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Sigawi T, Hamtzany O, Hurvitz N, Ishay Y, Dayan R, Arkadir D, Ilan Y. Investigating the Relationship between Chronic Liver Cirrhosis and Parkinsonism: A Comparative Analysis and a Suggested Diagnostic Scheme. Clin Pract 2024; 14:1375-1382. [PMID: 39051304 PMCID: PMC11270255 DOI: 10.3390/clinpract14040110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 06/28/2024] [Accepted: 07/08/2024] [Indexed: 07/27/2024] Open
Abstract
Aim: Neurological manifestations are common in patients with chronic liver diseases. This study aimed to depict the association between liver cirrhosis and Parkinson's disease (PD) and propose a clinically relevant diagnostic scheme. Methods: We examined patients' medical records with PD and chronic liver impairment secondary to cirrhosis or liver metastases for temporal correlations between liver insult and Parkinsonian signs. Results: Thirty-five individuals with PD and chronic liver impairment were included due to either cirrhosis or liver metastases. In all 22 patients with PD and liver metastases, the diagnosis of PD preceded the diagnosis of cancer. Conversely, patients with cirrhosis were often diagnosed with liver impairment before diagnosing PD. Age at diagnosis did not account for this difference. Conclusions: This study reinforces the potential clinical association between cirrhosis and PD. We also provide a diagnostic scheme that may guide therapeutic interventions and prognostic assessments.
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Affiliation(s)
- Tal Sigawi
- Department of Medicine, Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem 9112001, Israel; (T.S.); (O.H.); (N.H.); (Y.I.)
| | - Omer Hamtzany
- Department of Medicine, Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem 9112001, Israel; (T.S.); (O.H.); (N.H.); (Y.I.)
| | - Noa Hurvitz
- Department of Medicine, Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem 9112001, Israel; (T.S.); (O.H.); (N.H.); (Y.I.)
| | - Yuval Ishay
- Department of Medicine, Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem 9112001, Israel; (T.S.); (O.H.); (N.H.); (Y.I.)
| | - Roy Dayan
- Department of Neurology, Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem 9112001, Israel; (R.D.); (D.A.)
| | - David Arkadir
- Department of Neurology, Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem 9112001, Israel; (R.D.); (D.A.)
| | - Yaron Ilan
- Department of Medicine, Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem 9112001, Israel; (T.S.); (O.H.); (N.H.); (Y.I.)
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2
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Li S, Zhua Y, Liu X. Parkinsonism in liver diseases or dysfunction. Med Clin (Barc) 2024:S0025-7753(24)00356-7. [PMID: 38955605 DOI: 10.1016/j.medcli.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 04/20/2024] [Indexed: 07/04/2024]
Abstract
Parkinsonism in liver diseases or dysfunction, mainly including neurological manifestations in hereditary liver diseases and neurological complications of advanced liver diseases, occur in isolation or in combination with other movement disorders, and progress along disease course. Prominent akinetic-rigidity syndrome, various onset and progression, poor levodopa response and metabolism abnormalities reflected by serum biomarkers and neuroimaging, make this atypical parkinsonism recognizable and notable in clinical practice. Different susceptibility of brain areas, especially in basal ganglia, to manganese, iron, copper, ammonia overload, together with subsequent oxidative stress, neurotransmitter alterations, disturbed glia-neuron homeostasis and eventually neurotoxicity, contribute to parkinsonism under the circumstances of insufficient liver clearance ability. These mechanisms are interrelated and may interact collectively, adding to the complexity of clinical manifestations and treatment responses. This review summarizes shared clinical features of parkinsonism in liver diseases or dysfunction, depicts their underlying mechanisms and suggests practical flowchart for differential diagnosis.
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Affiliation(s)
- Sichen Li
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuxia Zhua
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xi Liu
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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3
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Zahr N, Sullivan E, Pfefferbaum A. [WITHDRAWN] Serum biomarkers of liver fibrosis identify changes in striatal metabolite levels. RESEARCH SQUARE 2024:rs.3.rs-2729490. [PMID: 37034697 PMCID: PMC10081358 DOI: 10.21203/rs.3.rs-2729490/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
The full text of this preprint has been withdrawn by the authors due to author disagreement with the posting of the preprint. Therefore, the authors do not wish this work to be cited as a reference. Questions should be directed to the corresponding author.
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4
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Kwong AJ, Zahr NM. Serum biomarkers of liver fibrosis identify globus pallidus vulnerability. Neuroimage Clin 2023; 37:103333. [PMID: 36868044 PMCID: PMC9996367 DOI: 10.1016/j.nicl.2023.103333] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 01/12/2023] [Accepted: 01/19/2023] [Indexed: 01/28/2023]
Abstract
The CNS manifestation of chronic liver disease can include magnetic resonance (MR) signal hyperintensities in basal ganglia structures. Here, relations between liver (serum-derived fibrosis scores) and brain (regional T1-weighted signal intensities and volumes) integrity were evaluated in a sample of 457 individuals including those with alcohol use disorders (AUD), people living with human immunodeficiency virus (HIV), those comorbid for AUD and HIV, and healthy controls. Liver fibrosis was identified from cutoff scores as follows: aspartate aminotransferase to platelet ratio index (APRI) > 0.7 in 9.4% (n = 43) of the cohort; fibrosis score (FIB4) > 1.5 in 28.0% (n = 128) of the cohort; and non-alcoholic fatty liver disease fibrosis score (NFS) > -1.4 in 30.2% (n = 138) of the cohort. Presence of serum-derived liver fibrosis was associated with high signal intensities selective to basal ganglia (i.e., caudate, putamen, and pallidum) structures. High signal intensities in the pallidum, however, explained a significant portion of the variance in APRI (25.0%) and FIB4 (23.6%) cutoff scores. Further, among the regions evaluated, only the globus pallidus showed a correlation between greater signal intensity and smaller volume (r = -0.44, p <.0001). Finally, higher pallidal signal intensity correlated worse ataxia (eyes open ρ = -0.23, p =.0002; eyes closed ρ = -0.21, p =.0005). This study suggests that clinically relevant serum biomarkers of liver fibrosis such as the APRI may identify individuals vulnerable to globus pallidus pathology and contribute to problems with postural balance.
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Affiliation(s)
- Allison J Kwong
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, School of Medicine, Redwood City, CA 94063, USA
| | - Natalie M Zahr
- Department of Psychiatry & Behavioral Sciences, Stanford University, School of Medicine, 401 Quarry Rd. Stanford, CA 94305, USA; Neuroscience Program, SRI International, Menlo Park, CA 94025, USA.
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5
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Zhang X, Liu J, Wang H. The cGAS-STING-autophagy pathway: Novel perspectives in neurotoxicity induced by manganese exposure. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2022; 315:120412. [PMID: 36240967 DOI: 10.1016/j.envpol.2022.120412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/28/2022] [Accepted: 10/07/2022] [Indexed: 06/16/2023]
Abstract
Chronic high-level heavy metal exposure increases the risk of developing different neurodegenerative diseases. Chronic excessive manganese (Mn) exposure is known to lead to neurodegenerative diseases. In addition, some evidence suggests that autophagy dysfunction plays an important role in the pathogenesis of various neurodegenerative diseases. Over the past decade, the DNA-sensing receptor cyclic GMP-AMP synthase (cGAS) and its downstream signal-efficient interferon gene stimulator (STING), as well as the molecular composition and regulatory mechanisms of this pathway have been well understood. The cGAS-STING pathway has emerged as a crucial mechanism to induce effective innate immune responses by inducing type I interferons in mammalian cells. Moreover, recent studies have found that Mn2+ is the second activator of the cGAS-STING pathway besides dsDNA, and inducing autophagy is a primitive function for the activation of the cGAS-STING pathway. However, overactivation of the immune response can lead to tissue damage. This review discusses the mechanism of neurotoxicity induced by Mn exposure from the cGAS-STING-autophagy pathway. Future work exploiting the cGAS-STING-autophagy pathway may provide a novel perspective for manganese neurotoxicity.
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Affiliation(s)
- Xin Zhang
- Department of Toxicology, School of Public Health, Lanzhou University, Lanzhou, Gansu, China
| | - Jingjing Liu
- Department of Toxicology, School of Public Health, Lanzhou University, Lanzhou, Gansu, China
| | - Hui Wang
- Department of Toxicology, School of Public Health, Lanzhou University, Lanzhou, Gansu, China.
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6
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A Novel Selenium Polysaccharide Alleviates the Manganese (Mn)-Induced Toxicity in Hep G2 Cells and Caenorhabditis elegans. Int J Mol Sci 2022; 23:ijms23084097. [PMID: 35456914 PMCID: PMC9029073 DOI: 10.3390/ijms23084097] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 03/31/2022] [Accepted: 04/05/2022] [Indexed: 12/14/2022] Open
Abstract
Manganese (Mn) is now known to have a variety of toxicities, particularly when exposed to it in the workplace. However, there are still ineffective methods for reducing Mn's hazardous effects. In this study, a new selenium polysaccharide (Se-PCS) was developed from the shell of Camellia oleifera to reduce Mn toxicity in vitro and in vivo. The results revealed that Se-PCS may boost cell survival in Hep G2 cells exposed to Mn and activate antioxidant enzyme activity, lowering ROS and cell apoptosis. Furthermore, after being treated with Se-PCS, Caenorhabditis elegans survived longer under Mn stress. daf-16, a tolerant critical gene, was turned on. Moreover, the antioxidant system was enhanced as the increase in strong antioxidant enzyme activity and high expression of the sod-3, ctl-2, and gst-1 genes. A variety of mutations were also used to confirm that Se-PCS downregulated the insulin signaling pathway. These findings showed that Se-PCS protected Hep G2 cells and C. elegans via the insulin/IGF-1 signaling pathway and that it could be developed into a promising medication to treat Mn toxicity.
