ATP-MgCl2 produces sustained improvement in hepatic mitochondrial function and blood flow after hepatic ischemia

In vivo imaging of hepatic hemodynamics and light scattering property during ischemia-reperfusion in rats based on spectrocolorimetry

A red-green-blue camera-based imaging method is proposed for estimating spatial maps of concentrations of oxyhemoglobin (CHbO), deoxyhemoglobin (CHbR), total hemoglobin (CHbT), tissue oxygen saturation (StO2), and scattering power (b) in liver tissue. Hemodynamic responses to hepatic ischemia-reperfusion of in vivo rat liver tissues induced by portal triad occlusion were evaluated. Upon portal triad occlusion, this method yielded images of decreased CHbO, CHbT, StO2, and b, and increased CHbR followed by a progressive increase in CHbO and StO2 during reperfusion. Time courses of the changes in CHbO, CHbR, CHbT, and StO2 over different regions of interest (ROIs) revealed that ischemia results in an abrupt significant (P<0.05) reduction in CHbO, CHbT, and StO2 with a simultaneous increase in CHbR compared to the baseline level, indicative of the hemodynamic responses during hepatic ischemia-reperfusion. Upon reperfusion, there was a gradual increase in CHbO and StO2, and decrease in CHbR. The change in average scattering power b implies the presence of morphological alterations in the cellular and subcellular structures induced by ischemia or anoxia. This study shows the potential of monitoring spatiotemporal changes in hemodynamic parameters and morphological changes in studies of hepatic pathophysiology.

Hypothermia in bleeding trauma: a friend or a foe?

The induction of hypothermia for cellular protection is well established in several clinical settings. Its role in trauma patients, however, is controversial. This review discusses the benefits and complications of induced hypothermia--emphasizing the current state of knowledge and potential applications in bleeding patients. Extensive pre-clinical data suggest that in advanced stages of shock, rapid cooling can protect cells during ischemia and reperfusion, decrease organ damage, and improve survival. Yet hypothermia is a double edged sword; unless carefully managed, its induction can be associated with a number of complications. Appropriate patient selection requires a thorough understanding of the pre-clinical literature. Clinicians must also appreciate the enormous influence that temperature modulation exerts on various cellular mechanisms. This manuscript aims to provide a balanced view of the published literature on this topic. While many of the advantageous molecular and physiological effects of induced hypothermia have been outlined in animal models, rigorous clinical investigations are needed to translate these promising findings into clinical practice.

The role of the mitochondrion in trauma and shock

The mitochondrion of the eukaryotic cell is well known as a "power plant" whose energy is made available via the high-energy phosphate bonds of ATP. This indispensable and superbly adapted organelle appears to have originated as an endosymbiotic bacterium rather than as a eukaryotic creation per se. However, under the dangerous conditions of trauma and shock, the mitochondrion can become destabilized and harm its host cell in a variety of ways. These contrary traits may be, in part, vestiges from the bacterial origins of mitochondria. The mitochondrion can respond to the stress of trauma and shock by opening pores that leak contents into the host cell's cytoplasm, an event that can trigger programmed cell death or necrosis. In addition, the enormous oxygen consumption by mitochondria presents a two-edged sword in that a deranged mitochondrion can produce reactive oxygen species that damage genes and gene products, inflicting considerable harm to the mitochondrion and its host cell. However, although trauma and shock can cause the mitochondrion to wreak havoc in many ways, an adjuvant intervention with exogenous ATP-MgCl2 after trauma and shock appears useful for reducing cell and organ damage under those conditions.

Metabolic disturbances in shock, and the role of ATP-MgCl2 and sex steroids

Hemorrhage following accidental injuries is a common cause of death in the industrialized world. Moreover, the impact of elective surgery and solid organ transplantation sometimes results in low flow conditions similar to those seen following hemorrhagic shock. A shortage in O(2) availability, or hypoxia, leads to sequential changes in cell metabolism and morphology, including inflammatory responses and the expression of hypoxia-inducible transcription factor-1, which controls the cellular adaptation to hypoxia. These endogenous adaptive responses show that O(2) deprivation is not an unforeseen event for cells. The purpose of this review article is to discuss the pathophysiologic principles of shock and the metabolic alterations that cells undergo during low flow conditions. Moreover, the rationale for therapeutic intervention by administering ATP-MgCl(2) and sex steroids following shock and trauma will also be discussed.

