Edema and increased endoneurial sodium in galactose neuropathy. Reversal with an aldose reductase inhibitor

Is diabetes the risk factor for poor neurological recovery after cervical spine surgery? A review of the literature

The poor prognosis of cervical spine surgery is mainly manifested as poor neurological recovery and the presence of new upper extremity dysfunction that promotes significant psychological and physiological burdens on patients. Many factors influence the prognosis of cervical spine surgery, including the age of patients, the time and mode of surgery, and the surgical technique used. However, in clinical studies, it has been observed that patients with diabetes have a higher probability of poor prognosis after surgery. Therefore, we review the pathophysiology of diabetic neuropathies and discuss its impact on cervical nerve system function, especially in cervical nerve roots and upper limb peripheral nerve conduction.

Current and Future Treatments for Classic Galactosemia

Type I (classic) galactosemia, galactose 1-phosphate uridylyltransferase (GALT)-deficiency is a hereditary disorder of galactose metabolism. The current therapeutic standard of care, a galactose-restricted diet, is effective in treating neonatal complications but is inadequate in preventing burdensome complications. The development of several animal models of classic galactosemia that (partly) mimic the biochemical and clinical phenotypes and the resolution of the crystal structure of GALT have provided important insights; however, precise pathophysiology remains to be elucidated. Novel therapeutic approaches currently being explored focus on several of the pathogenic factors that have been described, aiming to (i) restore GALT activity, (ii) influence the cascade of events and (iii) address the clinical picture. This review attempts to provide an overview on the latest advancements in therapy approaches.

Therapies for galactosemia: a patent landscape

Galactosemia is the inherited inability to metabolise galactose. The most common results from a lack of galactose 1-phosphate uridylyltransferase activity. The current treatment, removal of galactose from the diet, is inadequate and often fails to prevent long-term complications. Since 2015, three patents have been filed describing novel therapies. These are: the use of aldose reductase inhibitors to reduce cataracts and, possibly, other symptoms; salubrinal to stimulate cellular stress responses; mRNA therapy to increase cellular galactose 1-phosphate uridylyltransferase activity. The viability of all three is supported by academic studies. The potential and drawbacks of all three are discussed and evaluated.

Schwann cell interactions with axons and microvessels in diabetic neuropathy

The prevalence of diabetes worldwide is at pandemic levels, with the number of patients increasing by 5% annually. The most common complication of diabetes is peripheral neuropathy, which has a prevalence as high as 50% and is characterized by damage to neurons, Schwann cells and blood vessels within the nerve. The pathogenic mechanisms of diabetic neuropathy remain poorly understood, impeding the development of targeted therapies to treat nerve degeneration and its most disruptive consequences of sensory loss and neuropathic pain. Involvement of Schwann cells has long been proposed, and new research techniques are beginning to unravel a complex interplay between these cells, axons and microvessels that is compromised during the development of diabetic neuropathy. In this Review, we discuss the evolving concept of Schwannopathy as an integral factor in the pathogenesis of diabetic neuropathy, and how disruption of the interactions between Schwann cells, axons and microvessels contribute to the disease.

Mechanisms of diabetic neuropathy: Schwann cells

As ensheathing and secretory cells, Schwann cells are a ubiquitous and vital component of the endoneurial microenvironment of peripheral nerves. The interdependence of axons and their ensheathing Schwann cells predisposes each to the impact of injury in the other. Further, the dependence of the blood-nerve interface on trophic support from Schwann cells during development, adulthood, and after injury suggests these glial cells promote the structural and functional integrity of nerve trunks. Here, the developmental origin, injury-induced changes, and mature myelinating and nonmyelinating phenotypes of Schwann cells are reviewed prior to a description of nerve fiber pathology and consideration of pathogenic mechanisms in human and experimental diabetic neuropathy. A fundamental role for aldose-reductase-containing Schwann cells in the pathogenesis of diabetic neuropathy, as well as the interrelationship of pathogenic mechanisms, is indicated by the sensitivity of hyperglycemia-induced biochemical alterations, such as polyol pathway flux, formation of reactive oxygen species, generation of advanced glycosylation end products (AGEs) and deficient neurotrophic support, to blocking polyol pathway flux.

Homeostatic regulation of the endoneurial microenvironment during development, aging and in response to trauma, disease and toxic insult

The endoneurial microenvironment, delimited by the endothelium of endoneurial vessels and a multi-layered ensheathing perineurium, is a specialized milieu intérieur within which axons, associated Schwann cells and other resident cells of peripheral nerves function. The endothelium and perineurium restricts as well as regulates exchange of material between the endoneurial microenvironment and the surrounding extracellular space and thus is more appropriately described as a blood-nerve interface (BNI) rather than a blood-nerve barrier (BNB). Input to and output from the endoneurial microenvironment occurs via blood-nerve exchange and convective endoneurial fluid flow driven by a proximo-distal hydrostatic pressure gradient. The independent regulation of the endothelial and perineurial components of the BNI during development, aging and in response to trauma is consistent with homeostatic regulation of the endoneurial microenvironment. Pathophysiological alterations of the endoneurium in experimental allergic neuritis (EAN), and diabetic and lead neuropathy are considered to be perturbations of endoneurial homeostasis. The interactions of Schwann cells, axons, macrophages, and mast cells via cell-cell and cell-matrix signaling regulate the permeability of this interface. A greater knowledge of the dynamic nature of tight junctions and the factors that induce and/or modulate these key elements of the BNI will increase our understanding of peripheral nerve disorders as well as stimulate the development of therapeutic strategies to treat these disorders.

