Hepatic subcellular distribution of manganese in manganese and manganese-bilirubin induced cholestasis

Gut instinct: Navigating the landscape of parenteral support in short bowel syndrome

Depending on the remaining bowel anatomy and the degree of bowel adaptation, patients with short bowel syndrome (SBS) may require parenteral nutrition (PN) and/or intravenous fluid support, sometimes temporarily and sometimes permanently. Although the use of parenteral support in SBS is often lifesaving, it is not without its limitations. Herein, we undertake a focused review of several issues related to use of parenteral support in patients with SBS, including initiation of parenteral support, considerations when formulating PN, select complications, short-term and long-term nutrition monitoring, and weaning strategies.

Current Insights Regarding Intestinal Failure-Associated Liver Disease (IFALD): A Narrative Review

Intestinal failure-associated liver disease (IFALD) is a spectrum of liver disease including cholestasis, biliary cirrhosis, steatohepatitis, and gallbladder disease in patients with intestinal failure (IF). The prevalence of IFALD varies considerably, with ranges of 40-60% in the pediatric population, up to 85% in neonates, and between 15-40% in the adult population. IFALD has a complex and multifactorial etiology; the risk factors can be parenteral nutrition-related or patient-related. Because of this, the approach to managing IFALD is multidisciplinary and tailored to each patient based on the etiology. This review summarizes the current knowledge on the etiology and pathophysiology of IFALD and examines the latest evidence regarding preventative measures, diagnostic approaches, and treatment strategies for IFALD and its associated complications.

New insights into intestinal failure-associated liver disease in adults: A comprehensive review of the literature

Intestinal failure-associated liver disease (IFALD) remains one of the most common and serious complications of parenteral nutrition (PN), causing a wide spectrum of hepatic manifestations from steatosis and mild cholestasis to portal hypertension and end-stage liver failure. The prevalence of IFALD depends on the diagnostic criteria and ranges from 4.3% to 65%. Moreover, many factors are shown to contribute to its development, including nutrient deficiencies, toxicity of PN, infections, and alterations of bile acid metabolism and gut microbiota. Prevention and management of IFALD aim at ameliorating or eliminating the risk factors associated with IFALD. The use of PN formulations with a lower ratio omega-6-to-omega-3 polyunsaturated fatty acids, cycle PN, optimization of enteral stimulation and prevention and early treatment of infections constitute the main therapeutic targets. However, failure of improvement and severe IFALD with end-stage liver failure should be considered as the indications of intestinal transplantation. The aim of this review is to provide an update of the epidemiology, pathophysiology, and diagnosis of IFALD in the adult population as well as to present a clinical approach of the therapeutic strategies of IFALD and present novel therapeutic targets.

Elevated Whole-Blood Manganese Levels in Adult Patients Prescribed "Manganese-Free" Home Parenteral Nutrition

BACKGROUND

Manganese toxicity can occur as a complication of home parenteral nutrition (HPN). Patients can present with Parkinson disease-like symptoms. Preparations of trace elements (TEs) in parenteral nutrition (PN) generally provide amounts in excess of requirements. Our previous review observed 60% of adult HPN patients had high whole-blood manganese levels. Multi-TE (MTE) solutions were subsequently removed from all HPN formulations in January 2015. The aim of this evaluation was to determine whole-blood concentrations of manganese in adult patients receiving HPN to establish whether levels are now maintained within the normal reference range.

METHODS

A retrospective review of whole-blood manganese levels in all patients receiving HPN between January 2018 and January 2019 from 1 hospital site was carried out.

RESULTS

100 patients were included in the review (59 female and 41 male). Normal whole-blood manganese levels (73-219 nmol/L) were observed in 70% of patients and elevated levels (>219 nmol/L) in 30% of patients. In the patients with elevated levels, 57% had not received manganese supplementation for at least 1 year prior to manganese being measured. Markers of cholestasis were similar between the 2 groups.

CONCLUSIONS

Incidence of elevated whole-blood manganese concentrations in patients receiving HPN decreased from 60% to 30% upon discontinued use of an MTE solution. Elevated levels remain a concern despite patients being prescribed "manganese-free" PN. Patients receive this TE in amounts adequate to meet requirements through contamination and dietary intake alone, suggesting additional parenteral supplementation of manganese is not required.