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7
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Mulroy E, Baschieri F, Magrinelli F, Latorre A, Cortelli P, Bhatia KP. Movement Disorders and Liver Disease. Mov Disord Clin Pract 2021; 8:828-842. [PMID: 34401403 PMCID: PMC8354085 DOI: 10.1002/mdc3.13238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 04/24/2021] [Accepted: 04/27/2021] [Indexed: 12/15/2022] Open
Abstract
The association of movement disorders with structural or functional hepatic disease occurs in three principal scenarios: (1) combined involvement of both organ systems from a single disease entity, (2) nervous system dysfunction resulting from exposure to toxic compounds in the setting of defective hepatic clearance, or (3) hepatic and/or neurological injury secondary to exposure to exogenous drugs or toxins. An important early step in the workup of any patient with combined movement disorders and liver disease is the exclusion of Wilson's disease. Diagnostic delay remains common for this treatable disorder, and this has major implications for patient outcomes. Thereafter, a structured approach integrating variables such as age of onset, tempo of progression, nature and severity of liver involvement, movement disorder phenomenology, exposure to drugs/toxins and laboratory/neuroimaging findings is key to ensuring timely diagnosis and disease‐specific therapy. Herein, we provide an overview of disorders which may manifest with a combination of movement disorders and liver disease, structured under the three headings as detailed above. In each section, the most common disorders are discussed, along with important clinical pearls, suggested diagnostic workup, differential diagnoses and where appropriate, treatment considerations.
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Affiliation(s)
- Eoin Mulroy
- Department of Clinical and Movement Neurosciences UCL Queen Square Institute of Neurology London United Kingdom
| | - Francesca Baschieri
- IRCCS Istituto delle Scienze Neurologiche di Bologna Bologna Italy.,Dipartimento di Scienze Biomediche e Neuromotorie Università di Bologna Bologna Italy
| | - Francesca Magrinelli
- Department of Clinical and Movement Neurosciences UCL Queen Square Institute of Neurology London United Kingdom.,Department of Neurosciences Biomedicine and Movement Sciences, University of Verona Verona Italy
| | - Anna Latorre
- Department of Clinical and Movement Neurosciences UCL Queen Square Institute of Neurology London United Kingdom
| | - Pietro Cortelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna Bologna Italy.,Dipartimento di Scienze Biomediche e Neuromotorie Università di Bologna Bologna Italy
| | - Kailash P Bhatia
- Department of Clinical and Movement Neurosciences UCL Queen Square Institute of Neurology London United Kingdom
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8
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Mirallas O, Saoudi N, Gómez-Puerto D, Riveiro-Barciela M, Merino X, Auger C, Landolfi S, Blanco L, Garcia-Burillo A, Molero X, Salcedo-Allende MT, Capdevila J. Acquired hepatocerebral degeneration in a metastatic neuroendocrine tumor long-term survivor — an update on neuroendocrine neoplasm’s treatment: A case report. World J Hepatol 2021; 13:611-619. [PMID: 34131474 PMCID: PMC8173341 DOI: 10.4254/wjh.v13.i5.611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 02/04/2021] [Accepted: 04/09/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Metastatic small bowel low-grade neuroendocrine tumors (NETs) have a good prognosis. Surgery is the only curative treatment; however, this may induce advanced liver disease, particularly in long-term survivor patients. Acquired hepatocerebral degeneration or Parkinsonism in cirrhosis is characterized by rapidly progressive extrapyramidal symptoms in patients with advanced liver disease.
CASE SUMMARY A 70-year-old man presented to the emergency department with diminished consciousness and disorientation, and was diagnosed with hepatic encephalopathy. The patient was diagnosed in 1993 with a metastatic small bowel NET, for which he twice underwent hepatic surgery, with metastatic resection in 1993 and a right hepatectomy in 2002 to remove two hepatic metastases. In 2003, the patient started first-line chemotherapy and in 2004 started the first of three consecutive biological treatments, followed by radio-molecular therapy, achieving stable disease for 14 years. Disease progression was identified and he underwent an endoscopic retrograde cholangiopancreatography. However, in 2019 advanced liver disease was identified. We diagnosed the development of acquired hepatocerebral degeneration, an unusual long-term side effect after multiple hepatic procedures.
CONCLUSION The importance of regular and ongoing surveillance in long-term NET survivors who undergo hepatic procedures should be integrated into the therapeutic management plan, as some of these negative outcomes could be prevented.
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Affiliation(s)
- Oriol Mirallas
- Medical Oncology Department, Vall d'Hebron University Hospital, Vall Hebron Institute of Oncology, Barcelona 08035, Catalunya, Spain
| | - Nadia Saoudi
- Medical Oncology Department, Vall d'Hebron University Hospital, Vall Hebron Institute of Oncology, Barcelona 08035, Catalunya, Spain
| | - Diego Gómez-Puerto
- Medical Oncology Department, Vall d'Hebron University Hospital, Vall Hebron Institute of Oncology, Barcelona 08035, Catalunya, Spain
| | - Mar Riveiro-Barciela
- Liver Unit, Department of Internal Medicine, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona 08035, Catalunya, Spain
| | - Xavier Merino
- Radiodiagnostic Department, Vall d’Hebron University Hospital, Barcelona 08035, Catalunya, Spain
| | - Cristina Auger
- Radiodiagnostic Department, Vall d’Hebron University Hospital, Barcelona 08035, Catalunya, Spain
| | - Stefania Landolfi
- Pathology Department, Vall d'Hebron University Hospital, Barcelona 08035, Catalunya, Spain
| | - Laia Blanco
- Hepatobiliopancreatic Surgery and Transplantation Department, Vall d'Hebron University Hospital, Barcelona 08034, Catalunya, Spain
| | - Amparo Garcia-Burillo
- Nuclear Medicine Department, Vall d'Hebron University Hospital, Barcelona 08035, Catalunya, Spain
| | - Xavier Molero
- Hepatobiliopancreatic Surgery and Transplantation Department, Vall d'Hebron University Hospital, Barcelona 08034, Catalunya, Spain
| | | | - Jaume Capdevila
- Medical Oncology Department, Vall d'Hebron University Hospital, Vall Hebron Institute of Oncology, Barcelona 08035, Catalunya, Spain
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Abstract
PURPOSE OF REVIEW This article describes the neurologic sequelae of various nutritional micronutrient deficiencies, celiac disease, inflammatory bowel disease, and liver disease. Where relevant, appropriate treatments for these conditions are also discussed. The developing field of the microbiome and nervous system interaction is also outlined. RECENT FINDINGS Pathology in the gastrointestinal system can affect the nervous system when it causes micronutrient deficiency, when immune responses created by the gastrointestinal system affect the nervous system, when toxins caused by gastrointestinal organ failure harm the nervous system, and when treatments aimed at a gastrointestinal medical condition cause damage to the nervous system as a side effect. SUMMARY This article addresses familiar concepts and new developments in the treatment and understanding of diseases that affect the gut and nervous system simultaneously.
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10
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Apetauerova D, Hildebrand P, Scala S, Zani JW, Lipert L, Clark E, Fennell T, Gordon FD. A Prospective Study of the Prevalence of Parkinsonism in Patients With Liver Cirrhosis. Hepatol Commun 2021; 5:323-333. [PMID: 33553978 PMCID: PMC7850299 DOI: 10.1002/hep4.1624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/02/2020] [Accepted: 09/12/2020] [Indexed: 02/04/2023] Open
Abstract
Acquired hepatocerebral degeneration refers to a neurological syndrome consisting of various movement disorders and cognitive impairment in advanced liver cirrhosis or portosystemic shunt. Neurological signs and symptoms may be attributed to the accumulation of toxic substances in the brain. The most common neurological presentation of this is parkinsonism. Our prospective study aimed to investigate the prevalence of parkinsonism in patients with cirrhosis who were evaluated for liver transplant and to identify any correlation between findings on brain magnetic resonance imaging (MRI) and severity of parkinsonism. Of the 120 enrolled participants with liver cirrhosis, 62 (52%) exhibited signs of parkinsonism and all had MRI basal ganglia hyperintensity. Eighteen patients from this group were transplanted and showed statistically significant improvements in their Unified Parkinson's Disease Rating Scale (UPDRS) scores. Conclusion: The data suggest the reversibility of the neurological impairment seen in cirrhosis, and therefore the effectiveness of transplantation in improving parkinsonian symptoms. There was no correlation between severity of MRI findings and clinical motor UPDRS part III. Laboratory findings showed no correlation among the abnormal levels, MRI brain signal abnormality, or UPDRS scores.