Diabetes mellitus and the peripheral nervous system: manifestations and mechanisms

Diabetes targets the peripheral nervous system with several different patterns of damage and several mechanisms of disease. Diabetic polyneuropathy (DPN) is a common disorder involving a large proportion of diabetic patients, yet its pathophysiology is controversial. Mechanisms considered have included polyol flux, microangiopathy, oxidative stress, abnormal signaling from advanced glycation endproducts and growth factor deficiency. Although some clinical trials have demonstrated modest benefits in disease stabilization or pain therapy in DPN, robust therapy capable of reversing the disease is unavailable. In this review, general aspects of DPN and other diabetic neuropathies are examined, including a summary of recent therapeutic trials. A particular emphasis is placed on the evidence that the neurobiology of DPN reflects a unique yet common and disabling neurodegenerative disorder.

Novel sites of aldose reductase immunolocalization in normal and streptozotocin-diabetic rats

Glucose metabolism by aldose reductase (AR) is implicated in the pathogenesis of many diabetic complications, including neuropathy. We have re-evaluated the distribution of AR in the sciatic nerve and dorsal root ganglion (DRG) of normal rats, expanded these observations to describe the location of AR in the spinal cord and footpad skin, and investigated whether diabetes alters the distribution of AR. In sciatic nerve, AR was restricted to cytoplasm of myelinated Schwann cells and endothelial cells of epineurial, but not endoneurial, blood vessels. AR immunoreactivity (IR) was present in satellite cells in the DRG. In skin, AR-IR was detected in vascular endothelial cells, Schwann cells of myelinated fibers, and axons of perivascular sympathetic nerves. AR was localized selectively to oligodendrocytes of the white matter of spinal cord. The distribution of AR-IR in sciatic nerve, DRG, skin, and spinal cord was not altered by up to 12 weeks of streptozotocin-induced diabetes. Identification of perineuronal satellite cells, oligodendrocytes, and perivascular sympathetic nerves as AR-expressing cells reveals them as cellular sites with the potential to contribute to diabetic neuropathy.

Peripheral nerve regeneration in galactosaemic rats

The use of galactosaemia as a model for some aspects of diabetic polyneuropathy allows the influence of glycation to be studied independently of other effects. There are well-studied abnormalities of the peripheral nerves in galactosaemic rats, one of which is that the efficiency of regeneration is initially reduced. One possible cause could be that glycated myelin debris in macrophages is less degradable and interferes with macrophage function. Macrophage recognition and ingestion of myelin glycosylated in vitro increases with the duration of incubation in a sugar-rich medium. This study was performed to investigate a possible correlation between galactosaemia and regeneration, together with the role of macrophages. Galactosaemia was induced by adding galactose to the rats' diet for 2 months before injury. Following a crush lesion to the sciatic nerve, regeneration was found to be delayed, demonstrated by a reduction in mean myelinated fibre size and density 1 month after crush, although, 2 and 3 months later, the differences did not reach statistical significance. There were also more macrophages in the galactosaemic rats than in the control animals at all time points. The initial delay in regeneration in galactosaemic rats was therefore only temporary and there was little evidence of long-term deleterious effects. In addition to the morphometric results, immunohistochemistry showed that there were more macrophages in the galactosaemic rats than in the control animals at all time points. Correlating macrophage and myelinated fibre counts suggests that the persistence of debris-containing macrophages does not appear to have a significant inhibitory effect on nerve regeneration. No evidence was found for persistent basal laminal tubes around the regenerating clusters.

New trends in the etiopathogenesis of diabetic peripheral neuropathy

Neuropathy is well recognized as a major complication of insulin-dependent diabetes mellitus in adults, resulting in significant morbidity and possibly an increased mortality. Both the peripheral and autonomic nervous systems can be involved, and adolescents with diabetes can show early evidence of neuropathy. The pathogenesis of diabetic neuropathy remains unclear but is thought to involve various mechanisms. This complication can be traced to the metabolic effects of hyperglycemia and/or other effects of insulin deficiency on the various constituents of the peripheral nerve. The polyol pathway and/or nonenzymatic glycation affecting one or more cell types in the multicellular constituents of the peripheral nerve appear likely to have an inciting role. The role of other factors, such as possible direct neurotrophic effects of insulin and insulin-related growth factors, seems to be relevant.

Expression of aldose reductase and sorbitol dehydrogenase genes in Schwann cells isolated from rat: effects of high glucose and osmotic stress

To investigate the polyol pathway activity in Schwann cells, we determined the mRNA levels of aldose reductase (AR) and sorbitol dehydrogenase (SDH) in cultured cells under hyperglycemic or hyperosmotic conditions using competitive RT-PCR technique. The expressions of AR and SDH mRNAs in Schwann cells were unaltered by high (30 mM) glucose content in the medium. On the other hand, osmotic stress elicited significant increases in AR mRNA without any effect on SDH mRNA expression. The levels of AR mRNA determined by this RT-PCR system were significantly correlated with AR activity, as well as the levels of sorbitol accumulated in Schwann cells cultured under hyperosmotic conditions. These findings suggest that in contrast to the induction of AR expression by osmotic stress, high glucose per se does not up-regulate expression of the enzymes constituting the polyol pathway in Schwann cells. The RT-PCR system developed in this study may be a useful tool in ascertaining the relative contributions of AR and SDH to the metabolic derangements leading to diabetic complications.