Manganese activates NLRP3 inflammasome signaling and propagates exosomal release of ASC in microglial cells

Chronic, sustained inflammation underlies many pathological conditions, including neurodegenerative diseases. Divalent manganese (Mn²⁺) exposure can stimulate neurotoxicity by increasing inflammation. In this study, we examined whether Mn²⁺ activates the multiprotein NLRP3 inflammasome complex to promote neuroinflammation. Exposing activated mouse microglial cells to Mn²⁺ substantially augmented NLRP3 abundance, caspase-1 cleavage, and maturation of the inflammatory cytokine interleukin-1β (IL-1β). Exposure of mice to Mn²⁺ had similar effects in brain microglial cells. Furthermore, Mn²⁺ impaired mitochondrial ATP generation, basal respiratory rate, and spare capacity in microglial cells. These data suggest that Mn-induced mitochondrial defects drove the inflammasome signal amplification. We found that Mn induced cell-to-cell transfer of the inflammasome adaptor protein ASC in exosomes. Furthermore, primed microglial cells exposed to exosomes from Mn-treated mice released more IL-1β than did cells exposed to exosomes from control-treated animals. We also observed that welders exposed to manganese-containing fumes had plasma exosomes that contained more ASC than did those from a matched control group. Together, these results suggest that the divalent metal manganese acts as a key amplifier of NLRP3 inflammasome signaling and exosomal ASC release.

Trace Elements in Parenteral Nutrition: Considerations for the Prescribing Clinician

Trace elements (TEs) are an essential component of parenteral nutrition (PN). Over the last few decades, there has been increased experience with PN, and with this knowledge more information about the management of trace elements has become available. There is increasing awareness of the effects of deficiencies and toxicities of certain trace elements. Despite this heightened awareness, much is still unknown in terms of trace element monitoring, the accuracy of different assays, and current TE contamination of solutions. The supplementation of TEs is a complex and important part of the PN prescription. Understanding the role of different disease states and the need for reduced or increased doses is essential. Given the heterogeneity of the PN patients, supplementation should be individualized.

Redox dynamics of manganese as a mitochondrial life-death switch

Sten Orrenius, M.D., Ph.D., pioneered many areas of cellular and molecular toxicology and made seminal contributions to our knowledge of oxidative stress and glutathione (GSH) metabolism, organellar functions and Ca+2-dependent mechanisms of cell death, and mechanisms of apoptosis. On the occasion of his 80th birthday, we summarize current knowledge on redox biology of manganese (Mn) and its role in mechanisms of cell death. Mn is found in all organisms and has critical roles in cell survival and death mechanisms by regulating Mn-containing enzymes such as manganese superoxide dismutase (SOD2) or affecting expression and activity of caspases. Occupational exposures to Mn cause "manganism", a Parkinson's disease-like condition of neurotoxicity, and experimental studies show that Mn exposure leads to accumulation of Mn in the brain, especially in mitochondria, and neuronal cell death occurs with features of an apoptotic mechanism. Interesting questions are why a ubiquitous metal that is essential for mitochondrial function would accumulate to excessive levels, cause increased H2O2 production and lead to cell death. Is this due to the interactions of Mn with other essential metals, such as iron, or with toxic metals, such as cadmium? Why is the Mn loading in the human brain so variable, and why is there such a narrow window between dietary adequacy and toxicity? Are non-neuronal tissues similarly vulnerable to insufficiency and excess, yet not characterized? We conclude that Mn is an important component of the redox interface between an organism and its environment and warrants detailed studies to understand the role of Mn as a mitochondrial life-death switch.

From the Cover: Manganese Stimulates Mitochondrial H2O2 Production in SH-SY5Y Human Neuroblastoma Cells Over Physiologic as well as Toxicologic Range

