization, depression, seizures and coma. CSF from dogs with congenital shunts contained significantly increased amounts of glutamate (2 to 3-fold increase, p<0.01), glutamine (6-fold increase, p<0.05) and aromatic amino acids (phenylalanine, tyrosine and tryptophan) compared to CSF of control dogs. Concentrations of GABA and branched chain amino acids (valine, leucine, isoleucine) were within normal limits. Modifications of brain glutamate (an excitatory amino acid) as well as tryptophan (the precursor of serotonin) could contribute to the neurological syndrome characteristic of congenital PSE in dogs.

Alcohol, alcoholic brain damage, and GABAA receptor isoform gene expression

Selective variations in cerebral GABAA receptor pharmacology and function are observed in experimental animals subjected to a number of alcohol-treatment and -withdrawal paradigms, and where human alcoholics with and without a range of concomitant diseases are compared with non-alcoholic cases. Recombination studies have shown that variations in GABAA receptor pharmacology and function can result from altering its subunit isoform composition. This commentary examines the rôle of subunit isoform expression in the response to long-term alcohol administration in animals, and in the pathogenesis of alcoholism-related brain damage in human cases.

Effects of ammonia on L-glutamate uptake in cultured astrocytes

The effect of ammonia on L-glutamate (L-GLU) uptake was examined in cultured astrocytes. Acute ammonia treatment (5-10 mM) enhanced L-[3H]GLU uptake by 20-42% by increasing the Vmax; this persisted for 2 days and than started to decline. Ammonia, however, did not affect the uptake of D-[3H]aspartate (D-ASP), a non-metabolizable analog of L-GLU, that uses the same transport carrier as L-GLU. Also, L-GLU uptake was not affected during the first 2 min of the assay. Thus, ammonia did not have an acute effect of L-GLU transport (translocation); rather, ammonia enhanced the accumulation or "trapping" of L-GLU or its by-products. Chronic ammonia treatment, on the other hand, inhibited L-GLU transport in astrocytes by approximately 30-45% and this was due to a decrease in Vmax, suggesting that the number of L-GLU transporters was decreased. This inhibitory effect was observed after 1 day of treatment and persisted for at least 7 days. The inhibition of L-GLU transport was partially reversible following removal of ammonia. The effects of ammonia on L-GLU transport and uptake may explain the abnormal L-GLU neurotransmission observed in hyperammonemia/hepatic encephalopathy, and the brain swelling associated with fulminant hepatic failure.

Hepatic encephalopathy presenting as delirium and mania. The possible role of bilirubin

The case of a woman who suffered from hepatic encephalopathy is described. The psychiatric symptoms presented first as a delirium, changing into a manic syndrome. As the neurotoxic direct fraction of bilirubin was greater than 100 times normal, increasing and decreasing in a parallel fashion with the psychiatric symptoms, direct bilirubin is assumed to play a role in the pathogenesis of this case. This is discussed in the context of bilirubin encephalopathy, very seldom diagnosed in adults.

Adenosine influences the high-affinity uptake of transmitter glutamate and aspartate under conditions of hepatic encephalopathy

The high-affinity uptake of transmitter glutamate and aspartate in hippocampal slices incubated in sera from patients with hepatic encephalopathy was dramatically reduced in neuropil areas by more than 50% compared with the control level. Adenosine compensates for these reduction in reuptake capacity in a concentration-dependent fashion reaching normal values at 500 microM adenosine. The renormalization of glutamate and aspartate uptake caused by adenosine might reasonably be expected to have potential therapeutic implications for the treatment of hepatic encephalopathy.

Recent developments in the pathophysiology and treatment of hepatic encephalopathy

The pathophysiology of HE has not yet been clarified. At present the main mechanisms under discussion are the combined effects of different toxins, such as ammonia, mercaptans, phenols and short- and medium-chain fatty acids, as well as a change particularly in GABAergic and glutamatergic neurotransmission. In this chapter the current views on the importance of these individual factors in the pathophysiology of HE are discussed; possible connections between changes in neurotransmission and the effect of different neurotoxins are presented. In addition, possible therapies resulting from recent knowledge of the pathophysiology of this disease are discussed, such as the use of Bz receptor antagonists.