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Affiliation(s)
| | | | | | - Janet W Zani
- Lahey Hospital and Medical CenterBurlingtonMAUSA
| | | | - Erin Clark
- The University of New England College of Osteopathic MedicineBiddefordMEUSA
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11
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Vidal-González J, Quiroga S, Simón-Talero M, Genescà J. Spontaneous portosystemic shunts in liver cirrhosis: new approaches to an old problem. Therap Adv Gastroenterol 2020; 13:1756284820961287. [PMID: 33062057 PMCID: PMC7533929 DOI: 10.1177/1756284820961287] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/02/2020] [Indexed: 02/04/2023] Open
Abstract
Portal hypertension is the main consequence of liver cirrhosis, leading to severe complications such as variceal hemorrhage, ascites or hepatic encephalopathy. As an attempt to decompress the portal venous system, portal flow is derived into the systemic venous system through spontaneous portosystemic shunts (SPSSs), bypassing the liver. In this review, we aim to provide an overview of the published reports in relation to the prevalence and physiopathology behind the appearance of SPSS in liver cirrhosis, as well as the complications derived from its formation and its management. The role of SPSS embolization is specifically discussed, as SPSSs have been assessed as a therapeutic target, mainly for patients with recurrent/persistent hepatic encephalopathy and preserved liver function. Furthermore, different aspects of the role of SPSS in liver transplantation, as well as in candidates for transjugular intrahepatic portosystemic shunt are reviewed. In these settings, SPSS occlusion has been proposed to minimize possible deleterious effects, but results are so far inconclusive.
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Affiliation(s)
- Judit Vidal-González
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sergi Quiroga
- Radiology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | | | - Joan Genescà
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
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12
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Spindel J, Heckroth M, Marsano L. Antibody-negative autoimmune encephalitis as a complication of long-term immune-suppression for liver transplantation. BMJ Case Rep 2020; 13:13/9/e235777. [PMID: 32933909 DOI: 10.1136/bcr-2020-235777] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Autoimmune encephalitis is a rare spectrum of disease that can be a complication of chronic immunosuppression. Diagnosis often requires the presence of antineuronal antibodies, but many causative antibodies have not yet been identified. Antibody-negative autoimmune encephalitis (AbNAE) is especially difficult to diagnose and must rely largely on exclusion of other causes. In chronically immune-suppressed transplant recipients, the differential is broad, likely resulting in underdiagnosis and worse outcomes. Here, we present a 58-year-old liver transplant recipient taking tacrolimus for prevention of chronic rejection who presented with 5 days of confusion, lethargy and lightheadedness. He was diagnosed with AbNAE after an extensive workup and recovered fully after high-dose corticosteroids. Our case highlights the importance of recognising the association between chronic immunosuppression and autoimmune encephalitis. Autoimmune encephalitis, even in the absence of characterised antibodies, should be considered when transplant recipients present with central neurologic symptoms.
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Affiliation(s)
- Jeffrey Spindel
- Internal Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Matthew Heckroth
- Internal Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Luis Marsano
- Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
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13
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Mehkari Z, Mohammed L, Javed M, Althwanay A, Ahsan F, Oliveri F, Goud HK, Rutkofsky IH. Manganese, a Likely Cause of 'Parkinson's in Cirrhosis', a Unique Clinical Entity of Acquired Hepatocerebral Degeneration. Cureus 2020; 12:e10448. [PMID: 33072457 PMCID: PMC7557798 DOI: 10.7759/cureus.10448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
With idiopathic Parkinson's disease being a common entity, parkinsonism in acquired hepatocerebral degeneration (AHD) in the context of Manganese (Mn) has gained importance in recent years. An insight into the pathomechanisms behind this disease has been put forth. How can Mn as a divalent metal exert its effect in leading to chronic neurodegenerative disorder? Secondary to decreased excretion in liver cirrhosis, Mn significantly alters the striatal dopaminergic system. Management of this debilitating disease also focuses on different aspects where Mn has been involved in the pathogenesis. We have put forth the details behind Mn effects in Parkinson’s, which will be a guide for better understanding and management of this disease. A literature search was performed using PubMed as a sole database, and all the articles were peer-reviewed. The author tried to follow the PRISMA guidelines. Inclusion criteria were set for 10 years, with most studies with in the last seven years. All types of study designs were included relevant to the topic, clearly delineating the pathomechanisms of Mn in the disease and also its management. After extensive research, through the PubMed database, we found that Parkinson's disease is one of the neurological complications in advanced liver cirrhosis. Mn is an essential element behind its pathogenesis; it works at different cellular levels to promote neurotoxicity. From its influx to its effects on dopamine transporters (DAT), where it disrupts dopamine homeostasis also altering postsynaptic dopamine (D2) receptors, it disrupts mitochondria and the endoplasmic reticulum (ER) promotes oxidative stress and neuroinflammation. Misfolding of alpha-synuclein (α-Syn) is promoted on chronic exposure to Mn where α-Syn from being neuroprotective becomes neurotoxic. It also alters glutaminergic and gabaergic neurotransmission. In a nutshell, the diversity of its effect on nigrostriatal denervation is challenging. The importance of neuroimaging and various approaches to management is also discussed. AHD, an uncommon entity in advanced liver cirrhosis, needs more awareness so that it can be diagnosed earlier and better therapeutic options can be sought. Our study highlighted Mn mechanisms behind this clinical entity, putting forth grounds for a better understanding of this disease. Advanced research targeting Mn for managing this disease will be revolutionary.
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Affiliation(s)
- Zainab Mehkari
- Internal Medicine, California Institute of Behavioral Neuroscience & Psychology, Fairfield, USA
| | - Lubna Mohammed
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Moiz Javed
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Aldanah Althwanay
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Farah Ahsan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Federico Oliveri
- Cardiology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Harshit K Goud
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ian H Rutkofsky
- Psychiatry, Neuroscience, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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14
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Malaquias MJ, Pinto CM, Ramos C, Ferreira S, Gandara J, Almeida A, Cavaco S, Miranda HP, Magalhães M. Acquired hepatocerebral degeneration and hepatic encephalopathy: one or two entities? Eur J Neurol 2020; 27:2396-2404. [DOI: 10.1111/ene.14486] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/13/2020] [Indexed: 12/31/2022]
Affiliation(s)
- M. J. Malaquias
- Neurology Department Centro Hospitalar Universitário do Porto Porto Portugal
| | - C. M. Pinto
- Neuroradiology Department Centro Hospitalar Universitário do Porto Porto Portugal
| | - C. Ramos
- Neuroradiology Department Centro Hospitalar Universitário do Porto Porto Portugal
| | - S. Ferreira
- Hepatic Pancreatic Transplantation Unit Centro Hospitalar Universitário do Porto Porto Portugal
| | - J. Gandara
- Hepatic Pancreatic Transplantation Unit Centro Hospitalar Universitário do Porto Porto Portugal
| | - A. Almeida
- Chemistry Science Department Faculdade de Farmácia Universidade do Porto Porto Portugal
| | - S. Cavaco
- Neuropsychology Unit Centro Hospitalar Universitário do Porto Porto Portugal
| | - H. P. Miranda
- Hepatic Pancreatic Transplantation Unit Centro Hospitalar Universitário do Porto Porto Portugal
| | - M. Magalhães
- Neurology Department Centro Hospitalar Universitário do Porto Porto Portugal
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15
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Atypical neuroimaging findings in patients with acquired hepatocerebral degeneration. Neurol Sci 2019; 41:175-181. [PMID: 31494818 DOI: 10.1007/s10072-019-04068-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 09/03/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Acquired hepatocerebral degeneration (AHD) is now widely recognized by physicians. Although hyperintensity in the bilateral globus pallidus in T1-weighted magnetic resonance images (MRIs) are characteristic neuroimaging findings, accumulating reports indicate that atypical neuroimaging findings are not rare. This study aimed to describe the spectrum of atypical neuroimaging findings and related factors in patients with AHD. METHODS From February 2017 to January 2019, a retrospective study was conducted of 28 patients with AHD in the Shengjing Hospital of China Medical University. The neurological manifestations, clinical parameters, and biochemical and neuroimaging findings were analyzed. RESULTS Among 28 patients, 14 patients were diagnosed with viral hepatitis-caused hepatocirrhosis, which was the most common cause of AHD. Resting tremor, cognitive impairment, and parkinsonian gait were the most common neurologic symptoms. Bilateral globus pallidus T1-weighted hyperintensity was detected in 26 patients (26/28, 92.9%). Ten patients (10/28, 35.7%) were determined to have an atypical neuroimaging finding. Binary logistic regression analysis indicated that age at onset of neurologic symptoms (odds ratio = 1.29, 95% confidence interval [CI] 1.03-1.61; p = 0.030) and Child-Pugh scores (odds ratio = 2.52, 95% CI, 1.01-6.31; p = 0.048) were independently associated with atypical neuroimaging findings in AHD. CONCLUSION The clinical manifestations of AHD are diverse; resting tremor, cognitive impairment, and parkinsonian gait were the most common. More than one third of patients had atypical neuroimaging findings. Age at onset of neurologic symptoms and Child-Pugh scores may be important predictors of atypical neuroimaging findings in patients with AHD.