Manganese (Mn) is an abundant redox-active metal with well-characterized mitochondrial accumulation and neurotoxicity due to excessive exposures. Mn is also an essential co-factor for the mitochondrial antioxidant protein, superoxide dismutase-2 (SOD2), and the range for adequate intake established by the Institute of Medicine Food and Nutrition Board is 20% of the interim guidance value for toxicity by the Agency for Toxic Substances and Disease Registry, leaving little margin for safety. To study toxic mechanisms over this critical dose range, we treated human neuroblastoma SH-SY5Y cells with a series of MnCl₂ concentrations (from 0 to 100 μM) and measured cellular content to compare to human brain Mn content. Concentrations ≤10 μM gave cellular concentrations comparable to literature values for normal human brain, whereas concentrations ≥50 μM resulted in values comparable to brains from individuals with toxic Mn exposures. Cellular oxygen consumption rate increased as a function of Mn up to 10 μM and decreased with Mn dose ≥50 μM. Over this range, Mn had no effect on superoxide production as measured by aconitase activity or MitoSOX but increased H₂O₂ production as measured by MitoPY1. Consistent with increased production of H₂O₂, SOD2 activity, and steady-state oxidation of total thiol increased with increasing Mn. These findings have important implications for Mn toxicity by re-directing attention from superoxide anion radical to H₂O₂-dependent mechanisms and to investigation over the entire physiologic range to toxicologic range. Additionally, the results show that controlled Mn exposure provides a useful cell manipulation for toxicological studies of mitochondrial H₂O₂ signaling.

Gender influence on manganese induced depression-like behavior and Mn and Fe deposition in different regions of CNS and excretory organs in intraperitoneally exposed rats

Manganese (Mn) is an essential metal for mammals. It can modulate the action of endogenous substances, as neurotransmitters, but in excess also can trigger known neurotoxic effects. Many studies have been conducted assessing Mn neurotoxicity. However, Mn bioaccumulation in different brain tissues and behavior effects involving gender-specific studies are conflicted in the literature. Therefore, the aim of this work was to compare Mn effects, after 30days of intraperitoneal treatment, in male and female rats, submitted to forced swim and open field tests. After that, were evaluated Mn and Fe tissue levels in CNS, liver, and kidneys. Wistar rats were divided into saline, Mn 1mg/kg, Mn 5mg/kg, and imipramine (as forced swim control). Then, animals were euthanized by anesthesia overdose followed by decapitation and the collected tissue were striatum, hippocampus, brainstem, cortex, cerebellum, hepatic tissue, and renal tissue. Mn and Fe were determined by ICP-MS. There was a dose-dependent effect on accumulation of Mn in the cerebellum and brainstem to the dosage of 5mg/kg. In hippocampus there were bioaccumulation differences between gender and dose, and an increase of Fe in the groups exposed to Mn. Excess metals in the brain dissected has a strong influence on memory and learning processes and suggests pro-depressive effects, possibly triggered by the reduction of monoamines due to excessive metal bioaccumulation. It was concluded that, under this experimental design, Mn exposure cause metal deposition on dissected CNS, liver and kidney. There an effect at lower doses that was gender-dependent and males had more pronounced behavioral damage compared to females, although with increasing dose, females had an indication of motor damage.

Identification of dopaminergic neurons of the substantia nigra pars compacta as a target of manganese accumulation

Manganese serves as a cofactor to a variety of proteins necessary for proper bodily development and function. However, an overabundance of Mn in the brain can result in manganism, a neurological condition resembling Parkinson's disease (PD). Bulk sample measurement techniques have identified the globus pallidus and thalamus as targets of Mn accumulation in the brain, however smaller structures/cells cannot be measured. Here, X-ray fluorescence microscopy determined the metal content and distribution in the substantia nigra (SN) of the rodent brain. In vivo retrograde labeling of dopaminergic cells (via FluoroGold™) of the SN pars compacta (SNc) subsequently allowed for XRF imaging of dopaminergic cells in situ at subcellular resolution. Chronic Mn exposure resulted in a significant Mn increase in both the SN pars reticulata (>163%) and the SNc (>170%) as compared to control; no other metal concentrations were significantly changed. Subcellular imaging of dopaminergic cells demonstrated that Mn is located adjacent to the nucleus. Measured intracellular manganese concentrations range between 40-200 μM; concentrations as low as 100 μM have been observed to cause cell death in cell cultures. Direct observation of Mn accumulation in the SNc could establish a biological basis for movement disorders associated with manganism, specifically Mn caused insult to the SNc. Accumulation of Mn in dopaminergic cells of the SNc may help clarify the relationship between Mn and the loss of motor skills associated with manganism.