ATP-sensitive K(+) channel effects on nerve function, Na(+), K(+) ATPase, and glutathione in diabetic rats

Some vasodilators correct nerve conduction velocity and endoneurial blood flow deficits in diabetic rats. It is not known whether vasa nervorum has ATP-sensitive K(+) (K(ATP)) channels that mediate vasodilation, or whether K(ATP) channels could modulate peripheral nerve function. Therefore, we examined the effects of 2 weeks treatment with the K(ATP) channel openers, celikalim and WAY135201 (R-4-[3, 4-dioxo-2-(1, 2, 2-trimethyl-propylamino)-cyclobut-1-1-enylamino]-3-methoxy-+ ++benzonitri le), on sciatic nerve blood flow, conduction velocity, Na(+)-K(+) ATPase activity and glutathione content after 6 weeks of untreated streptozotocin-diabetes in rats. Blood flow and motor conduction velocity, 47.6% and 20.3% reduced by diabetes, respectively, were completely restored by both celikalim and WAY135201 treatments. Diabetes diminished sciatic Na(+)-K(+) ATPase activity by 47.6% and this was 80-90% corrected by the K(ATP) channel openers. Sciatic nerve glutathione content, 30.3% reduced by diabetes, was unaffected by celikalim or WAY135201. Thus, K(ATP) channel openers had marked beneficial effects on nerve perfusion and function in experimental diabetic neuropathy, and may be suitable for further study in clinical trials.

Diabetic neuropathies: features and mechanisms

Diabetic neuropathies include both focal neuropathies and diffuse polyneuropathy. Polyneuropathy, the most common of the diabetic neuropathies excluding focal entrapment, has not yet been explained by a single disease mechanism despite intensive investigation. A number of abnormalities appear to cascade into a 'vicious cycle' of progressive microvascular disease associated with motor, sensory and autonomic fiber loss. These abnormalities include excessive polyol (sugar alcohol) flux through the aldose reductase pathway, functional and structural alterations of nerve microvessels, nerve and ganglia hypoxia, oxidative stress, nonspecific glycosylation of axon and microvessel proteins, and impairment in the elaboration of trophic factors critical for peripheral nerves and their ganglia. While an initiating role for nerve ischemia in the development of polyneuropathy has been proposed, the evidence for it can be questioned. The role of sensory and autonomic ganglia in the development of polyneuropathy has had relatively less attention despite the possibility that they may be vulnerable to a variety of insults, particularly neurotrophin deficiency. Superimposed on the deficits of polyneuropathy is the failure of diabetic nerves to regenerate as effectively as nondiabetics. Polyneuropathy has not yet yielded to specific forms of treatment but a variety of new trials addressing plausible hypotheses have been initiated. This review will summarize some of the clinical, pathological and experimental work applied toward understanding human diabetic neuropathy and will emphasize ideas on pathogenesis.

Effects of seven days of galactose feeding and aldose reductase inhibition on mast cells and vessel morphometry in rat sciatic nerve

The association between mast cells and vessel morphometry in sciatic nerve was examined after seven days in animals fed a diet of 40% D-galactose and compared to control rats and to galactose-fed animals treated with the aldose reductase inhibitor, Tolrestat. Electron microscopy revealed an increase in the total number of mast cells and the number of degranulated mast cells in galactose-fed animals (7.8 +/- 2.9; 2.6 +/- 2.9; mean +/- SD) compared to controls (4.6 +/- 2.1; degranulated mast cells were not seen in any control nerves) and Tolrestat-treated, galactose-fed animals (4.4 +/- 2.5; 0.1 +/- 0.4). Although no significant differences were noted in the numbers of vessels between the three groups, an index of vasoconstriction was significantly increased in the galactose-fed animals (0.115 +/- 0.048; mean +/- SD) compared to controls (0.068 +/- 0.011) and Tolrestat-treated, galactose-fed animals (0.075 +/- 0.20). These data suggest that mast cell degranulation is associated with the vascular constriction induced by seven days of galactose intoxication and that both may be prevented by inhibiting aldose reductase.

Nerve function in galactosaemic rats: effects of evening primrose oil and doxazosin

Rats were fed for 6 weeks with a 40% galactose diet to chronically stimulate the polyol pathway. Sciatic motor and saphenous sensory nerve conduction velocity deficits of 22% and 14% respectively developed. Treatment with evening primrose oil or doxazosin from galactosaemia induction partially (approximately 60%) prevented the development of reduced motor and sensory conduction, the former treatment being more successful than the latter. Sciatic nerve resistance to hypoxic conduction failure was 49% increased by galactosaemia. This abnormality was 27% and 43% prevented by doxazosin and evening primrose oil respectively. Galactosaemic sciatic nerves had a 10% increase in water content and endoneurial capillary density was 24% reduced. While neither treatment affected water content, both caused angiogenesis, elevating capillary density by approximately 16%. The data support the hypothesis that, as in experimental diabetes mellitus, the main effect of polyol pathway activation on peripheral nerve function occurs indirectly via a neurovascular action.

In vivo study of brain metabolism in galactosemia by 1H and 31P magnetic resonance spectroscopy

In order to further evaluate different hypotheses concerning brain metabolism in galactosemia, six adult patients aged 18-29 years with classical galactosemia under dietary treatment underwent localized 1H and 31P magnetic resonance spectroscopy (MRS) in addition to conventional T1- and T2-weighted MRI. Galactose-1-phosphate levels in erythrocytes were 1.1-3.7 mg/dl, plasma concentrations of galactitol ranged from 8.4-14.2 mumol/l. Imaging revealed abnormal peripheral myelination in five and enlargement of lateral ventricles in two patients. Brain galactitol in parieto-occipital white matter was below detectability of 1H MRS leading to the assumption that brain concentrations of the free metabolite was well below 1 mmol/kg. Signal intensities of free myo-inositol, which was postulated to be indicative of changes in the second messenger pathway, were within the normal range. MRS data revealed a normal energy status of the brain. In summary 1H and 31P MRS indicated normal metabolite concentrations as compared to healthy controls.