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Jellinger KA. Neuropathology and pathogenesis of extrapyramidal movement disorders: a critical update-I. Hypokinetic-rigid movement disorders. J Neural Transm (Vienna) 2019; 126:933-995. [PMID: 31214855 DOI: 10.1007/s00702-019-02028-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 06/05/2019] [Indexed: 02/06/2023]
Abstract
Extrapyramidal movement disorders include hypokinetic rigid and hyperkinetic or mixed forms, most of them originating from dysfunction of the basal ganglia (BG) and their information circuits. The functional anatomy of the BG, the cortico-BG-thalamocortical, and BG-cerebellar circuit connections are briefly reviewed. Pathophysiologic classification of extrapyramidal movement disorder mechanisms distinguish (1) parkinsonian syndromes, (2) chorea and related syndromes, (3) dystonias, (4) myoclonic syndromes, (5) ballism, (6) tics, and (7) tremor syndromes. Recent genetic and molecular-biologic classifications distinguish (1) synucleinopathies (Parkinson's disease, dementia with Lewy bodies, Parkinson's disease-dementia, and multiple system atrophy); (2) tauopathies (progressive supranuclear palsy, corticobasal degeneration, FTLD-17; Guamian Parkinson-dementia; Pick's disease, and others); (3) polyglutamine disorders (Huntington's disease and related disorders); (4) pantothenate kinase-associated neurodegeneration; (5) Wilson's disease; and (6) other hereditary neurodegenerations without hitherto detected genetic or specific markers. The diversity of phenotypes is related to the deposition of pathologic proteins in distinct cell populations, causing neurodegeneration due to genetic and environmental factors, but there is frequent overlap between various disorders. Their etiopathogenesis is still poorly understood, but is suggested to result from an interaction between genetic and environmental factors. Multiple etiologies and noxious factors (protein mishandling, mitochondrial dysfunction, oxidative stress, excitotoxicity, energy failure, and chronic neuroinflammation) are more likely than a single factor. Current clinical consensus criteria have increased the diagnostic accuracy of most neurodegenerative movement disorders, but for their definite diagnosis, histopathological confirmation is required. We present a timely overview of the neuropathology and pathogenesis of the major extrapyramidal movement disorders in two parts, the first one dedicated to hypokinetic-rigid forms and the second to hyperkinetic disorders.
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Affiliation(s)
- Kurt A Jellinger
- Institute of Clinical Neurobiology, Alberichgasse 5/13, 1150, Vienna, Austria.
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Arenas A, Urzúa Á, Poniachik J, Carlos Diaz J, Castillo J, Saure A, Lembach H, Cancino A, Ibarra J, Besa C, Wolff R, Arrese M, Benítez C. Reversibility of Acquired Hepatocerebral Degeneration After Liver Transplantation. Liver Transpl 2018; 24:1133-1137. [PMID: 30142251 DOI: 10.1002/lt.25211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 08/22/2016] [Accepted: 10/31/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Alex Arenas
- Departamento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Álvaro Urzúa
- Departamento de Medicina Interna, Sección de Gastroenterología
| | - Jaime Poniachik
- Departamento de Medicina Interna, Sección de Gastroenterología.,Unidad de Trasplante Hepático, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Juan Carlos Diaz
- Cirugía, Hospital Clínico Universidad de Chile, Santiago, Chile.,Unidad de Trasplante Hepático, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Jaime Castillo
- Cirugía, Hospital Clínico Universidad de Chile, Santiago, Chile.,Unidad de Trasplante Hepático, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Alexandre Saure
- Cirugía, Hospital Clínico Universidad de Chile, Santiago, Chile.,Unidad de Trasplante Hepático, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Hans Lembach
- Cirugía, Hospital Clínico Universidad de Chile, Santiago, Chile.,Unidad de Trasplante Hepático, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Alejandra Cancino
- Unidad de Trasplante Hepático, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - José Ibarra
- Unidad de Trasplante Hepático, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Cecilia Besa
- Radiología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rodrigo Wolff
- Departamento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile.,Unidad de Trasplante Hepático, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Marco Arrese
- Departamento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile.,Unidad de Trasplante Hepático, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carlos Benítez
- Departamento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile.,Unidad de Trasplante Hepático, Pontificia Universidad Católica de Chile, Santiago, Chile
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Contrast Agent-Induced High Signal Intensity in Dentate Nucleus on Unenhanced T1-Weighted Images: Comparison of Gadodiamide and Gadoxetic Acid. Invest Radiol 2018; 52:389-395. [PMID: 28195932 DOI: 10.1097/rli.0000000000000360] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate whether an association exists between T1-signal increase in the dentate nucleus (DN) on unenhanced magnetic resonance imaging and previous administration of gadoxetic acid and gadodiamide. MATERIALS AND METHODS This retrospective study was approved by the institutional review board; the requirement for informed patient consent was waived. A total of 132 patients (male-female ratio, 86:46; mean age, 68.8 ± 11.6 years) who underwent imaging between December 2000 and April 2016 were divided into 4 groups: patients with 5 or more administrations of gadoxetic acid ("gadoxetic acid ≥5 administrations" group), only 1 administration of gadoxetic acid ("gadoxetic acid 1 administration" group), no gadolinium-based contrast agent (GBCA) administration or chronic liver disease (CLD; "no GBCA administration and no CLD" group), and 5 or more administrations of gadodiamide ("gadodiamide ≥5 administrations" group). Unenhanced T1-weighted images were quantitatively analyzed by 2 radiologists. Intergroup comparison of DN-to-pons signal intensity ratios was performed by the Dunn test, with the no GBCA administration and no CLD group as control. Interobserver agreement was assessed by intraclass correlation coefficients. RESULTS The DN-to-pons ratio of the "gadodiamide ≥5 administrations" group was significantly higher (P < 0.0001) and those of the "gadoxetic acid ≥5 administrations" and "gadoxetic acid 1 administration" groups did not differ significantly (P = 0.3912 and 1.0000, respectively) compared with the DN-to-pons ratio of the "no GBCA administration and no CLD" group. The interobserver intraclass correlation coefficient for measurement of DN-to-pons ratio was excellent (0.835; 95% confidence interval, 0.767-0.883). CONCLUSIONS Hyperintensity in the DN on unenhanced T1-weighted images is associated with previous administration of gadodiamide but not gadoxetic acid. Although the number of administrations for the 2 GBCA groups was identical, the administered dose of gadoxetic acid was only a quarter the amount of gadolinium as those with gadodiamide. This difference might influence the results of this study.
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Pigoni A, Iuculano F, Saetti C, Airaghi L, Burdick L, Spreafico S, Curioni M, Lombardi R, Valenti L, Fracanzani AL, Fargion S. Acquired hepatocerebral degeneration (AHD): a peculiar neurological impairment in advanced chronic liver disease. Metab Brain Dis 2018; 33:347-352. [PMID: 28918510 DOI: 10.1007/s11011-017-0107-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 09/06/2017] [Indexed: 12/11/2022]
Abstract
We discuss the case of a rare and often unrecognized neurologic syndrome, called Acquired Hepatocerebral Degeneration (AHD), observed in patients with advanced liver disease and portosystemic shunts. The clinical manifestations can be very heterogeneous and in our case included a combination of cerebellar and extrapyramidal signs, arisen in a period of few days. Brain Magnetic Resonance Imaging (MRI) showed, in T1-weighted images, diffuse bilateral hyper intensities in basal ganglia and biemispheric brain and cerebellar cortices, resembling paramagnetic deposits. No other neurological impairments, like stroke, infection or neoplasia, were found. It was excluded an episode of acute hepatic encephalopathy. We also ruled out Wilsonian degeneration, iron overload and autoimmune encephalitis and we lastly found high manganese levels as the possible cause of the brain paramagnetic deposits. Even though either serum Mn determination or its accumulation in the brain are not specific for AHD, however the chronic and progressively worsening of the neurological manifestations advocated a degenerative condition, possibly AHD. We finally opted for the early restoration of liver function by OLT, and we observed complete clinical symptoms' resolution and partial MRI reversal after a follow up of 6 months.
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Affiliation(s)
- A Pigoni
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
| | - F Iuculano
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy.
| | - C Saetti
- Neuroscience Section, Department of Pathophysiology and Transplantation (DEPT), University of Milan, Neurology Unit, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - L Airaghi
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
| | - L Burdick
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
| | - S Spreafico
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
| | - M Curioni
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
| | - R Lombardi
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
| | - L Valenti
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
| | - A L Fracanzani
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
| | - S Fargion
- Department of Pathophysiology and Transplantation, Unit of Internal Medicine, Ca' Granda IRCCS Foundation, Policlinico Hospital, University of Milan, Milan, Italy
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20
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Yoh K, Nishikawa H, Enomoto H, Iwata Y, Ishii A, Yuri Y, Ishii N, Miyamoto Y, Hasegawa K, Nakano C, Takata R, Nishimura T, Aizawa N, Sakai Y, Ikeda N, Takashima T, Iijima H, Nishiguchi S. Effect of physical exercise on sarcopaenia in patients with overt hepatic encephalopathy: a study protocol for a randomised controlled trial. BMJ Open Gastroenterol 2017; 4:e000185. [PMID: 29259793 PMCID: PMC5728260 DOI: 10.1136/bmjgast-2017-000185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 11/19/2017] [Accepted: 11/21/2017] [Indexed: 01/26/2023] Open
Abstract
Introduction Limited data are currently available for patients with overt hepatic encephalopathy (OHE)) receiving physical exercise (PE). The aim of the current study is to prospectively examine the effect of PE on sarcopaenia in patients with OHE. Methods and analysis At the time of patient recruitment, a precise assessment for nutritional status and daily physical activities will be performed in each subject. Study participants will be randomly assigned into two groups: (1) the PE group and (2) the control group. In the PE group, we will conduct guidance to study participants once a month at the outpatient nutrition guidance room. We will also instruct them to do exercise with >3 metabolic equivalents (mets; energy consumption in physical activities/resting metabolic rate) for 60 min per day and to do exercise >23 mets per week. Improvement of sarcopaenia as defined by muscle mass and muscle strength at 3 months after the randomisation will be the primary endpoint. Sarcopaenia will be defined based on the current Japanese guidelines. We prospectively compared the improvement of sarcopaenia in the two groups. Ethics and dissemination This study has received approval from the Institutional Review Board at Hyogo college of medicine (approval no. 2768). Final data will be publicly disseminated irrespective of the study results. A report releasing study results will be submitted for publication in an appropriate journal after completion of data collection. Trial registration number UMIN000029248; Pre-results. No patient is registered at the submission of our manuscript.