X-ray fluorescence imaging of the hippocampal formation after manganese exposure

Manganese (Mn) intoxication results in neurological conditions similar, but not identical, to idiopathic Parkinson's disease. While the mechanism(s) by which Mn exposure leads to neurotoxic effects remains unclear, studies by magnetic resonance imaging demonstrate a high Mn accumulation in the hippocampal formation (HPCf) of the brain. Metal quantification using this method is not possible. Using X-ray fluorescence imaging, we measured the distribution of Mn in the HPCf for a rodent model of chronic Mn exposure and quantitatively compared it with distributions of other biologically relevant metals. We found considerable increases in average Mn concentrations in all analyzed areas and we identified the dentate gyrus (DG) and the cornus ammonis 3 (CA3) layer as areas accumulating the highest Mn content (∼1.2 μg Mn per g tissue). The DG is significantly enriched with iron (Fe), while the CA3 layer has high zinc (Zn) content. Additionally, significant spatial correlations were found for Mn-Zn concentrations across the HPCf substructures and for Mn-Fe concentrations in the DG. Combined results support that at least two mechanisms may be responsible for Mn transport and/or storage in the brain, associated with either Fe or Zn. Subcellular resolution images of metal distribution in cells of the CA3 show diffuse Mn distributions consistent with Mn localization in both the cytoplasm and nucleus. Mn was not increased in localized intracellular Fe or copper accumulations. A consistent Mn-Zn correlation both at the tissue (40 μm × 40 μm) and cellular (0.3 μm × 0.3 μm) levels suggests that a Zn transport/storage mechanism in the HPCf is likely associated with Mn accumulation.

An analysis of the effects of Mn2+ on oxidative phosphorylation in liver, brain, and heart mitochondria using state 3 oxidation rate assays

Manganese (Mn) toxicity is partially mediated by reduced ATP production. We have used oxidation rate assays--a measure of ATP production--under rapid phosphorylation conditions to explore sites of Mn(2+) inhibition of ATP production in isolated liver, brain, and heart mitochondria. This approach has several advantages. First, the target tissue for Mn toxicity in the basal ganglia is energetically active and should be studied under rapid phosphorylation conditions. Second, Mn may inhibit metabolic steps which do not affect ATP production rate. This approach allows identification of inhibitions that decrease this rate. Third, mitochondria from different tissues contain different amounts of the components of the metabolic pathways potentially resulting in different patterns of ATP inhibition. Our results indicate that Mn(2+) inhibits ATP production with very different patterns in liver, brain, and heart mitochondria. The primary Mn(2+) inhibition site in liver and heart mitochondria, but not in brain mitochondria, is the F₁F₀ ATP synthase. In mitochondria fueled by either succinate or glutamate+malate, ATP production is much more strongly inhibited in brain than in liver or heart mitochondria; moreover, Mn(2+) inhibits two independent sites in brain mitochondria. The primary site of Mn-induced inhibition of ATP production in brain mitochondria when succinate is substrate is either fumarase or complex II, while the likely site of the primary inhibition when glutamate plus malate are the substrates is either the glutamate/aspartate exchanger or aspartate aminotransferase.

Liver disease due to parenteral and enteral nutrition

Liver disease due to parenteral and enteral nutrition is a well-recognized iatrogenic phenomenon, but its cause and pathogenesis have not been clearly elucidated. Various mechanisms have been postulated, but it is likely that the cause is multifactorial with significant interplay among several factors. A preventive approach to management is ideal but awaits a more complete understanding of the pathophysiology. A variety of management strategies has been proposed in small case series, but level 1 evidence-based guidelines have yet to be established. Although an abundance of both clinical and animal studies exist regarding liver disease associated with parenteral nutrition (PN), there is a paucity of data regarding enteral nutrition (EN)-associated hepatic disease. The latter probably reflects differences in the frequency and severity of PN- versus EN-associated liver disease. This article addresses the two routes of nutritional support individually, with the major focus on PN-associated liver disease.

Parenteral nutrition-associated liver complications in children

Parenteral nutrition is a life-saving therapy for patients with intestinal failure. It may be associated with transient elevations of liver enzyme concentrations, which return to normal after parenteral nutrition is discontinued. Prolonged parenteral nutrition is associated with complications affecting the hepatobiliary system, such as cholelithiasis, cholestasis, and steatosis. The most common of these is parenteral nutrition-associated cholestasis (PNAC), which may occur in children and may progress to liver failure. The pathophysiology of PNAC is poorly understood, and the etiology is multifactorial. Risk factors include prematurity, long duration of parenteral nutrition, sepsis, lack of bowel motility, and short bowel syndrome. Possible etiologies include excessive caloric administration, parenteral nutrition components, and nutritional deficiencies. Several measures can be undertaken to prevent PNAC, such as avoiding overfeeding, providing a balanced source of energy, weaning parenteral nutrition, starting enteral feeding, and avoiding sepsis.