Hepatic tissue oxygenation as a predictive indicator of ischemia-reperfusion liver injury

The purpose of this study was to determine whether hepatic tissue oxygenation after ischemia-reperfusion procedures is an indicator for later liver injury. Partial ischemia in the liver was induced by ligating the left pedicles. Rats were divided into two groups according to duration of ischemia: group A (30-min ischemia) and group B (60-min ischemia). Indices of blood oxygenation and blood volume in regional hepatic tissue, serum ALT levels and histological appearance of livers were evaluated. Twenty-four hours after ischemia and reflow, all rats in group A were alive, whereas only 67% survived in group B. Blood-oxygenation index and blood-volume index in group A rats rebounded quickly after reperfusion. In group B, blood-oxygenation index and blood-volume index remained significantly lower than in group A after reperfusion. Serum ALT levels at 60 and 120 min after reperfusion in group B were significantly higher than those in group A. Blood-oxygenation index measured at 5 and 60 min of reperfusion showed significant correlation with serum ALT levels at 120 min of reperfusion. When the percentage recovery of blood-oxygenation index at 5 and 60 min after reperfusion was more than 75%, all rats survived. No obvious signs of hepatocellular degeneration were observed histologically 5 min after reperfusion; however, substantial hepatocellular degeneration had occurred at 120 min of reperfusion in groups A and B. These data indicate that a decline in hepatic tissue oxygenation during the early phase of reperfusion (even when no obvious hepatocellular degeneration has been observed) can be a predictor of subsequent liver injury and prognosis.

Mechanism of liver injury following ischemia

To clarify whether ischemic liver injury is due to ischemia itself or reperfusion, histopathological and functional changes in the liver were examined before and after liver ischemia in rats with porto-systemic collateral channels. Effects of oxygen-derived free radical scavengers or an inhibitor of platelet aggregation on development of ischemic liver injury were also examined. Liver ischemia was produced by ligation of the portal vein and hepatic artery at liver hilum for 1 hr. The primary lesion of ischemic liver injury was cloudy swelling of liver cells in the periportal and midzonal regions; it developed during ischemia. The cloudy swelling of liver cells induced uneven distribution of sinusoidal blood flow after reperfusion, and consequently individual liver cell necrosis and focal hepatocellular necrosis in the midzonal regions developed later. Elevation of cytoplasmic enzyme activities in the serum after reperfusion was due to leakage across the damaged plasma membrane of liver cells. The treatment with superoxide dismutase, catalase, or heparin had not altered the liver injury that was attributed to ischemia, biochemically and histologically. These results suggest that ischemic liver injury is due to liver cell damage developed during ischemia, and that the ischemic liver injury is not alleviated or prevented by superoxide dismutase, catalase, or heparin.

Sodium flux and bioenergetics in the ischemic rat liver

Concurrent 23Na and 31P nuclear magnetic resonance spectroscopy has been employed to study the effects of ischemia upon the high-energy phosphagens and sodium ion concentration within the in vivo rat liver. High-energy phosphates in the form of ATP were depleted within 10 min of the onset of ischemia when measured by NMR. However, similar liver samples subjected to analytical biochemistry retained 27 +/- 12% of their ATP after a similar 10-min ischemic insult. Time-dependent 23Na NMR measurements, obtained in the presence of the shift reagent Dy(TTHA) to distinguish intracellular from extracellular sodium, revealed a rapid rise in the intracellular sodium when the liver was made ischemic. Intracellular and extracellular sodium concentrations approached equilibrium with an exponential time constant of 14.7 +/- 7 min. The initial rate of sodium influx was calculated to be 1.50 meq.l-1.min-1. The results indicate that the ischemic liver has a high passive sodium permeability and that NMR detectable 31P signals reflect the actual availability of cytosolic high-energy phosphates to enzymes, in this instance the membrane-bound [Na+, K+]-ATPase.