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Affiliation(s)
- Kazunori Yoh
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hiroki Nishikawa
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.,Center for Clinical Research and Education, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hirayuki Enomoto
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yoshinori Iwata
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Akio Ishii
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yukihisa Yuri
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Noriko Ishii
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yuho Miyamoto
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Kunihiro Hasegawa
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Chikage Nakano
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Ryo Takata
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Takashi Nishimura
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Nobuhiro Aizawa
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yoshiyuki Sakai
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Naoto Ikeda
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Tomoyuki Takashima
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hiroko Iijima
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Shuhei Nishiguchi
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.,Center for Clinical Research and Education, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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21
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Association of exposure to manganese and iron with relaxation rates R1 and R2*- magnetic resonance imaging results from the WELDOX II study. Neurotoxicology 2017; 64:68-77. [PMID: 28847517 DOI: 10.1016/j.neuro.2017.08.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 08/17/2017] [Accepted: 08/21/2017] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Magnetic resonance imaging is a non-invasive method that allows the indirect quantification of manganese (Mn) and iron (Fe) accumulation in the brain due to their paramagnetic features. The WELDOX II study aimed to explore the influence of airborne and systemic exposure to Mn and Fe on the brain deposition using the relaxation rates R1 and R2* as biomarkers of metal accumulation in regions of interest in 161 men, including active and former welders. MATERIAL AND METHODS We obtained data on the relaxation rates R1 and R2* in regions that included structures within the globus pallidus (GP), substantia nigra (SN), and white matter of the frontal lobe (FL) of both hemispheres, as well as Mn in whole blood (MnB), and serum ferritin (SF). The study subjects, all male, included 48 active and 20 former welders, 41 patients with Parkinson's disease (PD), 13 patients with hemochromatosis (HC), and 39 controls. Respirable Mn and Fe were measured during a working shift for welders. Mixed regression models were applied to estimate the effects of MnB and SF on R1 and R2*. Furthermore, we estimated the influence of airborne Mn and Fe on the relaxation rates in active welders. RESULTS MnB and SF were significant predictors of R1 but not of R2* in the GP, and were marginally associated with R1 in the SN (SF) and FL (MnB). Being a welder or suffering from PD or HC elicited no additional group effect on R1 or R2* beyond the effects of MnB and SF. In active welders, shift concentrations of respirable Mn>100μg/m3 were associated with stronger R1 signals in the GP. In addition to the effects of MnB and SF, the welding technique had no further influence on R1. CONCLUSIONS MnB and SF were significant predictors of R1 but not of R2*, indicative of metal accumulation, especially in the GP. Also, high airborne Mn concentration was associated with higher R1 signals in this brain region. The negative results obtained for being a welder or for the techniques with higher exposure to ultrafine particles when the blood-borne concentration was included into the models indicate that airborne exposure to Mn may act mainly through MnB.
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Feltracco P, Cagnin A, Carollo C, Barbieri S, Ori C. Neurological disorders in liver transplant candidates: Pathophysiology and clinical assessment. Transplant Rev (Orlando) 2017; 31:193-206. [DOI: 10.1016/j.trre.2017.02.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 12/29/2016] [Accepted: 02/20/2017] [Indexed: 12/14/2022]
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Shin HW, Park HK. Recent Updates on Acquired Hepatocerebral Degeneration. Tremor Other Hyperkinet Mov (N Y) 2017; 7:463. [PMID: 28975044 PMCID: PMC5623760 DOI: 10.7916/d8tb1k44] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 07/24/2017] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Acquired hepatocerebral degeneration (AHD) refers to a chronic neurological syndrome in patients with advanced hepatobiliary diseases. This comprehensive review focuses on the pathomechanism and neuroimaging findings in AHD. METHODS A PubMed search was performed using the terms "acquired hepatocerebral degeneration," "chronic hepatocerebral degeneration," "Non-Wilsonian hepatocerebral degeneration," "cirrhosis-related parkinsonism," and "manganese and liver disease." RESULTS Multiple mechanisms involving the accumulation of toxic substances such as ammonia or manganese and neuroinflammation may lead to widespread neurodegeneration in AHD. Clinical characteristics include movement disorders, mainly parkinsonism and ataxia-plus syndrome, as well as cognitive impairment with psychiatric features. Neuroimaging studies of AHD with parkinsonism show hyperintensity in the bilateral globus pallidus on T1-weighted magnetic resonance images, whereas molecular imaging of the presynaptic dopaminergic system shows variable findings. Ataxia-plus syndrome in AHD may demonstrate high-signal lesions in the middle cerebellar peduncles on T2-weighted images. DISCUSSION Future studies are needed to elucidate the exact pathomechanism and neuroimaging findings of this heterogeneous syndrome.
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Affiliation(s)
- Hae-Won Shin
- Department of Neurology, Chung-Ang University College of Medicine, Seoul, Republic of Korea
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institute of Health, Bethesda, MD, USA
| | - Hee Kyung Park
- Department of Neurology, Inje University Ilsan-Paik Hospital, Goyang, Republic of Korea
- Movement Disorder Center, Department of Neurosciences, University of California San Diego, San Diego, CA, USA
- *To whom correspondence should be addressed. E-mail:
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Patel VC, White H, Støy S, Bajaj JS, Shawcross DL. Clinical science workshop: targeting the gut-liver-brain axis. Metab Brain Dis 2016; 31:1327-1337. [PMID: 26446022 DOI: 10.1007/s11011-015-9743-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Accepted: 10/02/2015] [Indexed: 02/08/2023]
Abstract
A clinical science workshop was held at the ISHEN meeting in London on Friday 11th September 2014 with the aim of thrashing out how we might translate what we know about the central role of the gut-liver-brain axis into targets which we can use in the treatment of hepatic encephalopathy (HE). This review summarises the integral role that inter-organ ammonia metabolism plays in the pathogenesis of HE with specific discussion of the roles that the small and large intestine, liver, brain, kidney and muscle assume in ammonia and glutamine metabolism. Most recently, the salivary and gut microbiome have been shown to underpin the pathophysiological changes which culminate in HE and patients with advanced cirrhosis present with enteric dysbiosis with small bowel bacterial overgrowth and translocation of bacteria and their products across a leaky gut epithelial barrier. Resident macrophages within the liver are able to sense bacterial degradation products initiating a pro-inflammatory response within the hepatic parenchyma and release of cytokines such as tumour necrosis factor alpha (TNF-α) and interleukin-8 into the systemic circulation. The endotoxemia and systemic inflammatory response that are generated predispose both to the development of infection as well as the manifestation of covert and overt HE. Co-morbidities such as diabetes and insulin resistance, which commonly accompany cirrhosis, may promote slow gut transit, promote bacterial overgrowth and increase glutaminase activity and may need to be acknowledged in HE risk stratification assessments and therapeutic regimens. Therapies are discussed which target ammonia production, utilisation or excretion at an individual organ level, or which reduce systemic inflammation and endotoxemia which are known to exacerbate the cerebral effects of ammonia in HE. The ideal therapeutic strategy would be to use an agent that can reduce hyperammonemia and reduce systemic inflammation or perhaps to adopt a combination of therapies that can address both.
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Affiliation(s)
- Vishal C Patel
- Institute of Liver Studies, King's College London School of Medicine, King's College Hospital, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Helen White
- Institute of Liver Studies, King's College London School of Medicine, King's College Hospital, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Sidsel Støy
- Institute of Liver Studies, King's College London School of Medicine, King's College Hospital, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Jasmohan S Bajaj
- McGuire VA Medical Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Debbie L Shawcross
- Institute of Liver Studies, King's College London School of Medicine, King's College Hospital, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
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26
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Lee EY, Flynn MR, Du G, Lewis MM, Herring AH, Van Buren E, Van Buren S, Kong L, Mailman RB, Huang X. Editor's Highlight: Lower Fractional Anisotropy in the Globus Pallidus of Asymptomatic Welders, a Marker for Long-Term Welding Exposure. Toxicol Sci 2016; 153:165-73. [PMID: 27466214 DOI: 10.1093/toxsci/kfw116] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Welding fumes contain several metals including manganese (Mn), iron (Fe), and copper (Cu) that at high exposure may co-influence welding-related neurotoxicity. The relationship between brain accumulation of these metals and neuropathology, especially in welders with subclinical exposure levels, is unclear. This study examined the microstructural integrity of basal ganglia (BG) regions in asymptomatic welders using diffusion tensor imaging (DTI). METHODS Subjects with (n = 43) and without (age- and gender-matched controls; n = 31) history of welding were studied. Occupational questionnaires estimated short-term (HrsW; welding hours and E90; cumulative exposure, past 90 days) and long-term (YrsW; total years welding and ELT; cumulative exposure, lifetime) exposure. Whole blood metal levels (Mn, Fe, and Cu) were obtained. Brain MRI pallidal index (PI), R1 (1/T1), and R2* (1/T2*) were measured to estimate Mn and Fe accumulation in BG [caudate, putamen, and globus pallidus (GP)]. DTI was used to assess BG microstructural differences, and related with exposure measurements. RESULTS When compared with controls, welders had significantly lower fractional anisotropy (FA) in the GP. In welders, GP FA values showed non-linear relationships to YrsW, blood Mn, and PI. GP FA decreased after a critical level of YrsW or Mn was reached, whereas it decreased with increasing PI values until plateauing at the highest PI values. GP FA, however, did not show any relationship with short-term exposure measurements (HrsW, E90), blood Cu and Fe, or R(2)* values. CONCLUSION GP FA captured microstructural changes associated with chronic low-level Mn exposure, and may serve as a biomarker for neurotoxicity in asymptomatic welders.