Hypermanganesemia in long-term intravenous nutrition and chronic liver disease

BACKGROUND

Hypermanganesemia and cholestatic liver disease are both recognized complications of long-term IV nutrition. Manganese is primarily excreted in bile, and recent studies have indicated that manganese toxicity may play a role in the pathogenesis of IV nutrition-associated cholestasis.

METHODS

Whole blood and plasma manganese concentrations were measured in patients receiving long-term home IV nutrition (HIN, n = 30). Whole blood manganese concentrations also were measured in patients with chronic liver disease (CLD, n = 10) and control subjects (n = 10).

RESULTS

Whole blood manganese concentrations of all CLD patients were within the reference interval (73 to 210 nmol/L) and were not different from those of the control group (151 +/- 44 nmol/L, CLD vs 155 +/- 35 nmol/L, control; not significant), despite the presence of cholestasis. In contrast, whole blood manganese concentration was increased (>210 nmol/L) in 26 patients, and plasma manganese concentration increased (>23 nmol/L) in 23 of the patients receiving HIN. None of the patients exhibited neurologic signs of manganese toxicity. There was no correlation between whole blood manganese concentrations and markers of cholestasis, IV manganese intake, or duration of HIN. However, plasma manganese concentration correlated both with average weekly IV manganese intake (r = .44, p = .02) and with gamma-glutamyl transferase (r = .43, p = .02) and alkaline phosphatase activities (r = .55, p = .003).

CONCLUSIONS

Cholestatic liver disease does not appear to contribute to increased whole blood manganese concentrations in patients not receiving HIN. Plasma manganese concentrations in patients receiving HIN reflect recent manganese exposure and impaired excretion where cholestasis is present. The lack of relationship between plasma and whole blood manganese concentrations suggests that factors other than manganese intake and excretion affect intracellular concentrations.

New approaches to understanding the etiology and treatment of total parenteral nutrition-associated cholestasis

Total parenteral nutrition-associated cholestasis (TPN-AC) may be a fatal disease. The only known effective treatment is to discontinue TPN and institute full enteral feedings. However, this is not possible for many patients with severe gastrointestinal failure. Current research supports two theories regarding the etiology of TPN-AC. One proposes that the enteral fast disrupts the enterohepatic circulation. Cholestasis, in this hypothesis, results from a combination of altered gut hormone production and endotoxins produced by bacterial translocation. The second theory implicates the direct toxicity of TPN solution. Amino acid solutions and plant sterols in intralipid have generated much interest. Ursodeoxycholic acid and S-adenosyl-L-methionine are promising treatments for TPN-AC. They have been proven to be effective in animals and adult liver diseases. Cholecystokinin also has been investigated as a possible prophylactic agent. However, results from these experiments do not conclusively show a beneficial effect.

Alteration of lipid composition of hepatic membranes associated with manganese-bilirubin induced cholestasis

One hypothesis concerning the pathogenesis of manganese-bilirubin (Mn-BR)-induced cholestasis is that the molecular organization of the bile canalicular membrane is altered. The purpose of the present study was to evaluate lipid composition and fluidity of hepatic membranes during cholestasis in male Sprague-Dawley rats. To induce cholestasis, manganese (Mn, 4.5 mg/kg, intravenously [i.v.]) was given 15 min before bilirubin (BR, 25 mg/kg, i.v.). The rats were killed 30 min after BR injection, at which time bile flow was decreased by approximately 40% compared to control values. Liver cell plasma membranes enriched in canalicular fractions (BCM) and plasma membranes enriched in sinusoidal and lateral fractions (PM), microsomes, mitochondria and cytosol were isolated by differential centrifugation. Total lipids were extracted and measured colorimetrically. To assess fluidity, membranes were incubated in vitro with fluorescent probes [1,6-diphenyl-1,3,5-hexatriene and 1-(4'-trimethyl-ammonium-phenyl)-6-phenyl-1,3,5-hexatriene]. After Mn-BR treatment, BCM cholesterol incorporation increased markedly (about 3-fold) accompanied by a decrease in fluidity. BCM phospholipid content was unaltered by the cholestatic challenge. In PM-enriched fractions, the changes in cholesterol and phospholipid content after Mn-BR treatment were not statistically significant (P > 0.05) compared to controls. Furthermore, the biochemical alterations in PM were not accompanied by changes in membrane fluidity. These results support the hypothesis that altered lipid composition and fluidity of BCM are involved in the pathogenesis of Mn-BR cholestasis.