ATP-MgCl2 restores the depressed hepatocellular function and hepatic blood flow following hemorrhage and resuscitation

Although ATP-MgCl2 produces a myriad of beneficial effects following organ ischemia and simple hemorrhagic shock in animal models which involved heparinization and/or blood resuscitation, it is not known whether ATP-MgCl2 has any salutary effect on the depressed active hepatocellular function (AHF) and hepatic microvascular blood flow (HMBF) in a nonheparinized model of trauma and severe hemorrhage in the absence of blood resuscitation. To determine this, rats underwent a midline laparotomy (i.e., trauma induced) and were bled to and maintained at a mean arterial pressure of 40 mm Hg until 40% of the maximum shed blood volume was returned in the form of Ringer's lactate (RL). The animals were then resuscitated with four times the volume of shed blood with RL. ATP-MgCl2, 50 mumoles/kg body weight (BW) each or an equivalent volume of normal saline, was infused intravenously for 95 min during and following crystalloid resuscitation. At 1.5 and 4 hr after resuscitation, AHF (Vmax, maximal velocity of indocyanine green clearance; Km, efficiency of the active transport process) was determined without blood sampling by using an in vivo indocyanine green clearance technique. HMBF was measured with laser Doppler flowmetry. Results indicate that Vmax, Km, and HMBF decreased significantly at 1.5-4 hr after hemorrhage and resuscitation. ATP-MgCl2 infusion restored the depressed Vmax, Km, and HMBF and prevented the occurrence of hepatic edema. The restoration of AHF with ATP-MgCl2 treatment may be due to its direct salutary effect on the active indocyanine green transport process and/or due to improvement in hepatic microcirculation.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypomagnesemia in patients in postoperative intensive care

In order to study the clinical consequences of postoperative hypomagnesemia, the serum magnesium (Mg) concentration was measured in samples of blood collected from 193 patients admitted to two postoperative ICUs. On admission to the ICU, 117 patients (61 percent) had hypomagnesemia (serum Mg less than 1.5 mEq/dl), 66 patients (34 percent) had normomagnesemia (1.5 to 2.0 mEq/dl), and ten patients (5 percent) had hypermagnesemia (greater than 2.0 mEq/dl). There were no correlations between the severity of illness score (r = 0.145) or the degree of hypoproteinemia (r = 0.01) and the postoperative serum Mg level. Patients with severe hypomagnesemia (serum Mg less than or equal to 1.0 mEq/dl) experienced hypokalemia more often (p less than 0.02) than the others in the study. Furthermore, those with severe hypomagnesemia had a higher mortality rate (7/17 or 41 percent) than the remainder of the population studied (22/176 or 13 percent) (p less than 0.02). Those with severe hypomagnesemia had received aminoglycosides more often (p less than 0.001) than those with normal serum Mg concentrations. The serum Mg level was not a sensitive (68 percent) or specific (37 percent) predictor of survival. Our conclusions were as follows: (1) hypomagnesemia is common in postoperative ICU patients; and (2) patients in the postoperative ICU who have severe hypomagnesemia have a higher mortality and more hypokalemia than similarly ill patients with normomagnesemia. Because of the association between aminoglycoside therapy and severe hypomagnesemia, we recommend measurement of this variable in those patients receiving aminoglycosides. Furthermore, Mg replacement therapy is recommended for those patients with serum Mg values of 1 mEq/dl or less.