The role of polyols in the pathophysiology of hypergalactosemia

Cellular accumulation of galactitol has been suggested to cause the apparent dietary-independent, long-term complications in classic galactosemia. Experimental animals rendered hypergalactosemic by galactose feeding accumulate tissue galactitol, as well as millimolar quantities of galactose, and manifest biochemical, physiological and pathological abnormalities which are generally eliminated or curtailed by the concomitant administration of an aldose reductase inhibitor. This includes reduced cellular content of the cyclic polyol, myo-inositol, which like galactitol may function as an alternate intracellular osmolyte. However, the abnormalities detected in experimental galactosemic animals are more compatible with findings in experimental diabetes mellitus than in human galactosemia. Because patients with galactokinase deficiency fail to manifest the CNS and ovarian complications which characterize classic galactosemia, yet during long-term lactose restriction excrete comparable urinary quantities of galactitol, this polyol alone is not likely to play an important role during postnatal life in the pathogenesis of long-term complications. Notwithstanding, a role for either galactitol or myo-inositol in an intrauterine toxicity cannot be dismissed.

Severe radicular pathology in rats with longstanding diabetes

There few pathological abnormalities in nerves from animals with diabetes. Reported changes consist of mild distal axonal atrophy, axoglial disjunction and minimal segmental demyelination and remyelination. These changes are seen in distal nerves but no studies of radicular pathology in diabetic animals have been reported. We therefore studied peripheral nerve and radicular pathology in rats with longstanding, severe, chemically-induced diabetes. We found marked interstitial edema and severe changes of myelin in the roots of diabetic rats, particularly in the dorsal root. The earliest changes consist of myelin splitting, occurring at the intraperiod line. This progresses to myelin ballooning, accompanied by both tubulovescicular myelin degeneration and macrophage stripping, all of which tend to predominate in large myelinated fibers. There is minimal axonal degeneration. Despite these severe changes in nerve roots, the distal peripheral nerves show no discernible edema and only minimal myelin splitting without demyelination or axonal degeneration. The radicular changes are almost identical to those seen in much older nondiabetic animals. This suggests that they may represent an acceleration of the normal aging process, perhaps related to increased glycation of myelin proteins induced by accumulation of glucose rich interstitial endoneurial edema.

Galactosemia produces ARI-preventable nodal changes similar to those of diabetic neuropathy

The present study was designed to examine the development of structural changes, characteristic of diabetic neuropathy, in chronic galactosemia and their responsiveness to inhibition of the polyol-pathway. Sprague-Dawley rats weighing 70-90 g were given a 50% galactose diet continued for 4 or 8 months. Half of these animals were simultaneously given the aldose reductase inhibitor (ARI) WAY 121-509. ARI-treatment normalized galactitol and myoinositol levels in the sciatic nerve. At 4 months, sciatic nerve conduction velocity (NCV) in galactosemic rats was reduced by 30% which was prevented in ARI-treated rats. At 8 months galactosemia reduced NCV to 58% of control values, while ARI-treatment for 8 months improved NCV to 71% of control values. ARI-treatment prevented in galactosemic rats nodal structural changes characteristic of diabetic neuropathy, whereas axonal atrophy was not affected by ARI-treatment, which may in part account for the only partial prevention of the NCV slowing at 8 months. Nerve fiber regeneration was increased 4-fold in ARI-treated rats compared with untreated galactosemic rats. These data suggest that chronic galactosemia produces a neuropathy structurally similar to diabetic neuropathy. The lack of an ARI-treatment effect on axonal atrophy suggests that this defect is not polyol related in galactosemia.

Permeability and surface area of the blood-nerve barrier in galactose intoxication

The blood-nerve movement of a small molecular weight non-electrolyte was studied in control and galactose-fed rats by measuring the permeability-surface area (PSA) product of the blood-nerve interface to [14C]mannitol in sciatic nerve using an in vivo injection method. PSA products were measured after 9 to 11 months of feeding control rats a diet containing 0% galactose and galactose-intoxicated rats a diet containing 40% galactose. Nerves of the galactose-fed group were hydrated as reflected by a significant increase in nerve water content and wet weight to dry weight ratio (both P < 0.05). Compared to controls, PSA products were increased by 51% (P < 0.01) in galactose-fed animals when referenced to nerve dry weight (13.59 +/- 2.90 x 10(-5) ml/s/g dry wt. versus 8.99 +/- 1.59 x 10(-5) ml/s/g dry wt.; mean +/- S.D.; galactose vs. control, respectively) or by 30% (P < 0.001) when referenced to nerve length (2.43 +/- 0.43 x 10(-5) ml/s/mm vs. 1.87 +/- 0.48 x 10(-5) ml/s/mm) but not when referenced to nerve wet weight. It is suggested that in galactose intoxication, where endoneurial volume changes reflect increases in nerve water content, PSA products are best normalized to dry weight or length, which are not affected by volume changes. Normalized to dry weight, the blood-nerve barrier surface area (i.e. vessels and perineurium) was determined by morphometric methods to be increased by 34% in the galactose-intoxicated group.(ABSTRACT TRUNCATED AT 250 WORDS)

Decreased endoneurial fluid electrolytes in normal rat sciatic nerve after aldose reductase inhibition

The role of the enzyme aldose reductase in nerve homeostasis was examined by treating rats with an aldose reductase inhibitor. Female Sprague-Dawley rats were treated with Ponalrestat (25 mg/kg/day) or with excipient alone for 4 to 12 weeks before examining electrophysiologic function, endoneurial fluid electrolyte concentrations, nerve polyol levels, water content and (Na+,K+)-ATPase activity. Sorbitol, the product of glucose metabolism by aldose reductase, was detected in all nerves from control animals, whereas it was below detection limits in 7 of 11 nerves from Ponalrestat-treated rats. Ponalrestat treatment reduced endoneurial fluid sodium and chloride concentrations by 25% and 37%, respectively (both P < 0.001). No differences in nerve water content, conduction velocity, or ATPase activities were detected. These data, and previous studies demonstrating that increased flux through aldose reductase causes the accumulation of endoneurial electrolytes, suggest a role for this enzyme in modulation of the endoneurial microenvironment. However, short-term inhibition of aldose reductase does not appear to affect nerve function. Thus, our findings do not elicit concerns regarding the use of aldose reductase inhibitors in the treatment of clinical diabetic neuropathy.