Manganese toxicity in children receiving long-term parenteral nutrition

BACKGROUND

In patients receiving long-term parenteral nutrition (PN), cholestatic disease and nervous system disorders have been associated with high blood concentrations of manganese. In such patients, the normal homoeostatic mechanisms of the liver and gut are bypassed and the requirement for this trace element is not known; nor has it been certain whether hypermanganesaemia causes the cholestasis or vice versa. We explored the direction of effect by serial tests of liver function after withdrawal of manganese supplements from children receiving long-term PN. We also examined the relation between blood manganese concentrations and brain lesions, as indicated by clinical examination and magnetic resonance imaging (MRI).

METHODS

From a combined group of 57 children receiving PN we identified 11 with the combination of hypermanganesaemia and cholestasis; one also had a movement disorder. Manganese supplements were reduced in the first three and withdrawn in the remainder. MRI was done in two of these children. We also looked at manganese concentrations and MRI scans in six children who had received PN for more than 2 years without developing liver disease.

FINDINGS

In the hypermanganesaemia/cholestasis group, four of the 11 patients died. In the seven survivors baseline whole-blood manganese was 615-1840 nmol/L, and after 4 months it had declined by a median of 643 nmol/L (p < 0.01). Over the same interval total bilirubin declined by a median of 70 mumol/L (p < 0.05). Two of these children had movement disorders, one of whom survived to have an MRI scan; this showed, with T1 weighted images, bilateral symmetrically increased signal intensity in the globus pallidus and subthalamic nuclei. Such changes were also seen in five other children--one from the hypermanganesaemia/cholestasis group and four of six in the long-term PN group without liver disease (in all of whom blood manganese was above normal).

INTERPRETATION

The cholestasis complicating PN is multifactorial, but these results add to the evidence that manganese contributes. In view of the additional hazard of basal ganglia damage from high manganese levels in children receiving long-term PN, we recommend a low dose regimen of not more than 0.018 mumol/kg per 24 h together with regular examination of the nervous system.

Effect of manganese dipyridoxal diphosphate on liver magnetic resonance imaging and serum bilirubin in rats with removable biliary obstruction

RATIONALE AND OBJECTIVES

It is known that manganese dipyridoxal diphosphate (Mn-DPDP) causes persisting liver enhancement in cholestatic rats, that free Mn++ plus bilirubin induces intrahepatic cholestasis, and that free Mn++ is released in vivo after Mn-DPDP injection. Hence, there is a concern about potential secondary intrahepatic cholestasis in patients who have biliary obstruction. In this study, we further investigated this issue.

METHODS

Removable total biliary obstruction (RTBO) was induced in 12 rats. Six of them (group A) received Mn-DPDP (25 mumol/kg). The others (group B) served as control animals. The data from serial magnetic resonance imaging and serum bilirubin tests were compared.

RESULTS

Without Mn-DPDP, a minimal increase of the liver intensity was observed in both groups because of cholestasis. In group A, the intensity of the liver was strongly enhanced with Mn-DPDP but normalized within 48 hr after removal of the obstruction. In both groups, total bilirubin levels increased up to 131.67 mumol/l 2 days after RTBO but rapidly decreased within 4 hr and almost normalized within 24 hr after removal of the obstruction, suggesting a lack of Mn-DPDP influence on the bilirubin level.

CONCLUSION

We found that Mn-DPDP did not cause secondary intrahepatic cholestasis. Retained Mn++ is likely eliminated after restoration of bile flow. These results indicate that Mn-DPDP can be used in patients who have obstructive jaundice as long as it is followed by successful bile drainage.