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Affiliation(s)
- Eun-Young Lee
- *Department of Neurology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033
| | - Michael R Flynn
- Department of Environmental Sciences and Engineering, University of North Carolina, Chapel Hill, North Carolina 27599
| | - Guangwei Du
- *Department of Neurology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033
| | - Mechelle M Lewis
- *Department of Neurology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033; Department of Pharmacology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033
| | - Amy H Herring
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina 27599
| | - Eric Van Buren
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina 27599
| | - Scott Van Buren
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina 27599
| | - Lan Kong
- Department of Public Health Sciences
| | - Richard B Mailman
- *Department of Neurology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033; Department of Pharmacology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033
| | - Xuemei Huang
- *Department of Neurology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033; Department of Pharmacology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033; Department of Radiology; Department of Neurosurgery; Department of Kinesiology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033
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27
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Abstract
OPINION STATEMENT Liver disease, both in its acute and chronic forms, can be associated with a wide spectrum of neurologic manifestations, both central and peripheral, ranging in severity from subclinical changes to neurocritical conditions. Neurologists are frequently consulted to participate in their management. In this review, we present an overview of management strategies for patients with hepatic disease whose clinical course is complicated by neurologic manifestations. Type A hepatic encephalopathy (HE), which occurs in acute liver failure, is a neurologic emergency, and multiple measures should be taken to prevent and treat cerebral edema. In Type C HE, which occurs in chronic liver disease, management should be aimed at correcting precipitant factors and hyperammonemia. There is an increasing spectrum of drug treatments available to minimize ammonia toxicity. Acquired hepatocerebral degeneration is a rare complication of the chronic form of HE, with typical clinical and brain MRI findings, whose most effective treatment is liver transplantation. Epilepsy is frequent and of multifactorial cause in patients with hepatic disease, and careful considerations should be made regarding choice of the appropriate anti-epileptic drugs. Several mechanisms increase the risk of stroke in hepatic disease, but many of the drugs used to treat and prevent stroke are contraindicated in severe hepatic failure. Hepatitis C infection increases the risk of ischemic stroke. Hemorrhagic stroke is more frequent in patients with liver disease of alcoholic etiology. Viral hepatitis is associated with a wide range of immune-mediated complications, mostly in the peripheral nervous system, which respond to different types of immunomodulatory treatment. Several drugs used to treat hepatic disease, such as the classical and the new direct-acting antivirals, may have neurologic complications which in some cases preclude its continued use.
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28
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Tuschl K, Meyer E, Valdivia LE, Zhao N, Dadswell C, Abdul-Sada A, Hung CY, Simpson MA, Chong WK, Jacques TS, Woltjer RL, Eaton S, Gregory A, Sanford L, Kara E, Houlden H, Cuno SM, Prokisch H, Valletta L, Tiranti V, Younis R, Maher ER, Spencer J, Straatman-Iwanowska A, Gissen P, Selim LAM, Pintos-Morell G, Coroleu-Lletget W, Mohammad SS, Yoganathan S, Dale RC, Thomas M, Rihel J, Bodamer OA, Enns CA, Hayflick SJ, Clayton PT, Mills PB, Kurian MA, Wilson SW. Mutations in SLC39A14 disrupt manganese homeostasis and cause childhood-onset parkinsonism-dystonia. Nat Commun 2016; 7:11601. [PMID: 27231142 PMCID: PMC4894980 DOI: 10.1038/ncomms11601] [Citation(s) in RCA: 204] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 04/12/2016] [Indexed: 02/07/2023] Open
Abstract
Although manganese is an essential trace metal, little is known about its transport and homeostatic regulation. Here we have identified a cohort of patients with a novel autosomal recessive manganese transporter defect caused by mutations in SLC39A14. Excessive accumulation of manganese in these patients results in rapidly progressive childhood-onset parkinsonism-dystonia with distinctive brain magnetic resonance imaging appearances and neurodegenerative features on post-mortem examination. We show that mutations in SLC39A14 impair manganese transport in vitro and lead to manganese dyshomeostasis and altered locomotor activity in zebrafish with CRISPR-induced slc39a14 null mutations. Chelation with disodium calcium edetate lowers blood manganese levels in patients and can lead to striking clinical improvement. Our results demonstrate that SLC39A14 functions as a pivotal manganese transporter in vertebrates.
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Affiliation(s)
- Karin Tuschl
- Genetics and Genomic Medicine, UCL Institute of Child Health, University College London, London WC1N 1EH, UK.,Department of Cell and Developmental Biology, University College London, London WC1E 6BT, UK
| | - Esther Meyer
- Developmental Neurosciences, UCL Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Leonardo E Valdivia
- Department of Cell and Developmental Biology, University College London, London WC1E 6BT, UK
| | - Ningning Zhao
- Department of Cell, Development and Cancer Biology, Oregon Health &Sciences University, Portland, Oregon 97239, USA
| | - Chris Dadswell
- Department of Chemistry, School of Life Sciences, University of Sussex, Brighton BN1 9QJ, UK
| | - Alaa Abdul-Sada
- Department of Chemistry, School of Life Sciences, University of Sussex, Brighton BN1 9QJ, UK
| | - Christina Y Hung
- Division of Genetics and Genomics, Department of Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Michael A Simpson
- Division of Genetics and Molecular Medicine, King's College London School of Medicine, London SE1 9RT, UK
| | - W K Chong
- Department of Radiology, Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JH, UK
| | - Thomas S Jacques
- Developmental Biology and Cancer, UCL Institute of Child Health and Department of Histopathology, Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JH, UK
| | - Randy L Woltjer
- Department of Pathology, Oregon Health &Science University, Portland, Oregon 97239, USA
| | - Simon Eaton
- Developmental Biology and Cancer Programme, UCL Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Allison Gregory
- Department of Molecular &Medical Genetics, Oregon Health &Science University, Portland, Oregon 97239, USA
| | - Lynn Sanford
- Department of Molecular &Medical Genetics, Oregon Health &Science University, Portland, Oregon 97239, USA
| | - Eleanna Kara
- Institute of Neurology, University College London, London WC1N 3BG, UK.,Alzheimer's Disease Research Centre, Department of Neurology, Harvard Medical School and Massachusetts General Hospital, Charlestown, Massachusetts 02129, USA
| | - Henry Houlden
- Institute of Neurology, University College London, London WC1N 3BG, UK
| | - Stephan M Cuno
- Institute of Human Genetics, Technische Universität München, Munich 81675, Germany.,Institute of Human Genetics, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg 85764, Germany
| | - Holger Prokisch
- Institute of Human Genetics, Technische Universität München, Munich 81675, Germany.,Institute of Human Genetics, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg 85764, Germany
| | - Lorella Valletta
- Unit of Molecular Neurogenetics, IRCCS, Foundation Neurological Institute 'C. Besta', Milan 20133, Italy
| | - Valeria Tiranti
- Unit of Molecular Neurogenetics, IRCCS, Foundation Neurological Institute 'C. Besta', Milan 20133, Italy
| | - Rasha Younis
- Department of Medical and Molecular Genetics, University of Birmingham, Birmingham B15 2TT, UK
| | - Eamonn R Maher
- Centre for Rare Diseases and Personalised Medicine, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK.,Department of Medical Genetics, School of Clinical Medicine, University of Cambridge, and Cambridge NIHR Biomedical Research Centre, Cambridge CB2 0QQ, UK
| | - John Spencer
- Department of Chemistry, School of Life Sciences, University of Sussex, Brighton BN1 9QJ, UK
| | - Ania Straatman-Iwanowska
- MRC Laboratory for Molecular Cell Biology and Cell Biology Unit, University College London, London WC1E 6BT, UK
| | - Paul Gissen
- Genetics and Genomic Medicine, UCL Institute of Child Health, University College London, London WC1N 1EH, UK.,MRC Laboratory for Molecular Cell Biology and Cell Biology Unit, University College London, London WC1E 6BT, UK.,Department of Metabolic Medicine, Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JH, UK
| | - Laila A M Selim
- Department of Paediatric Neurology, Faculty of Medicine, Cairo University Children's Hospital, Cairo 11432, Egypt
| | - Guillem Pintos-Morell
- Department of Paediatrics, Section of Paediatric Nephrology, Genetics and Metabolism, Unit of Rare Diseases, University Hospital 'Germans Trias I Pujol', Universitat Autònoma de Barcelona, Badalona 08916, Spain
| | - Wifredo Coroleu-Lletget
- Department of Paediatrics, Paediatric Neurology and Neonatology Unit, University Hospital 'Germans Trias I Pujol', Badalona 08916, Spain
| | - Shekeeb S Mohammad
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, Kids Research Institute at the Children's Hospital at Westmead, University of Sydney, Westmead NSW 2145, Australia
| | - Sangeetha Yoganathan
- Department of Neurological Sciences, Christian Medical College Hospital, Vellore 632 004, India
| | - Russell C Dale
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, Kids Research Institute at the Children's Hospital at Westmead, University of Sydney, Westmead NSW 2145, Australia
| | - Maya Thomas
- Department of Neurological Sciences, Christian Medical College Hospital, Vellore 632 004, India
| | - Jason Rihel
- Department of Cell and Developmental Biology, University College London, London WC1E 6BT, UK
| | - Olaf A Bodamer
- Division of Genetics and Genomics, Department of Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Caroline A Enns
- Department of Cell, Development and Cancer Biology, Oregon Health &Sciences University, Portland, Oregon 97239, USA
| | - Susan J Hayflick
- Department of Molecular &Medical Genetics, Oregon Health &Science University, Portland, Oregon 97239, USA.,Department of Neurology, Oregon Health &Science University, Portland, Oregon 97239, USA.,Department of Pediatrics, Oregon Health &Science University, Portland, Oregon 97239, USA
| | - Peter T Clayton
- Genetics and Genomic Medicine, UCL Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Philippa B Mills
- Genetics and Genomic Medicine, UCL Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Manju A Kurian
- Developmental Neurosciences, UCL Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Stephen W Wilson
- Department of Cell and Developmental Biology, University College London, London WC1E 6BT, UK
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29
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Yalçın D, Oğuz-Akarsu E, Sökmen M. Acquired hepatocerebral degeneration. NEUROSCIENCES (RIYADH, SAUDI ARABIA) 2016; 21:164-7. [PMID: 27094529 PMCID: PMC5107273 DOI: 10.17712/nsj.2016.2.20150164] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acquired hepatocerebral degeneration is a rare, mostly irreversible neurological syndrome that occurs in patients with chronic liver disease, particularly in those with surgically or spontaneously induced portosystemic shunts. Typical magnetic resonance findings are T1 hyperintensity in the pallidum, substantia nigra, periaquaductal gray matter. In this paper, we report a case of a 51-year-old woman presented with hepatic encephalopathy episodes and typical magnetic resonance findings, who does not develop any neurological signs or symptoms, nor cognitive decline in the follow up period, lasting for 3 years.