Hepatic Encephalopathy

Hepatic encephalopathy occurs in a number of different species as a result of either congenital portacaval shunts or acquired liver disease. Despite intensive research, the neurochemical basis of the disorder has not been defined. Theories to explain the cerebral dysfunction that accompanies acute or chronic hepatic failure include 1) ammonia acting as the putative neurotoxin, 2) perturbed monoamine neurotransmission as a result of altered plasma amino acid metabolism, 3) an imbalance between excitatory amino acid neurotransmission, mediated by glutamate, and inhibitory amino acid neurotransmission, mediated by gamma-aminobutyric acid, and 4) increased cerebral concentrations of an endogenous benzodiazepine-like substance.

Amino acid release from cerebral cortex in experimental acute liver failure, studied by in vivo cerebral cortex microdialysis

Both increased gamma-aminobutyric acid (GABA)-ergic and decreased glutamatergic neurotransmission have been suggested relative to the pathophysiology of hepatic encephalopathy. This proposed disturbance in neurotransmitter balance, however, is based mainly on brain tissue analysis. Because the approach of whole tissue analysis is of limited value with regard to in vivo neurotransmission, we have studied the extracellular concentrations in the cerebral cortex of several neuroactive amino acids by application of the in vivo microdialysis technique. During acute hepatic encephalopathy induced in rats by complete liver ischemia, increased extracellular concentrations of the neuroactive amino acids glutamate, taurine, and glycine were observed, whereas extracellular concentrations of aspartate and GABA were unaltered and glutamine decreased. It is therefore suggested that hepatic encephalopathy is associated with glycine potentiated glutamate neurotoxicity rather than with a shortage of the neurotransmitter glutamate. In addition, increased extracellular concentration of taurine might contribute to the disturbed neurotransmitter balance. The observation of decreasing glutamine concentrations, after an initial increase, points to a possible astrocytic dysfunction involved in the pathophysiology of hepatic encephalopathy.

CNQX binding to non-NMDA glutamate receptors in canine cerebro-cortical crude synaptosomal membranes: pharmacological characterization and comparison of binding parameters in dogs with congenital portosystemic encephalopathy and control dogs

The pharmacological profile and binding characteristics of the non-NMDA antagonist of glutamate receptors [3H]6-cyano-7-nitro-quinoxaline-2,3-dione (CNQX), were investigated in triton-washed crude synaptosomal membranes prepared from canine cerebral cortex. [3H]CNQX binding was inhibited by various glutamate agonists and antagonists, the rank order of potency being CNQX greater than alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) = quisqualate = kainate greater than glutamate. Two binding sites for [3H]CNQX were apparent when non-specific binding (NSB) was defined with unlabelled CNQX. In contrast, when NSB was defined with saturating concentrations of unlabelled AMPA and kainate, only one binding site was identified which corresponded to the high affinity site identified when CNQX was used to define NSB. No physiologically relevant differences were found in binding parameters for [3H]CNQX membranes from dogs with congenital portosystemic encephalopathy (PSE) when compared with control dogs. The affinity constant (Ki) of AMPA displacement of [3H]CNQX binding was not significantly different in PSE dogs compared with control dogs. These results suggest that the antagonist site on cortical non-NMDA receptors is not perturbed in dogs with congenital PSE.

Neurochemical studies of hepatic encephalopathy

Despite intensive research, the neurochemical basis of hepatic encephalopathy (HE) has not been defined. Theories that are currently favoured to explain the cerebral dysfunction that accompanies acute or chronic hepatic failure include: (1) ammonia acting as the putative neurotoxin; (2) perturbed monoamine neutrotransmission as a result of altered plasmo amino acid metabolism; (3) an imbalance between excitatory amino acid neurotransmission, mediated by glutamate, and inhibitory amino acid neurotransmission, mediated by gamma-aminobutyric acid (GABA); and (4) increased cerebral concentrations of an endogenous benzodiazepine-like substance. Studies of amino acid neurotransmitter receptors in HE have yielded conflicting results. The majority of studies in different animal models of acute and chronic HE and in patients have reported that brain GABA receptor density and affinity are unchanged. There have been fewer studies of excitatory amino acid receptors and these have also yielded conflicting results. However, the majority suggest that components of the glutamate receptor system are perturbed in HE. Further investigation is required to determine the significance of these findings to the pathogenesis of HE.