Sural nerve water in vivo in normal humans measured by magnetic resonance spectroscopy: relation to age, height, gender, and neurological profile

To enable the quantitative assessment of peripheral nerve structure and function, we determined the normal values for sural nerve hydration structure as measured by magnetic resonance proton imaging, and for neurological function with scores for neuropathic symptoms, signs, and nerve conduction properties. Normal human sural nerves contain 24.8 +/- 3.4% water. The structural water content of the nerves did not vary systematically in relation to age, height, gender, sural nerve conduction, neurologic symptoms, or examination deficits. In contrast, the neurological function scores were significantly influenced by age and selectively by height. Both nerve structure and function were stable over a 1-year interval. Measurement of human sural nerve water content in vivo by magnetic resonance proton imaging, and quantitation of the neurological profile of symptoms, signs, and conduction velocity are useful, noninvasive tools for the investigation of diseases in which changes in nerve structure may be related to alterations in nerve function.

A freeze-fracture study of the perineurium in galactose neuropathy: morphological changes associated with endoneurial oedema

Feeding rats with galactose as 40% of their diet results in peripheral nerve oedema related to the intrafascicular accumulation of galactitol and sodium. In this study, associated changes in the perineurium were examined by the freeze-fracture replication technique. Perineurial cells are linked by tight junctions (zonulae occludentes). In normal animals these are made up of anastomosing strands organized in a belt-like arrangement along the margins of continuous cells. The majority of the tight junctions in the galactose-fed animals displayed structural abnormalities. These ranged from slight separation of the strands to fragmentation and dispersal, with looping of isolated strands. Some of the tight junctions contained large dilated compartments within the junctional network. Short lengths of intramembranous particles, probably representing assembly or disassembly of tight junctional strands, were also observed. The membranes of perineurial cells normally possess numerous openings of caveolae. A quantitative assessment showed that the mean density of these caveolae openings was increased in the galactose-fed rats as compared with controls. The alterations in the tight junctions resemble those that have been produced experimentally in epithelia by subjecting them to abnormal osmotic gradients. They also resemble those seen in human diabetic neuropathy in which osmotic disturbances involving the perineurium have been considered to occur. If the alterations involve the inner layers of the perineurium, they are likely to impair its barrier function. The increased number of caveolae openings in galactose neuropathy may represent a reaction to the endoneurial oedema and indicate that the pinocytotic-like vesicles have a transport function.

Dose-dependent alterations in nerve polyols and (Na+,K+)-ATPase activity in galactose intoxication

Nerve polyol content and (Na+,K+)-adenosine triphosphatase (ATPase) activity of nerve homogenates were studied in a colony of rats fed diets containing either 0%, 10%, 20%, or 40% galactose for 4 months. Nerve water and dulcitol content exhibited dose-dependent increases, whereas nerve myo-inositol content declined with increasing dietary galactose. Homogenate (Na+,K+)-ATPase activity increased with increasing galactose consumption of up to 20% dietary intake and thereafter remained consistently elevated at twice the activity of 0% galactose-fed values. Nerves of rats fed 40% galactose were also examined at the light microscope level and showed evidence of both edema and myelin splitting. These data demonstrate that increased nerve water content, dulcitol accumulation, and myo-inositol depletion parallel the previously reported dose-related increase of endoneurial fluid sodium and chloride in nerves of galactose-fed rats and suggest that elevated nerve homogenate (Na+,K+)-ATPase activity may be related to one or more of these consequences of exaggerated polyol pathway flux.

Nerve conduction velocity and axonal transport of 6-phosphofructokinase activity in galactose-fed rats

This study examined sciatic motor nerve conduction velocity (MNCV) and the accumulation of 6-phosphofructokinase (PFK) activity proximal and distal to a sciatic nerve ligature in rats fed a diet containing 20% galactose for 4 weeks. MNCV was reduced in the galactose-fed rats to 94% of controls, (P less than 0.05) but PFK activity accumulations were not different from those in controls. Daily administration of the aldose reductase inhibitor ponalrestat throughout the study to another group of galactose-fed rats prevented dulcitol accumulation, myo-inositol depletion and increased water content of the sciatic nerve seen in galactose-fed rats. This effective aldose reductase inhibition also prevented the reduced MNCV and had no effect on accumulations of PFK activity. These data support earlier work suggesting that deficits in the axonal transport of PFK activity in diabetic rats are unrelated to either exaggerated flux through the polyol pathway, polyol accumulation or ischemic hypoxia and indicate the possible need for the elucidation of other pathogenic mechanisms which may contribute to the development of diabetic neuropathy.

Fine-structural localization of aldose reductase and ouabain-sensitive, K(+)-dependent p-nitro-phenylphosphatase in rat peripheral nerve

Aldose reductase was visualized by light and electron microscopy using a goat anti-rat antibody with immunoperoxidase and immunogold, respectively. Ouabain-sensitive, K(+)-dependent, p-nitro-phenylphosphatase, a component of (Na+, K+)-ATPase, was localized at the electron microscopic level by enzyme histochemistry using p-nitro-phenylphosphate as substrate. In peripheral nerve, spinal ganglia and roots, the Schwann cell of myelinated fibers was the principal site of aldose reductase localization. Immunostaining was intense in the paranodal region and the Schmidt-Lanterman clefts as well as in cytoplasm of the terminal expansions of paranodal myelin lamellae and the nodal microvilli. Schwann cell cytoplasm of unmyelinated fibers were faintly labelled. Endoneurial vessel endothelia, pericytes and perineurium failed to bind appreciable amounts of aldose reductase antibody. However, mast cell granules bound antibody strongly. In contrast, p-nitro-phenylphosphatase reaction product was detected in the nodal axolemma, terminal loops of Schwann cell cytoplasm and the innermost layer of perineurial cells. In endothelial cells, reaction product was localized on either the luminal or abluminal, or on both luminal and abluminal plasmalemma. Endothelial vesicular profiles were often loaded with reaction product. Occasional staining of myelin and axonal organelles was noted. Mast cells lacked reaction product.