Calcium accumulation and neuronal damage in the rat hippocampus following cerebral ischemia

The present study was undertaken to correlate calcium accumulation with the development of neuronal necrosis following transient ischemia. After 10 min of forebrain ischemia in the rat--a period that leads to reproducible damage of CA1 pyramidal cells--determination of calcium concentration and evaluation of morphological signs of cell body necrosis in the dorsal hippocampus were performed at various recirculation times. Tissue calcium concentration was not different from control at the end of ischemic period and did not change after 3, 6, 12, or 24 h of recirculation. However, after 48 h, calcium content increased significantly, with a further increase being seen after 72 h. At early recovery periods, only scattered necrotic neurons were observed. After 48 h, only 2 of 12 hemispheres showed more than 25 necrotic cells per section. More conspicuous neuronal death was observed after 72 h. The results thus demonstrate that net accumulation of calcium in regio superior of the hippocampus precedes marked necrosis of CA1 pyramidal cells. The results suggest that one primary event in the delayed death of these cells is membrane dysfunction with increased calcium cycling.

Quantitative analysis of the effect of ATP-MgCl2 and adenosine-MgCl2 on the extent of necrosis in rat liver after ischemia

The effect of the administration of ATP-MgCl2 and adenosine-MgCl2 on the volume density of necrosis occurring 24 hr following 60 min of ischemia in rat liver has been studied. The extent of necrosis in the lobes submitted to ischemia has been assayed by morphometric analysis of fresh liver slices incubated in tetranitro BT. The administration of ATP-MgCl2 (1.25 mumole of each solved in 0.5 ml 0.9% NaCl) reduced the volume density of necrotic areas in the liver of a fasted rat from about 15% to almost zero, provided that the compounds are given as a continuous infusion spread over a period of 15 min and the administration is started before the circulatory flow is restored following ischemia. However, the extent of necrosis was not reduced by ATP-MgCl2 administration when ischemia was induced in the liver of a fed rat which showed a more massive necrosis (about 30%). Increasing concentrations of ATP-MgCl2 to 5 mumole did not result in any improvement. Adenosine-MgCl2 reduced the extent of necrosis after ischemia in a fasted rat in the same way as ATP-MgCl2. The conclusion is drawn that ATP as a direct source of energy and adenosine as a substrate for ATP-synthesis can protect the liver against ischemic damage, whereas MgCl2 plays a supporting role.

Acute intestinal ischemia studies by phosphorus nuclear magnetic resonance spectroscopy

31P nuclear magnetic resonance (NMR) spectroscopy has been used to follow the metabolism of acutely ischemic rat small intestine and its recovery after reversal of ischemia. Loops of small intestine were subjected to occlusive external pressure for up to 60 minutes, followed by a recovery period. The depletion of PCr and ATP is rapid and complete within 20 minutes. Recovery from ischemia is also rapid but with recovery ATP levels lower than initial values after prolonged ischemic periods. Intestinal shock was avoided. Clinical recovery correlated with shorter ischemic periods. 31P NMR spectroscopy thus appears to be a suitable technique for studying the effects of pharmacological agents and other treatments for amelioration of ischemic effects on the bowel.

Hepatic ischemia models for determining the effects of ATP-MgCl2 treatment

Although ATP-MgCl2 treatment after global hepatic ischemia has been shown to improve cell function, a recent report has failed to confirm this in a model of regional hepatic ischemia. To determine the reason for this, rats were anesthetized and blood vessels to the left and median lobes of the liver were occluded. After 90 min of ischemia, the ligature around those vessels was removed. In Model 1, blood flow to the right lobes of the liver was then occluded whereas in Model 2, flow to those lobes was left intact. In both models the rats received intravenously 1.0 ml of saline or ATP-MgCl2 (12.5 mumole each) after ischemia. One hour after reflow, hepatic blood flow in the right and/or left lobe was measured following which mitochondria from the respective lobes were isolated and their function measured. The results indicated that although ATP-MgCl2 infusion following hepatic ischemia significantly improved hepatic blood flow and mitochondrial function in Model 1 (in which the right lobes were ligated following release of the occlusion to the left and median lobes), it failed to do so in Model 2 (in which the right lobes were not occluded after release of the occlusion to the left and median lobes). These results emphasize the importance of the rapid restoration of blood flow following hepatic ischemia. In the presence of shunts such as occur in Model 2, it is unlikely that any therapeutic agent would be effective.