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Affiliation(s)
- Destînâ Yalçın
- From the Neurology Clinic (Yalçın, Akarsu), and Gastroenterology Clinic (Sökmen), Ümraniye Research and Training Hospital, İstanbul, Turkey,Address correspondence and reprint request to: Dr. Destînâ Yalçın, Associate Professor, Neurology Clinic, Ümraniye Research and Training Hospital, İstanbul, Turkey. E-mail:
| | - Emel Oğuz-Akarsu
- From the Neurology Clinic (Yalçın, Akarsu), and Gastroenterology Clinic (Sökmen), Ümraniye Research and Training Hospital, İstanbul, Turkey
| | - Mehmet Sökmen
- From the Neurology Clinic (Yalçın, Akarsu), and Gastroenterology Clinic (Sökmen), Ümraniye Research and Training Hospital, İstanbul, Turkey
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30
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Li SJ, Li Y, Chen JW, Yuan ZX, Mo YH, Lu GD, Jiang YM, Ou CY, Wang F, Huang XW, Luo YN, Ou SY, Huang YN. Sodium Para-aminosalicylic Acid Protected Primary Cultured Basal Ganglia Neurons of Rat from Manganese-Induced Oxidative Impairment and Changes of Amino Acid Neurotransmitters. Biol Trace Elem Res 2016; 170:357-65. [PMID: 26286965 DOI: 10.1007/s12011-015-0472-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 08/07/2015] [Indexed: 12/22/2022]
Abstract
Manganese (Mn), an essential trace metal for protein synthesis and particularly neurotransmitter metabolism, preferentially accumulates in basal ganglia. However, excessive Mn accumulation may cause neurotoxicity referred to as manganism. Sodium para-aminosalicylic acid (PAS-Na) has been used to treat manganism with unclear molecular mechanisms. Thus, we aim to explore whether PAS-Na can inhibit Mn-induced neuronal injury in basal ganglia in vitro. We exposed basal ganglia neurons with 50 μM manganese chloride (MnCl2) for 24 h and then replaced with 50, 150, and 450 μM PAS-Na treatment for another 24 h. MnCl2 significantly decreased cell viability but increased leakage rate of lactate dehydrogenase and DNA damage (as shown by increasing percentage of DNA tail and Olive tail moment). Mechanically, Mn reduced glutathione peroxidase and catalase activity and interrupted amino acid neurotransmitter balance. However, PAS-Na treatment reversed the aforementioned Mn-induced toxic effects. Taken together, these results showed that PAS-Na could protect basal ganglia neurons from Mn-induced neurotoxicity.
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Affiliation(s)
- Shao-Jun Li
- Department of Toxicology, School of Public Health, Guangxi Medical University, 22 Shuang-yong Rd., Nanning, 530021, Guangxi, China
| | - Yong Li
- Department of Toxicology, School of Public Health, Guangxi Medical University, 22 Shuang-yong Rd., Nanning, 530021, Guangxi, China
| | - Jing-Wen Chen
- Department of Toxicology, School of Public Health, Guangxi Medical University, 22 Shuang-yong Rd., Nanning, 530021, Guangxi, China
| | - Zong-Xiang Yuan
- Department of Toxicology, School of Public Health, Guangxi Medical University, 22 Shuang-yong Rd., Nanning, 530021, Guangxi, China
| | - Yu-Huan Mo
- Department of Toxicology, School of Public Health, Guangxi Medical University, 22 Shuang-yong Rd., Nanning, 530021, Guangxi, China
| | - Guo-Dong Lu
- Department of Toxicology, School of Public Health, Guangxi Medical University, 22 Shuang-yong Rd., Nanning, 530021, Guangxi, China
| | - Yue-Ming Jiang
- Department of Toxicology, School of Public Health, Guangxi Medical University, 22 Shuang-yong Rd., Nanning, 530021, Guangxi, China.
| | - Chao-Yan Ou
- Department of Toxicology, School of Public Health, Guilin Medical University, Guilin, 541004, China
| | - Fang Wang
- Department of Toxicology, School of Public Health, Guangxi Medical University, 22 Shuang-yong Rd., Nanning, 530021, Guangxi, China
| | - Xiao-Wei Huang
- Department of Toxicology, School of Public Health, Guangxi Medical University, 22 Shuang-yong Rd., Nanning, 530021, Guangxi, China
| | - Yi-Ni Luo
- Department of Toxicology, School of Public Health, Guangxi Medical University, 22 Shuang-yong Rd., Nanning, 530021, Guangxi, China
| | - Shi-Yan Ou
- Department of Toxicology, School of Public Health, Guangxi Medical University, 22 Shuang-yong Rd., Nanning, 530021, Guangxi, China
| | - Yan-Ni Huang
- Department of Toxicology, School of Public Health, Guangxi Medical University, 22 Shuang-yong Rd., Nanning, 530021, Guangxi, China
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31
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MRI pallidal signal in children exposed to manganese in drinking water. Neurotoxicology 2016; 53:124-131. [DOI: 10.1016/j.neuro.2016.01.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 12/30/2015] [Accepted: 01/06/2016] [Indexed: 12/25/2022]
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32
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Qavi AH, Hammad S, Rana AI, Salih M, Shah NH, Dar FS, Ahmad A. Reversal of acquired hepatocerebral degeneration with living donor liver transplantation. Liver Transpl 2016; 22:125-9. [PMID: 26283624 DOI: 10.1002/lt.24306] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 08/07/2015] [Accepted: 08/13/2015] [Indexed: 01/13/2023]
Affiliation(s)
- Ahmed Hassaan Qavi
- Departments of Neurology Shifa International Hospital Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Sahla Hammad
- Departments of Neurology Shifa International Hospital Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Atif I Rana
- Departments of Radiology Shifa International Hospital Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Mohammad Salih
- Departments of Gastroenterology and Hepatology Shifa International Hospital Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Najmul Hassan Shah
- Departments of Gastroenterology and Hepatology Shifa International Hospital Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Faisal S Dar
- Departments of Liver Transplantation, Hepatobiliary, and Pancreatic Surgery Shifa International Hospital Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Arsalan Ahmad
- Departments of Neurology Shifa International Hospital Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
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33
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Romeiro FG, Augusti L. Nutritional assessment in cirrhotic patients with hepatic encephalopathy. World J Hepatol 2015; 7:2940-2954. [PMID: 26730273 PMCID: PMC4691697 DOI: 10.4254/wjh.v7.i30.2940] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 09/23/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatic encephalopathy (HE) is one of the worst complications of liver disease and can be greatly influenced by nutritional status. Ammonia metabolism, inflammation and muscle wasting are relevant processes in HE pathophysiology. Malnutrition worsens the prognosis in HE, requiring early assessment of nutritional status of these patients. Body composition changes induced by liver disease and limitations superimposed by HE hamper the proper accomplishment of exams in this population, but evidence is growing that assessment of muscle mass and muscle function is mandatory due to the role of skeletal muscles in ammonia metabolism. In this review, we present the pathophysiological aspects involved in HE to support further discussion about advantages and drawbacks of some methods for evaluating the nutritional status of cirrhotic patients with HE, focusing on body composition.