Freeze-fracture observations on normal and abnormal human perineurial tight junctions: alterations in diabetic polyneuropathy

Perineurial cells in the human sural nerve possess tight junctions which in freeze-fracture replicas are seen to be composed of networks of branching and anastomosing P face strands and E face grooves. Isolated circular tight junctions (maculae occludentes) may represent attachment devices between adjacent perineurial lamellae. At the overlapping margins of the cells, a belt-like tight junction (zonula occludens) encircles the cells and is believed to comprise a paracellular diffusion barrier. As the permeability of the perineurium has been found to be altered in diabetic polyneuropathy, the zonulae occludentes have been studied. In freeze-fracture replicas from cases of diabetic polyneuropathy a mixed population of structurally normal and abnormal junctions was observed. In some, the strands were abnormally curved with reduced numbers of intersections, the intervening plasma membrane displaying prominent P face concavities and E face convexities. At other sites, the junctions were severely disorganized and represented by fragmented and isolated strands with few intersections and numerous free ends. These abnormalities resemble changes that have been produced experimentally in epithelial tight junctions by osmotic damage. The possibility is considered that similar mechanisms could result in the alterations of the perineurial tight junctions in diabetic polyneuropathy and account for its impaired permeability barrier properties.

Disruption of cellular elements and water in neurotoxicity: studies using electron probe X-ray microanalysis

Regulation of elements and water in nerve cells is a complex, multifaceted process which appears to be vulnerable to neurotoxic events. However, much of our knowledge concerning the potential role of elements in nerve cell injury is limited by the relatively gross level of corresponding analyses. If we are to confirm and understand the proposed role, more precise and detailed information is needed. As indicated in this commentary, research employing electron probe microanalysis and digital X-ray imaging has begun to provide this necessary information. Recent EPMA studies of nerve and glial cells in the peripheral and central nervous systems have shown that each cell type and their corresponding morphologic compartments exhibit unique distributions of elements and water. The use of microprobe analysis has allowed us to document precisely how elements and water redistribute in morphological compartments of damaged nerve cells. Accumulating evidence from EPMA studies suggests that, rather than being an epiphenomenon, intracellular changes in diffusible elements might mediate the functional and structural consequences of neurotoxic insult. It is also evident from this research that elements other than Ca might play a pertinent role in the injury response and that changes in intraneuronal elemental composition might develop according to a specific temporal pattern, e.g., transection-induced sequential alterations in axonal K, Na, Cl, and Ca. Therefore, rather than conducting end-point studies, longitudinal investigations are necessary to define the sequential pattern of elemental perturbation associated with a given neurotoxic event. Such research can also help identify the role of individual elements in the injury response. Future microprobe studies should be combined with measurements of ion levels (e.g., using fura-2 or ion selective electrodes) to provide a comprehensive and dynamic view of elemental deregulation. In addition, parallel biochemical studies should be performed to determine mechanisms of elemental disruption and possible biochemical and metabolic consequences of this disruption. Although evidence presented in this commentary suggests that each type of neurotoxic event produces a characteristic pattern of decompartmentalization, further work is necessary to confirm this possibility. Finally, based on a presumed involvement of elements in nerve injury, efforts are currently underway in several laboratories to develop appropriate pharmacological therapies for certain chemical- and trauma-induced neuropathological conditions (Dretchen et al., 1986; El-Fawal et al., 1989; Beattie et al., 1989).(ABSTRACT TRUNCATED AT 400 WORDS)

Developmental changes in blood-nerve transfer of albumin and endoneurial albumin content in rat sciatic nerve

The rate of entry of albumin into the endoneurial space and its content within that compartment during development were investigated by measuring the permeability coefficient-surface area product to 125I-albumin (PSA) of the blood-nerve interface (BNI), endoneurial residual plasma volume (Vp), blood-nerve interface index to albumin, and endoneurial water content in sciatic nerves of rats ranging in age from 1 to 24 weeks. There was a 30-fold reduction in PSA and a 4-fold decrease in Vp from 2 to 24 weeks, indicating that the endoneurial capillaries and perineurium become less permeable during development. On the other hand, the Alb-BNI index was relatively small at 1 week, increased to a peak value around 6-8 weeks, and then decreased to adult values by 13 weeks. The smaller Alb-BNI index in the neonatal period is consistent with endoneurial albumin being cleared across a permeable perineurium by epineurial lymphatics. Subsequently, as the perineurium becomes less permeable, endoneurial albumin content increases. It then decreases as the endoneurial capillary permeability also decreases. Additionally, metabolic clearance of albumin, especially during the first 2-3 weeks, by axons and glia to meet the nutritive requirements of rapid axonal growth and myelination could be partly responsible for a lower Alb-BNI index. It is suggested that in the developing nerve, the combination of epineurial lymphatics and a relatively permeable perineurium, together with axonal and glial uptake and protein catabolism aid in the clearance of plasma-derived osmolytes from the endoneurial space, and thus prevent the elevation of endoneurial hydrostatic pressure and onset of oedema that would have been seen in an adult nerve with a comparably permeable BNI.