Hepatic concentrations of zinc, copper and manganese in infants with extrahepatic biliary atresia

The objective of this study was to determine the concentration of Zinc (Zn), Copper (Cu) and Manganese (Mn) in hepatic tissue from extrahepatic biliary atresia (EHBA). Liver biopsy samples were obtained at time of portoenterostomy from 49 infants ages 1.1 to 20.7 months (median 2.1) with EHBA. Samples were dry ashed and analyzed by flame (Zn) or flameless (Cu and Mn) atomic absorption spectrophotometry. Hepatic Cu concentrations are physiologically elevated at birth and decline rapidly during the first 2 month of life, therefore only samples from 29 infants, ages greater than 8 weeks were considered for Cu. Concentrations (mg/kg dry weight, mean and range) were: Zn 142 (70-507), Cu 204 (19-570), Mn 9.1 (2.8-21.8) vs. literature controls in the same age range: Zn 262 (82-543), Cu 92, Mn 4.3 (3.3-11.5). No correlations were found between serum alkaline phosphatase, AST or total bilirubin and hepatic trace element concentrations, between trace element concentrations and age, or between Cu and Mn. Decreased bile flow with intrahepatic cholestasis may result in hepatic accumulation of Mn as well as Cu. The low hepatic Zn concentrations indicate the need for further study of Zn metabolism in this population.

Manganese in long term paediatric parenteral nutrition

The current practice of providing manganese supplementation to neonates on long term parenteral nutrition is leading to a high incidence of hypermanganesaemia. Magnetic resonance imaging (MRI) studies in adults on long term manganese parenteral nutrition have shown changes in TI weighted MRI images and similar findings in a neonate receiving trace element supplementation are reported here. Whole blood manganese concentration in the infant was 1740 nmol/l (or 8.3 times upper reference limit). In all neonates on long term parenteral nutrition with evidence of cholestatic liver disease so far investigated, the whole blood manganese concentrations were > 360 nmol/l (reference range 73-210). Manganese supplementation to patients on long term parenteral nutrition requires reappraisal, particularly in those who develop cholestatic liver disease associated with parenteral nutrition.

Functional changes of the biliary tree associated with experimentally induced cholestasis: sulfobromophthalein on manganese-bilirubin combinations

Administration of combinations of manganese (Mn) and bilirubin (BR) to rats results in a severe, but reversible diminution of bile flow, an effect that can be abolished if sulfobromophthalein (BSP) is given at a specific time prior to BR. Some studies suggest that changes in the bile canalicular membrane (BCM) are critical to the response. One aim of the present work was to determine if functional changes in BCM also become more marked with increasing doses of BR. A second aim was to investigate the protective effects of BSP on MnBR-altered biliary function. The permeability of the biliary tree was evaluated by the segmented retrograde intrabiliary injection (SRII) procedure in male Sprague-Dawley rats treated with varying combinations and dosages of Mn, BR, and BSP. [3H]Mannitol and [3H]inulin were used as marker substances of the biliary tree (canalicular membrane and tight junctions, respectively). Administration of Mn, followed 15 min later by BR, led to a reduction in bile flow that was dose-dependent on BR. The percentage recovery of both inulin and mannitol in bile after SRII also decreased significantly with increasing dosages of BR. When BSP was given 10 min before BR, MnBR-induced reduction in bile flow was abolished. BSP treatment also prevented MnBR-induced reduction in biliary recovery of both inulin and mannitol after SRII; this was more evident with mannitol than with inulin. BSP protection against MnBR cholestasis depends upon when it is administered relative to BR injection. The relationship of BSP relative to BR injection was comparable for both reduced bile flow and the recoveries of marker substances in bile after SRII. The data are consistent with the conclusion that changes in biliary tree permeability, particularly at the canalicular membrane, likely lead to MnBR-induced cholestasis.

Biliary excretion in Sprague-Dawley and Gunn rats during manganese-bilirubin-induced cholestasis

We previously showed that alterations of the bile canalicular membrane are likely to occur following a cholestatic regimen composed sequentially of manganese and bilirubin. The present study was designed primarily to investigate the biliary excretion of organic bile constituents following administration of the manganese-bilirubin combination. Experiments in hyperbilirubinemic Gunn rats were also performed to determine whether the unconjugated or the conjugated form of bilirubin is involved in this cholestatic interaction. Male Sprague-Dawley rats and male homozygous Gunn rats were given the following (i.v.): (a) manganese (4.5 mg per kg); (b) unconjugated bilirubin (25 mg per kg); (c) bilirubin ditaurate (38 mg per kg); (d) manganese-unconjugated bilirubin, or (e) manganese-bilirubin ditaurate. Bile flow was measured and bile was analyzed for manganese, total bilirubin, bile salts, cholesterol and phospholipid content. The results show that: (i) manganese-unconjugated bilirubin treatment caused about a 50% reduction in bile flow in Sprague-Dawley rats, whereas in Gunn rats the manganese-bilirubin ditaurate treatment resulted in about a 75% reduction, and (ii) in both strains, bile salt excretion was not appreciably modified during the cholestatic phase, as biliary bile salt concentration increased. The results suggest that although important differences regarding the form of bilirubin apparently exist, unconjugated bilirubin could be implicated in the cholestatic interaction in both strains of rats. Manganese-bilirubin-induced cholestasis is not related to a defect in bile salt excretion. The latter supports our contention that diminished canalicular membrane permeability to water is likely to be a key factor in this form of experimental cholestasis.