Reduced somatostatin-like immunoreactivity in the brain of LEC rats with hepatic encephalopathy

Somatostatin-14-like immunoreactivity (S14LI) and somatostatin-28(1-12)-like immunoreactivity (S28(1-12)LI) in the brain of LEC (Long Evans Cinnamon) rats with hepatic encephalopathy were measured. Significant reduction of both S14LI and S28(1-12)LI was observed in the hypothalamus, medulla oblongata, striatum and spinal cord. Both of the immunoreactivities in the hypothalamus of these rats were approx. 50% of those in LEC rats without hepatic encephalopathy. The amounts of reduction of S14LI significantly correlated with those of reduction of S28(1-12)LI. No significant difference in gel chromatographic profiles of S14LI and S28(1-12)LI was observed between LEC rats with and without hepatic encephalopathy. These results suggest that the reduction of somatostatin-like immunoreactivity in LEC rats with hepatic encephalopathy may be caused by a decrease in production of prosomatostatin rather than altered degradation.

Hyperammonemic alterations in the uptake and release of glutamate and aspartate by rat cerebellar preparations

Release and uptake of neurotransmitter amino acids, glutamate and aspartate, were studied in the synaptosomes, astrocytes and in the perikarya of granule neurons isolated from the cerebella of normal and hyperammonemic rats. During acute hyperammonemia, depolarization-induced release of both the amino acids from the synaptosomes was elevated. The Vmax values of high-affinity uptake systems were elevated without alterations in the Km values for these two amino acids during acute hyperammonemic states. In the case of the low-affinity uptake system of these two amino acids, there was a decrease in the Km values without alterations in the Vmax values. These results are discussed in relation to the mechanism of ammonia toxicity.

Hyperammonaemia does not impair brain function in the absence of net glutamine synthesis

1. It has been established that chronic hyperammonaemia, whether caused by portacaval shunting or other means, leads to a variety of metabolic changes, including a depression in the cerebral metabolic rate of glucose (CMRGlc) increased permeability of the blood-brain barrier to neutral amino acids, and an increase in the brain content of aromatic amino acids. The preceding paper [Jessy, DeJoseph & Hawkins (1991) Biochem. J. 277, 693-696] showed that the depression in CMRGlc caused by hyperammonaemia correlated more closely with glutamine, a metabolite of ammonia, than with ammonia itself. This suggested that ammonia (NH3 and NH4+) was without effect. The present experiments address the question whether ammonia, in the absence of net glutamine synthesis, induces any of the metabolic symptoms of cerebral dysfunction associated with hyperammonaemia. 2. Small doses of methionine sulphoximine, an inhibitor of glutamine synthetase, were used to raise the plasma ammonia levels of normal rats without increasing the brain glutamine content. These hyperammonaemic rats, with plasma and brain ammonia levels equivalent to those known to depress brain function, behaved normally over 48 h. There was no depression of cerebral energy metabolism (i.e. the rate of glucose consumption). Contents of key intermediary metabolites and high-energy phosphates were normal. Neutral amino acid transport (tryptophan and leucine) and the brain contents of aromatic amino acids were unchanged. 3. The data suggest that ammonia is without effect at concentrations less than 1 mumol/ml if it is not converted into glutamine. The deleterious effect of chronic hyperammonaemia seems to begin with the synthesis of glutamine.

Decreased glucose utilization in discrete brain regions of rat in thioacetamide-induced hepatic encephalopathy as measured with [3H]-deoxyglucose

To evaluate the possible contribution of bioenergetic failure in the particular brain regions to the pathomechanism of hepatic encephalopathy (HE), local cerebral metabolic rate for glucose (LCMRglue) was evaluated from [3H]-deoxyglucose uptake in frontal, visual and auditory cortex, striatum, cerebellum and medulla oblongata of rats with acute HE induced with a hepatotoxin--thioacetamide (TAA). HE caused a decrease of LCMRglue in all the regions studied. The strongest decrease (about 65%) was noted in hippocampus and cerebral cortex--the two regions rich in glutamatergic neurons. The results indicate a possible link between decreased energy metabolism and impaired excitatory, glutamatergic neurotransmission--the two factors whose contribution to HE has so far been implicated separately.