Induction of aldose reductase expression in rat kidney mesangial cells and Chinese hamster ovary cells under hypertonic conditions

Rat kidney cortex mesangial cells (MES) and Chinese hamster ovary cells (CHO) responded to hypertonicity (600 mosmol/kg) in culture by accumulating sorbitol. The accumulation of sorbitol was due to increased aldose reductase (AR) activity, apparently brought about by increased levels of AR mRNA and protein. The levels of AR mRNA increased approximately 60-fold in MES cells and 30-fold in CHO cells by 24 h in culture media (300 mosmol/kg supplemented with 150 mM NaCl, 600 mosmol/kg total). AR activity also markedly increased (14- to 16-fold above control), but MES took 4 days and CHO 6 days to reach this maximum. Other osmolytes, raffinose and sorbitol (at concentrations of 250 to 300 mM) elicited the same response as that of 150 mM NaCl. These data show that AR expression is induced in MES and CHO cells under hypertonic conditions. Of special interest is the induction of large amounts of AR in rat kidney cortex mesangial cells, a target tissue of diabetes and a site where excessive accumulation of sorbitol is suspected to be a critical factor in diabetic nephropathy.

Role of the blood-nerve barrier in experimental nerve edema

Nerve edema is a common response to the nerve injury seen in many peripheral neuropathies and is an important component of Wallerian degeneration. However, independent pathologic effects of nerve edema that aggravate or induce nerve injury extend the role of edema beyond that of an epiphenomenon of injury. New insights into the mechanism and impact of nerve edema come largely from animal models. In the following review, we discuss the cause and consequences of nerve edema with particular reference to endoneurial fluid pressure and its relevance to the nerve microenvironment. Experimental models of nerve edema include conditions with increased vascular permeability such as lead poisoning, experimental allergic neuritis, and murine globoid leukodystrophy. Increased perineurial permeability induced by local anesthetics and neurolytic drugs can also induce nerve edema sufficient to increase endoneurial fluid pressure. Both perineurial and vascular permeability are increased after damage induced by crush, freeze, or laser injury. One of the most important forms of nerve edema is induced by external compression; the significance of this change is that edema has local compressive effects that persist after the external pressure has been relaxed. Nerve edema and increased endoneurial fluid pressure also occur in conditions in which vascular permeability appears to be unchanged such as experimental diabetic neuropathy and in hexachlorophene intoxication. In both of these conditions, reduced nerve blood flow has been demonstrated in rats and is viewed as a consequence of increased endoneurial fluid pressure. Whatever its mechanism, endoneurial edema has important structural and functional consequences for nerve fibers. A clear understanding of the underlying pathology of the nerve microenvironment may provide useful insights into treatment of clinical neuropathies.

Blood-nerve transfer of albumin and its implications for the endoneurial microenvironment

Blood-nerve transfer of plasma albumin was studied by measuring the permeability coefficient-surface area (PS) product of the blood-nerve barrier (BNB) to 125I-albumin in rat sciatic nerve using the i.v. bolus injection method. The calculated PS was 6.3 +/- 0.5 (S.E.M.) x 10(-7) ml.g-1.s-1. This value is smaller by more than an order of magnitude of that measured for sucrose and confirms the relative impermeance of the BNB to blood-borne solutes. From a review of the available evidence, it is concluded that normal blood-nerve exchange occurs predominantly across the endoneurial microvasculature, and the PS of the BNB reflects the permeability of capillaries to a greater extent than that of the perineurium. The only capillaries found to be less permeable than these are the cerebral capillaries. Proximo-distal differences (sciatic vs tibial) of the PS could not be detected. Blood-nerve albumin transfer was calculated at 1.2 mg.g-1.day-1, and the daily turnover of endoneurial albumin to be about 30%. It is postulated that small increases in PS of BNB to albumin lead to an elevation of endoneurial albumin concentration and, through the operation of Starling forces, subsequently produce endoneurial oedema. A major question posed by the results of this study is the identity of pathways for clearance of albumin and other macromolecules from the endoneurium.

Aldose reductase in the etiology of diabetic complications. 3. Neuropathy

Aldose reductase has been shown to be present in both autonomic and somatic nerves. Activation of this enzyme and the polyol pathway has been demonstrated in diabetic animal models to cause a range of biochemical, functional, and structural consequences that include the accumulation of sorbitol and fructose; axoglial dysjunction; paranodal demyelination; abnormalities in axonal transport, blood flow, and vascular permeability; and resistance to ischemic transmission of action potentials. These data provide an insight into the range of processes that if activated may either singly or in combination result in altered patterns of nerve function and structural alterations in diabetic neuropathy. In animal models of diabetes, it has been shown that inhibition of aldose reductase can modify these diabetes-induced changes. It is hoped that the results of large-scale controlled trials will provide clinical evidence to support these data.

Proximodistal gradient in endoneurial fluid pressure

Endoneurial fluid pressure measurements were made in the interstitial space of rat L5 dorsal root ganglia and in the corresponding sciatic nerves. Endoneurial fluid pressure was always higher in the ganglia than in the paired distal nerve. This proximodistal gradient in endoneurial fluid pressure may be the driving force responsible for the proximodistal convection of endoneurial fluid.

Dose-dependence of endoneurial fluid sodium and chloride accumulation in galactose intoxication

Endoneurial edema in galactose neuropathy was studied in a colony of Sprague-Dawley rats fed diets containing 0%, 10%, 20% or 40% D-galactose for approx. 200 days. Endoneurial fluid was analyzed by X-ray microanalysis for electrolyte concentration, by microgravimetry of whole nerve segments for water content, by measurement of endoneurial fluid pressure and by morphometry in transverse sections of nerve. Galactose intoxication resulted in dose-dependent increases in endoneurial fluid sodium and chloride that were directly associated with increases in nerve water content and endoneurial fluid pressure. The presence of edema and its dose-dependence was also confirmed by morphometric analysis of sciatic nerves at the light microscopic level. The data demonstrate that electrolyte-induced osmotic imbalances in endoneurial fluid are dependent on the amount of galactose ingested and suggest that the dose-related accumulation of sodium and chloride in endoneurial fluid contributes substantially to the pathogenesis of galactose neuropathy.

