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Ream RS, Li Y, Marklin GF. Circulating Levels of Vitamins A, C, and E-Alpha in Organ Donors After the Neurologic Determination of Death. Prog Transplant 2024:15269248241288561. [PMID: 39380414 DOI: 10.1177/15269248241288561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2024]
Abstract
INTRODUCTION The antioxidant effects of vitamins may attenuate the oxidative stress on organs imposed by ischemia-reperfusion injury during the process of organ transplantation from brain-dead donors. Circulating levels of vitamins A, C, and E-α in donors after brain death and their relationships to donor demographics, management, organ utilization, and recipient outcomes are largely unknown. METHODS An observational, prospective, cohort study of 84 consecutive brain-dead organ donors managed at a single organ procurement recovery center was conducted. Vitamin levels were drawn immediately prior to procurement. RESULTS Levels of serum vitamins A and E-α and plasma vitamin C were below normal in 80%, 85%, and 92% of donors and deficient in 40%, 62%, and 63%, respectively. Vitamin C deficiency was associated with a longer time between death and specimen collection (P = .004). Death from head trauma and stroke were associated with lower levels of vitamin A than from anoxic causes (P = .003) and smokers had greater vitamin C deficiency (P = .03). During donor management, vitamin C deficiency was associated with longer vasopressor support (P = .03) and normal levels of vitamin E-α were associated with reaching a lower alanine transferase compared to those with subnormal levels (P < .05). Donors deficient in vitamin E-α were less likely to have a liver recovered for transplantation (P = .005). Vitamin levels were not associated with the recipient outcomes examined. CONCLUSION Circulating vitamins A, C, and E-α is profoundly low in brain-dead organ donors, associated with relevant demographic features of the donor, and may influence donor management and organ utilization.
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Affiliation(s)
- Robert S Ream
- Department of Pediatric Critical Care, St Louis University, St. Louis, MO, USA
| | - Yi Li
- Department of Nutrition and Dietetics, Doisy College of Health Sciences, St Louis University, St. Louis, MO, USA
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Guo S, Li Z, Liu Y, Cheng Y, Jia D. Ferroptosis: a new target for hepatic ischemia-reperfusion injury? Free Radic Res 2024; 58:396-416. [PMID: 39068663 DOI: 10.1080/10715762.2024.2386075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 06/20/2024] [Accepted: 06/21/2024] [Indexed: 07/30/2024]
Abstract
Ischemia-reperfusion injury (IRI) can seriously affect graft survival and prognosis and is an unavoidable event during liver transplantation. Ferroptosis is a novel iron-dependent form of cell death characterized by iron accumulation and overwhelming lipid peroxidation; it differs morphologically, genetically, and biochemically from other well-known cell death types (autophagy, necrosis, and apoptosis). Accumulating evidence has shown that ferroptosis is involved in the pathogenesis of hepatic IRI, and targeting ferroptosis may be a promising therapeutic approach. Here, we review the pathways and phenomena involved in ferroptosis, explore the associations and implications of ferroptosis and hepatic IRI, and discuss possible strategies for modulating ferroptosis to alleviate the hepatic IRI.
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Affiliation(s)
- Shanshan Guo
- Department of Nephropathy, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zexin Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xinxiang Medical University, Weihui, China
| | - Yi Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xinxiang Medical University, Weihui, China
| | - Ying Cheng
- Department of Organ Transplantation, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Degong Jia
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xinxiang Medical University, Weihui, China
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Jiang W, Brown KGM, Koh C, Karunaratne S, Solomon M, Beckenkamp PR, Cole R, Steffens D. Outcome Heterogeneity in Prehabilitation Trials-Are We Comparing Apples and Oranges? J Surg Res 2024; 296:366-375. [PMID: 38306943 DOI: 10.1016/j.jss.2023.12.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/11/2023] [Accepted: 12/29/2023] [Indexed: 02/04/2024]
Abstract
INTRODUCTION Over the last decade, the number of prehabilitation randomised controlled trials (RCTs) has increased significantly. Therefore, this review aimed to describe the outcomes reported in prehabilitation RCTs in patients undergoing cancer surgery. METHODS A search was conducted in Embase, Allied and Complementary Medicine Database, The Cochrane Library, PsycINFO, MEDLINE, and Cumulated Index to Nursing and Allied Health Literature from inception to July 2021. We included RCTs evaluating the effectiveness of preoperative exercise, nutrition, and psychological interventions on postoperative complications and length of hospital stay in adult oncology patients who underwent thoracic and gastrointestinal cancer surgery. The verbatim outcomes reported in each article were extracted, and each outcome was assessed to determine whether it was defined and measured using a validated tool. Verbatim outcomes were grouped into standardized outcomes and categorized into domains. The quality of outcome reporting in each identified article was assessed using the Harman tool (score range 0-6, where 0 indicated the poorest quality). RESULTS A total of 74 RCTs were included, from which 601 verbatim outcomes were extracted. Only 110 (18.3%) of the verbatim outcomes were defined and 270 (44.9%) were labeled as either "primary" or "secondary" outcomes. Verbatim outcomes were categorized into 119 standardized outcomes and assigned into one of five domains (patient-reported outcomes, surgical outcomes, physical/functional outcomes, disease activity, and intervention delivery). Surgical outcomes were the most common outcomes reported (n = 71 trials, 95.9%). The overall quality of the reported outcomes was poor across trials (median score: 2.0 [IQR = 0.00-3.75]). CONCLUSIONS Prehabilitation RCTs display considerable heterogeneity in outcome reporting, and low outcome reporting quality. The development of standardized core outcome sets may help improve article quality and enhance the clinical utility of prehabilitation following cancer surgery.