Alterations in cortical [3H]kainate and alpha-[3H]amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid binding in a spontaneous canine model of chronic hepatic encephalopathy

Excitatory amino acid receptor binding parameters were investigated in a spontaneous dog model of chronic hepatic encephalopathy. L-[3H]Glutamate, (+)-[3H]-5-methyl-10,11-dihydro-5H-dibenzo[a,d]cyclohepten-5,10-im ine maleate ([3H]MK-801), [3H]kainate, and alpha-[3H]-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid ([3H]AMPA) binding experiments were performed using crude cerebrocortical synaptosomal membrane preparations from dogs with congenital portosystemic encephalopathy (PSE) and control dogs. There was no change in the affinity or density of L-[3H]-glutamate or [3H]MK-801 binding sites in dogs with congenital PSE compared with control dogs. However, in the PSE dogs there was a significant reduction in the density of [3H]kainate binding sites compared with control dogs and abolition of the low-affinity [3H]AMPA binding site. The relative binding capacity of PSE synaptosomal membranes for [3H]kainate and [3H]AMPA was expressed as the ratio Bmax/KD. There was a significant inverse correlation between the Bmax/KD ratio for [3H]AMPA binding and the worst grade of encephalopathy experienced by each dog. These results suggest that there is a significant perturbation of cerebrocortical non-N-methyl-D-aspartate receptor binding in dogs with congenital PSE which may have relevance to the pathogenesis of hepatic encephalopathy.

Taurine release from brain slices in thioacetamide-induced hepatic encephalopathy in rats

The possible involvement of taurine in the pathogenesis of hepatic encephalopathy was studied in rats injected with thioacetamide. Spontaneous release of exogenous labeled taurine was not affected in any brain area studied, but the potassium-stimulated release was enhanced in the striatum in thioacetamide-treated rats. High concentrations of ammonium ions also evoked greater release of taurine from striatal slices in rats with thioacetamide-induced hepatic encephalopathy.

Brain histamine in rats with hepatic encephalopathy

Chronic liver failure induced by portocaval anastomosis (PCA) in Wistar rats resulted in a dramatic increase in histamine concentration in hypothalamus and a smaller, but clearly pronounced, elevation in the rest of brain. Between 10 and 120 days following surgery, shunted rats exhibited a histamine level 2.4- to 13-fold higher in hypothalamus and 1.5- to 2.5-fold higher in the rest of brain as compared to their control, sham-operated pairs. There were no significant changes in histamine concentration in the other examined tissues. The increase in brain histamine could not be attributed to the inhibition of its degradation, because activity of histamine N-methyltransferase remained unchanged for at least 40 days. Although the activity of histidine decarboxylase also remained unchanged when measured at a saturating concentration of L-histidine, the increase in histamine content in brain seems to be due to its enhanced synthesis brought about by increased availability of L-histidine in the tissue, as indicated by two to four times higher concentrations of this amino acid in PCA rats.

Influence of ammonia, octanoate, quinolinate and hypoxic conditions on NAD(P)H fluorescence of hippocampal slices

Acute exposure of rat hippocampal slices to high concentrations of the neurotoxicants, ammonia, octanoate and quinolinate, was monitored by microscope fluorimetry and NAD(P)H absorption. High concentrations of ammonia or octanoate, or a combination of both, reduced the fluorescence signals under aerobic conditions to a similar extent as observed in the case of CN(?)-induced model hypoxia. Quinolinate alone did not produce any effect, nor was it effective in the presence of ammonia or octanoate. Ammonia or octanoate or a combination of both neurotoxicants being present, administration of 2-oxoglutarate or valine was found to prevent efficiently changes in fluorimetric response in a protective manner. The results are interpreted as being supportive of the notion that these compounds may entail a mechanism of protective potency. Glutamate being substituted for glucose of the normal incubation medium, addition of ammonia produced higher oxidation states of nicotinamide nucleotides (K(m app) = 16.9 mM; SD = 3.1; n = 7) only when excessive ammonia concentrations were chosen. Hence, it is conjectured that glutamate uptake and metabolization are not essentially reduced by ammonia levels even in the case of severe hyperammonaemia.

Increased brain content of the endogenous benzodiazepine receptor ligand, octadecaneuropeptide (ODN), following portacaval anastomosis in the rat

Evidence suggests that endogenous benzodiazepine receptor ligands such as diazepam binding inhibitor (DBI) and its metabolite octadecaneuropeptide (ODN) may be implicated in the pathogenesis of hepatic encephalopathy. Using an immunocytochemical technique and an antibody of high specific activity to synthetic ODN, we studied the effects of portacaval anastomosis (PCA) on ODN distribution in rat brain. Four weeks after PCA, ODN immunolabeling was increased in several brain regions including cerebral cortex, hippocampus, hypothalamus and thalamus. Increased ODN immunolabeling was confined to nonneuronal elements such as astrocytes and ependymal cells. Neuropathological evaluation of brain following PCA reveals astrocytic rather than neuronal changes. These results are consistent with a role for endogenous neuropeptide ligands for astrocytic benzodiazepine receptors in the pathogenesis of hepatic encephalopathy.