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34
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Huang FZ, Hou X, Zhou TQ, Chen S. Hepatic encephalopathy coexists with acquired chronic hepatocerebral degeneration. ACTA ACUST UNITED AC 2015; 20:277-9. [PMID: 26166598 PMCID: PMC4710335 DOI: 10.17712/nsj.2015.3.20140759] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Hyperkinetic extrapyramidal syndrome is the typical clinical characteristic of acquired hepatocerebral degeneration (AHD), but is usually not observed with hepatic encephalopathy (HE). We present a case of AHD coexisting with HE. Both conditions were secondary to liver cirrhosis and hepatitis C virus infection. The brain MRI showed bilateral and symmetric high T1 signal-intensity in the globus pallidus, and diffuse high signal-intensity of the hemispheric white matter on T2-FLAIR images. As we usually neglect the existence of AHD, the diagnosis is often ignored, especially when it coexists with HE. This case highlights the need to distinguish irreversible AHD from HE.
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Affiliation(s)
- Feng-Zhen Huang
- Department of Neurology & Institute of Translational Medicine at University of South China, the First People`s Hospital of Chenzhou, Chenzhou, Hunan, P. R. China
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35
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Ex vivo magnetic resonance imaging in South African manganese mine workers. Neurotoxicology 2015; 49:8-14. [PMID: 25912463 DOI: 10.1016/j.neuro.2015.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 03/14/2015] [Accepted: 04/13/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Manganese (Mn) exposure is associated with increased T1-weighted magnetic resonance imaging (MRI) signal in the basal ganglia. T1 signal intensity has been correlated with occupational Mn exposure but not with clinical symptomatology or neuropathology. OBJECTIVES This study investigated predictors of ex vivo T1 MRI basal ganglia signal intensity in neuropathologic tissue obtained from deceased South African mine workers. METHODS A 3.0 T MRI was performed on ex vivo brain tissue obtained from 19 Mn mine workers and 10 race- and sex-matched mine workers of other commodities. Basal ganglia regions of interest were identified for each subject with T1-weighted intensity indices generated for each region. In a pathology subset, regional T1 indices were compared to neuronal and glial cell density and tissue metal concentrations. RESULTS Intensity indices were higher in Mn mine workers than non-Mn mine workers for the globus pallidus, caudate, anterior putamen, and posterior putamen with the highest values in subjects with the longest cumulative Mn exposure. Intensity indices were inversely correlated with the neuronal cell density in the caudate (p=0.040) and putamen (p=0.050). Tissue Mn concentrations were similar in Mn and non-Mn mine workers. Tissue iron (Fe) concentration trended lower across all regions in Mn mine workers. CONCLUSIONS Mn mine workers demonstrated elevated basal ganglia T1 indices when compared to non-Mn mine workers. Predictors of ex vivo T1 MRI signal intensity in Mn mine workers include duration of Mn exposure and neuronal density.
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36
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Abstract
Hepatic and gastrointestinal disorders can produce a wide spectrum of neurologic complications both affecting the central nervous system (CNS) and the peripheral nervous system. These manifestations range in severity from coma in acute liver failure and acute pancreatitis, to minor cognitive changes in chronic portosystemic encephalopathy and hepatitis C. Cerebrovascular diseases can complicate hepatitis C infection and inflammatory bowel disease. Demyelinating disorders may co-exist with inflammatory bowel disease. Anti-tumor necrosis factor alpha drugs may induce demyelination. Ataxia may occur in malabsorption syndromes and in gluten related disorders. Characteristic movement disorders are key features of acquired hepatocerebral degeneration and of Whipple disease. Multiple types of neuropathy can be found in association with hepatitis, inflammatory bowel disease and gluten related disorders.
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Affiliation(s)
- José M Ferro
- Department of Neurosciences, Service of Neurology, Hospital de Santa Maria, University of Lisbon, Av. Prof. Egas Moniz, 1649-035, Lisboa, Portugal,
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37
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Sureka B, Bansal K, Patidar Y, Rajesh S, Mukund A, Arora A. Neurologic Manifestations of Chronic Liver Disease and Liver Cirrhosis. Curr Probl Diagn Radiol 2015; 44:449-61. [PMID: 25908229 DOI: 10.1067/j.cpradiol.2015.03.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 03/17/2015] [Accepted: 03/18/2015] [Indexed: 12/29/2022]
Abstract
The normal functioning of brain is intimately as well as intricately interrelated with normal functioning of the liver. Liver plays a critical role of not only providing vital nutrients to the brain but also of detoxifying the splanchnic blood. Compromised liver function leads to insufficient detoxification thus allowing neurotoxins (such as ammonia, manganese, and other chemicals) to enter the cerebral circulation. In addition, portosystemic shunts, which are common accompaniments of advanced liver disease, facilitate free passage of neurotoxins into the cerebral circulation. The problem is compounded further by additional variables such as gastrointestinal tract bleeding, malnutrition, and concurrent renal failure, which are often associated with liver cirrhosis. Neurologic damage in chronic liver disease and liver cirrhosis seems to be multifactorial primarily attributable to the following: brain accumulation of ammonia, manganese, and lactate; altered permeability of the blood-brain barrier; recruitment of monocytes after microglial activation; and neuroinflammation, that is, direct effects of circulating systemic proinflammatory cytokines such as tumor necrosis factor, IL-1β, and IL-6. Radiologist should be aware of the conundrum of neurologic complications that can be encountered in liver disease, which include hepatic encephalopathy, hepatocerebral degeneration, hepatic myelopathy, cirrhosis-related parkinsonism, cerebral infections, hemorrhage, and osmotic demyelination. In addition, neurologic complications can be exclusive to certain disorders, for example, Wilson disease, alcoholism (Wernicke encephalopathy, alcoholic cerebellar degeneration, Marchiafava-Bignami disease, etc). Radiologist should be aware of their varied clinical presentation and radiological appearances as the diagnosis is not always straightforward.
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Affiliation(s)
- Binit Sureka
- Department of Radiology/Interventional Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Kalpana Bansal
- Department of Radiology/Interventional Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Yashwant Patidar
- Department of Radiology/Interventional Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - S Rajesh
- Department of Radiology/Interventional Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Amar Mukund
- Department of Radiology/Interventional Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Ankur Arora
- Department of Radiology/Interventional Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India.
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38
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Hoet P, Roels HA. Significance and Usefulness of Biomarkers of Exposure to Manganese. MANGANESE IN HEALTH AND DISEASE 2014. [DOI: 10.1039/9781782622383-00355] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Manganese (Mn) accomplishes functions essential to maintaining human health, but at the same time this trace element can be toxic at low levels of exposure and accurate estimation of internal exposure is needed. A biomarker of exposure to Mn is meaningful only if there is sufficient knowledge of the toxicokinetics determining its presence in a biological medium (e.g. whole blood, plasma, urine, hair, nail). Moreover, biological monitoring of exposure to Mn is useful only when the biomarker is sufficiently specific and sensitive to distinguish exposed from non-exposed subjects, when it is dose-related to the external exposure (current, recent, or time-integrated), and when it displays reasonable dose–effect/response relationships with the occurrence of adverse effects on the central nervous system, the critical target for Mn exposure. Human investigations in which biomarkers of Mn exposure meet all these criteria are hard to locate. Overall, the available studies report poor or no associations on an individual basis between external (Mn in air or drinking water) and internal (Mn in blood, urine, hair, or nail) Mn exposure indices. This may be to some extent explained by features inherent of the Mn metabolism (homeostatic control), the Mn biomarker's half-life with respect to the exposure window, and the variable nature of external exposure scenarios. Studies particularly dealing with Mn inhalation exposure, different or poorly described methodological approaches, or air sampling strategies may render direct comparison and interpretation of results a tedious task. Nevertheless, several studies report significant dose–effect associations between biomarkers of Mn exposure and subclinical deficits of psychomotor or neuropsychological test performances. Because directly associated with the site of toxic action and providing the magnetic resonance imaging is done no later than three months after Mn exposure ceased, the Mn T1 relaxation time is potentially the better biomarker of Mn exposure in a clinical context (e.g. after long-term parenteral nutrition, chronic liver failure, methcathinone drug abuse). Magnetic resonance imaging is, however, unpractical as a tool for biological monitoring of exposure to Mn in the occupational setting (inhalation) and in the general population (air, drinking water). In conclusion, it would be inappropriate to recommend, on the basis of the currently available evidence, a reliable well-validated biomarker of exposure to Mn, or to establish a health-based threshold value for subclinical neurotoxic effects.
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Affiliation(s)
- Perrine Hoet
- Université catholique de Louvain (UCL), Institut de Recherche Expérimentale et Clinique (IREC), Louvain Centre for Toxicology and Applied Pharmacology (LTAP) Bruxelles Belgium
| | - Harry A. Roels
- Université catholique de Louvain (UCL), Institut de Recherche Expérimentale et Clinique (IREC), Louvain Centre for Toxicology and Applied Pharmacology (LTAP) Bruxelles Belgium
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Two-year follow-up after chelating therapy in a patient with adult-onset parkinsonism and hypermanganesaemia due to SLC30A10 mutations. J Neurol 2013; 261:227-8. [PMID: 24276520 DOI: 10.1007/s00415-013-7187-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 11/01/2013] [Accepted: 11/07/2013] [Indexed: 10/26/2022]
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