Ganglioside treatment of streptozotocin-diabetic rats prevents defective axonal transport of 6-phosphofructokinase activity

This study measured axonal transport of 6-phosphofructokinase (PFK) and aldolase activities in the sciatic nerves of rats with short-term streptozotocin-induced diabetes. The diabetic rats showed deficits in anterograde (69% of controls; p less than 0.001) and retrograde (33% of controls; p less than 0.01) accumulations of PFK activity as well as its content per unit length of unconstricted sciatic nerve (86% of controls; p less than 0.05). There were no accumulation deficits in aldolase activity in the nerves of the diabetic rats, although the activity per unit length of unconstricted nerve was deficient (81% of controls; p less than 0.05). Treatment of diabetic rats with mixed bovine brain gangliosides (10 mg/kg of body weight/day, i.p.) did not affect the deficit in PFK activity in unconstricted nerve (84% of ganglioside-treated controls; p less than 0.01), but all the other defects in enzyme activities were prevented completely. The diabetic rats also showed a reduction of 7% (p less than 0.01) in sciatic nerve dry weight per unit length, which was prevented by ganglioside treatment. In contrast, the reduced motor nerve conduction velocity, accumulation of polyol pathway metabolites, and depletion of myo-inositol, characteristic of untreated short-term diabetes, were unaffected by ganglioside treatment.

Perineurial sodium-potassium-ATPase activity in streptozotocin-diabetic rats

Perineurial sodium-potassium-ATPase activity was estimated in streptozotocin-diabetic rats and compared with that in control animals. Total ATPase activity was found to be reduced by 34% and ouabain-sensitive ATPase activity by 53%. This finding is significant in relation to the putative role of the perineurium as a metabolically active perifascicular diffusion barrier that regulates the composition of the endoneurial fluid, as is its possible relevance to the occurrence of endoneurial edema in diabetes.

Depletion of myo-inositol and amino acids in galactosemic neuropathy

A depletion of not only myo-inositol (MI) but also taurine and other amino acids was observed in the sciatic nerve of a galactosemic rat. Treatment of the galactosemic rats with sorbinil, an aldose reductase (AR) inhibitor, was found to block galactitol formation and protect against the loss of MI, taurine, and other amino acids. Incubation studies of sciatic nerve have revealed that [3H]MI and [3H]taurine were actively taken up and concentrated. Incubation of the nerve in a high-galactose medium showed a decrease in the accumulation of [3H]MI and [3H]taurine whereas the galactitol level increased. Time-course studies have shown that the galactitol level reached a plateau before a substantial decrease in the accumulation of [3H]MI and [3H]taurine occurred. The addition of AR inhibitors in the galactose medium significantly protected against the loss in the capacity of the nerve to accumulate [3H]MI and [3H]taurine. Hypertonicity of the galactose medium also seemed to have a protective effect similar to that of AR inhibitors.

Treatment with an aldose reductase inhibitor can reduce the susceptibility of fast axonal transport following nerve compression in the streptozotocin-diabetic rat

The effect of treatment with an aldose reductase inhibitor on the susceptibility of peripheral nerves to compression was studied in rats made diabetic by the injection of streptozotocin (50 mg.kg-1). The response to nerve compression was determined in untreated diabetic rats after 22 days of diabetes and compared with the response in two similar groups of diabetic rats which had been treated with the aldose reductase inhibitor 'Statil' (ICI 128436; 25 mg.kg-1.day-1 orally) either from the induction of diabetes or for 7 days prior to nerve compression. Two groups of non-diabetic rats were treated with 'Statil' for either 22 days or 7 days to act as controls. Inhibition of fast axonally transported proteins was induced by local compression of the sciatic nerves 4 h after application of 3H-leucine to the motor neurone cell bodies in the spinal cord. The inhibition of fast axonal transport was quantified by calculation of a transport block ratio. Compression at 30 mmHg for 3 h induced a significantly greater (p less than 0.05) inhibition of axonal transport at the site of compression in nerves of untreated diabetic rats (transport block ratio 0.96 +/- 0.24, n = 8) than in nerves of control rats treated with the aldose reductase inhibitor for either the shorter time of 7 days (0.71 +/- 0.17, n = 10) or the longer time of 22 days (0.69 +/- 0.08, n = 5).(ABSTRACT TRUNCATED AT 250 WORDS)

Opposite effects of diabetes and galactosaemia on adenosine triphosphatase activity in rat nervous tissue

This study measured the ouabain-sensitive adenosine triphosphatase activity in sciatic nerve, lumbar dorsal root ganglia and superior cervical ganglia from control rats, rats with 8 weeks streptozotocin-induced diabetes and rats fed a diet containing 20% galactose for 8 weeks. Whilst the sciatic nerves of the diabetic rats showed a 42% reduction in ouabain-sensitive adenosine triphosphatase activity, the galactose-fed rats showed an increase of 124% (p less than 0.01 and p less than 0.005, respectively, compared to controls). There was also a reduction (by 30% compared to controls; p less than 0.05) in the ouabain-sensitive adenosine triphosphatase activity of the dorsal root ganglia from the diabetic rats, but their superior cervical ganglia did not show a significant fall. The ganglia of the galactosaemic rats showed no change in ouabain-sensitive adenosine triphosphatase activity compared to controls. These changes coexisted with increases in appropriate polyol pathway metabolites in all tissues of both diabetic and galactosaemic rats. There were also depletions of myo-inositol in the sciatic nerves and dorsal root ganglia of diabetic and galactosaemic rats, but their superior cervical ganglia contained levels of myo-inositol which were similar to those of controls. The nerves of the galactosaemic rats showed increased water content; the nerves of the diabetic rats did not. The data argue against a simple relationship between myo-inositol depletion and impaired Na/K adenosine triphosphatase activity in association with exaggerated polyol pathway flux in peripheral nervous tissue.