Changes in brain metabolism during hyperammonemia and acute liver failure: results of a comparative 1H-NMR spectroscopy and biochemical investigation

The effects of hyperammonemia on brain function have been studied in three different experimental models in the rat: acute liver ischemia, urease-treated animals and methionine sulfoximine-treated animals. To quantify the development of encephalopathy, clinical grading and electroencephalographic spectral analysis were used as indicators. In all three experimental models brain ammonia concentrations increased remarkably associated with comparable increases in severity of encephalopathy. Furthermore, in vivo 1H-nuclear magnetic resonance spectroscopy of a localized cerebral cortex region showed a decrease in glutamate concentration in each of the aforementioned experimental models. This decreased cerebral cortex glutamate concentration was confirmed by biochemical analysis of cerebral cortex tissue post mortem. Furthermore, an increase in cerebral cortex glutamine and lactate concentration was observed in urease-treated rats and acute liver ischemia rats. As expected, no increase in cerebral cortex glutamine was observed in methionine sulfoximine-treated rats. These data support the hypothesis that ammonia is of key importance in the pathogenesis of acute hepatic encephalopathy. Decreased availability of cerebral cortex glutamate for neurotransmission might be a contributing factor to the pathogenesis of hyperammonemic encephalopathy. A surprising new finding revealed by 1H-nuclear magnetic resonance spectroscopy was a decrease of cerebral cortex phosphocholine compounds in all three experimental models. The significance of this finding, however, remains speculative.

Hepatic encephalopathy influences high-affinity uptake of transmitter glutamate and aspartate into the hippocampal formation

The present work was carried out to study the influence of ammonia and factors from sera and cerebrospinal fluid (CSF) from patients with different degrees of chronic liver diseases on [3H]D-aspartate (Asp) and [3H]L-glutamate (Glu) high-affinity uptake into the rat hippocampal formation. For comparison, high-affinity uptake of Glu and Asp was determined in human hippocampal brain tissue obtained at autopsy from cirrhotic patients dying in hepatic coma and from control brains free from neurological, psychiatric, or hepatic diseases. Sera and CSF from patients with chronic liver failure and hepatic encephalopathy (HE) were seen to reduce dramatically Glu and Asp uptake into rat hippocampal dendritic layers. A close inverse relationship was found to exist between the level of ammonia in the sera and the inhibition of uptake, both phenomena correlating highly with the extent of liver failure. The present findings, obtained after dilution of sera from patients with HE while maintaining initial ammonium levels, elucidate, however, that ammonia alone cannot account for the reduction in Glu/Asp uptake capacity. The inhibition of Asp uptake into human hippocampal formation of patients dying in hepatic coma was even more pronounced when compared to that found in rat hippocampus incubated in sera and CSF from patients. Glu/Asp uptake into brain tissue is supposed to be an important factor in the pathogenesis of HE accompanying liver dysfunctions.

Activation of arginine metabolism to glutamate in rat brain synaptosomes in thioacetamide-induced hepatic encephalopathy: an adaptative response?

Crude (P2) synaptosomes derived from rats with acute hepatic encephalopathy (HE) induced with thioacetamide showed a slightly increased uptake of radiolabeled arginine (ARG) and a 2.5-fold enhanced conversion of newly taken-up ARG to both glutamate (GLU) and gamma-aminobutyric acid (GABA) as compared with control synaptosomes. Pulse treatment of the preloaded synaptosomes with a high potassium medium decreased their radioactive GLU and GABA content without affecting the content of the precursor ARG. This result, which was identical with control or HE preparations, appears to indicate that ARG contributes at least, in part, to the synthesis of neurotransmitter GLU or GABA. As measured in purified synaptosomal preparations, HE increased by about 50% the activities of arginase and ornithine-delta-aminotransferase--the two enzymes of the ARG to GLU shunt. It is postulated that increased conversion of ARG to GLU may compensate for excessive utilization of the latter amino acid as an ammonia trap during HE and, as such, may be considered as an adaptative response of the synaptic compartment to this pathological condition.