Chlordecone is a potent in vitro inhibitor of oligomycin-insensitive Mg2+ -ATPase of rat bile canaliculi-enriched fraction

The oligomycin-insensitive Mg2+ -ATPase (OIMATPase) of rat bile canaliculi-enriched fraction (BCEF) was inhibited by chlordecone (CD) in vitro (IC-50 = 25 microM). Kinetic analysis indicated noncompetitive inhibition. Inhibition of OIMATPase by filipin but not by atractyloside verified plasma membrane origin of activity. The cholestatic agents alpha-naphthyl isothiocyanate (ANIT) and taurolithocholate (TLC) decreased OIMATPase activity at in vitro concentrations of 33 and 162 microM, while taurocholate (a choleretic bile salt), ethynylestradiol, and manganese did not. Cholestatic drugs with primary intracellular sites of action (colchicine and phalloidin) were ineffective OIMATPase inhibitors in this concentration range. Inhibition of OIMATPase by N-ethylmaleimide (NEM) and dicyclohexylcarbodiimide (DCCD) indicated some H+ -ATPase activity in BCEF. In vitro sensitivity of OIMATPase of BCEF to CD, ANIT, and TLC suggested the bile canaliculus as a subcellular-level target for their cholestatic actions.

Potentiation by methyl isobutyl ketone of the cholestasis induced in rats by a manganese-bilirubin combination or manganese alone

Haloalkane-induced hepatonecrogenesis can be potentiated by the prior administration of methyl isobutyl ketone (MIBK). In a previous study, MIBK was shown to potentiate the cholestasis induced by taurolithocholate in rats. We investigated the possibility that this ketone could potentiate the cholestasis induced by a combination of manganese and bilirubin (Mn-BR) or by manganese alone in rats. Dosages varying from 1.88 to 15 mmol/kg MIBK were administered once, 18 hr prior to the administration of the cholestatic Mn-BR combination. The cholestatic effect of the manganese-bilirubin combination is enhanced with dosages of MIBK of 3.75 mmol/kg and more. Daily ketone pretreatment for 3 days resulted in an increased response to the cholestatic challenges of either Mn-BR or Mn alone. MIBK per se is devoid of cholestatic properties, since the bile flow measured prior to the cholestatic challenge is not decreased and in some cases is significantly greater than that from vehicle-pretreated animals. These results show that MIBK can potentiate cholestatic as well as necrogenic forms of hepatotoxicity.

Modification of biliary tree permeability in rats treated with a manganese-bilirubin combination

Previous studies in this laboratory demonstrated incorporation of manganese (Mn) and bilirubin (BR) in rat liver bile canalicular membrane (BCM) following a cholestatic regimen composed sequentially of Mn plus BR. The present study investigates biliary tree permeability using segmented retrograde intrabiliary injection (SRII) with [3H]mannitol and [3H]inulin as marker substances. Male Sprague-Dawley rats were given the following iv: (a) Mn (high and low dose), (b) BR, (c) sulfobromophthalein (BSP), (d) Mn-BSP-BR, (e) MnBR. Results obtained with mannitol showed a approximately 63% decrease (p less than 0.05) in marker recovery following administration of MnBR combination. While BSP alone had no effect on mannitol recovery, BSP abolished the MnBR response when administered in the Mn-BSP-BR sequence. With inulin, Mn (high dose), MnBR, and Mn-BSP-BR all produced a approximately 45% decrease (p less than 0.05) in recovery, while BSP or BR alone caused a approximately 25% decrease (p less than 0.05). Mn (low dose) was without effect. These results and others obtained when the time pattern of the MnBR treatment was modified suggest: (1) MnBR treatment increases biliary tree permeability by altering both BCM and the junctional complex; (2) BCM alteration is probably the more critical event, since BSP, which protects against MnBR cholestasis, protected against the MnBR-induced change in mannitol recovery, but exerted no effect on inulin recovery.