Uptake of gamma-aminobutyric acid and L-glutamic acid by synaptosomes from postmortem human cerebral cortex: multiple sites, sodium dependence and effect of tissue preparation

The uptake of gamma-aminobutyric acid (GABA) and L-glutamic acid by synaptosomes prepared from frozen postmortem human brain was shown to be effected via distinct high and low affinity sites. At approximately 17 h postmortem delay, the kinetic parameters for GABA uptake were: high affinity site, Km 7.1 +/- 2.5 microM, Vmax 18.7 +/- 4.8 nmol.min-1 per 100 mg protein; low affinity site, Km 2 +/- 1 mM, Vmax 425 +/- 250 nmol.min-1 per 100 mg protein (means +/- S.E.M., n = 13). Kinetic parameters for L-glutamate uptake were: high affinity site, Km 7.5 +/- 1.0 microM, Vmax 85 +/- 8 nmol.min-1 per 100 mg protein; low affinity site, Km 1.8 +/- 1.2 mM. Vmax 780 +/- 175 nmol.min-1 per 100 mg protein (n = 11). A detailed kinetic analysis of high affinity GABA uptake was performed over a range of sodium ion concentrations. The results were consistent with a coupling ratio of one Na+ ion to one GABA molecule; a similar result was found with rat brain synaptosomes. However, rat and human synaptosomes differed in the degree to which the substrate affinity of the high affinity GABA uptake site varied with decreasing Na+ ion concentration. High affinity GABA uptake was markedly affected by the method used to freeze and divide the tissue, but did not vary greatly in different cortical regions. There was some decline of high affinity GABA uptake activity with postmortem delay, apparently due to a loss of sites rather than a change in site affinity.

Activities of neuronal and astrocytic marker enzymes in autopsied brain tissue from patients with hepatic encephalopathy

Activities of the gamma-aminobutyric acid (GABA) and cholinergic nerve-terminal marker enzymes glutamic acid decarboxylase (GAD) and choline acetyltransferase (CAT) as well as the astrocytic enzyme glutamine synthetase (GS) were measured in homogenates of dissected brain tissue obtained at autopsy from nine cirrhotic patients dying in hepatic encephalopathy and an equal number of control subjects matched for age, agonal status, and time interval from death to freezing of autopsied material. GAD activities varied as a function of agonal status in control samples, confirming a previous report, but were unchanged in brain tissue from cirrhotic patients, suggesting no loss of integrity of presynaptic GABA nerve terminals in this disease. On the other hand, GS activities were selectively decreased by 25% (P less than 0.01) in caudate nuclei of cirrhotic patients, reflecting, no doubt, the severe astrocytosis consistently observed in this brain structure. CAT activities, expressed per milligram of protein, were found to be increased by 30% (P less than 0.01) in the prefrontal cortex of cirrhotic patients. Whether such changes result from a relative increase in CAT as a consequence of losses of astrocytic protein or reflect altered cholinergic function in hepatic encephalopathy associated with chronic liver disease awaits further study.

Amino acid changes in autopsied brain tissue from cirrhotic patients with hepatic encephalopathy

Brain tissue was obtained at autopsy from nine cirrhotic patients dying in hepatic coma and from an equal number of controls, free from neurological, psychiatric, or hepatic diseases, matched for age and time interval from death to freezing of dissected brain samples. Glutamine, glutamate, aspartate, and gamma-aminobutyric acid (GABA) levels were measured in homogenates of cerebral cortex (prefrontal and frontal), caudate nuclei, hypothalamus, cerebellum (cortex and vermis), and medulla oblongata as their o-phthalaldehyde derivatives by HPLC using fluorescence detection. Glutamine concentrations were found to be elevated two- to fourfold in all brain structures, the largest increases being observed in prefrontal cortex and medulla oblongata. Glutamate levels were selectively decreased in prefrontal cortex (by 20%), caudate nuclei (by 27%), and cerebellar vermis (by 17%) from cirrhotic patients. On the other hand, GABA content of autopsied brain tissue from these patients was found to be within normal limits in all brain structures. It is suggested that such region-selective reductions of glutamate may reflect loss of the amino acid from the releasable (neurotransmitter) pool. These findings may be of significance in the pathogenesis of hepatic encephalopathy resulting from chronic liver disease.