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Affiliation(s)
- Wilson Jiang
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia
| | - Kilian G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; Department of Colorectal Surgery, Camperdown, NSW, Australia
| | - Cherry Koh
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; Department of Colorectal Surgery, Camperdown, NSW, Australia; Institute of Academic Surgery (IAS), Camperdown, NSW, Australia
| | - Sascha Karunaratne
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; Institute of Academic Surgery (IAS), Camperdown, NSW, Australia
| | - Michael Solomon
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; Department of Colorectal Surgery, Camperdown, NSW, Australia; Institute of Academic Surgery (IAS), Camperdown, NSW, Australia
| | - Paula R Beckenkamp
- Faculty of Medicine and Health, Discipline of Physiotherapy, The University of Sydney, Camperdown, NSW, Australia
| | - Ruby Cole
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; Institute of Academic Surgery (IAS), Camperdown, NSW, Australia.
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Lu X, Wang Z, Chen L, Wei X, Ma Y, Tu Y. Efficacy and safety of selenium or vitamin E administration alone or in combination in ICU patients: A systematic review and meta-analysis. Clin Nutr ESPEN 2023; 57:550-560. [PMID: 37739705 DOI: 10.1016/j.clnesp.2023.07.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/25/2023] [Accepted: 07/29/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Micronutrient administration that contributes to antioxidant defense has been extensively studied in critically ill patients, but consensus remains elusive. Selenium and vitamin E are two important micronutrients that have synergistic antioxidant effects. This meta-analysis aimed to assess the effect of selenium or vitamin E administration alone and the combination of both on clinical outcomes in patients hospitalized in the ICU. METHODS After electronic searches on PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), SinoMed, VIP database and Wanfang data, initially 1767 papers were found, and 30 interventional studies were included in this analysis. We assessed the risk-difference between treatment and control (standard treatment) groups by pooling available data on length of stay (ICU length of stay and hospital length of stay), mortality (ICU mortality, hospital mortality, 28-day mortality, 6-month mortality and all-cause mortality), duration of mechanical ventilation, adverse events and new infections. RESULTS By analyzing the included studies, we found no significant effect of selenium administration alone on mortality, mechanical ventilation duration, or adverse events in ICU patients. However, after excluding studies with high heterogeneity, the meta-analysis showed that selenium alone reduced the length of hospital stay (MD: -1.38; 95% CI: -2.52, -0.23; I-square: 0%). Vitamin E administration alone had no significant effect on mortality, duration of mechanical ventilation, or adverse events in ICU patients. However, after excluding studies with high heterogeneity, the meta-analysis showed that vitamin E alone could reduce the length of ICU stay (MD: -1.27; 95% CI: -1.86, -0.67; I-square: 16%). Combined administration of selenium and vitamin E had no significant effect on primary outcomes in ICU patients. CONCLUSIONS Selenium administration alone may shorten the length of hospital stay, while vitamin E alone may reduce the length of ICU stay. The putative synergistic beneficial effect of combined administration of selenium and vitamin E in ICU patients has not been observed, but more clinical studies are pending to confirm it further.
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Affiliation(s)
- Xin Lu
- Department of Pharmacy, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai 200092, China; Department of Critical Care Medicine, School of Anesthesiology, Naval Medical University, Shanghai 200433, China
| | - Zhibin Wang
- Department of Pharmacy, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai 200092, China; Department of Critical Care Medicine, School of Anesthesiology, Naval Medical University, Shanghai 200433, China
| | - Linlin Chen
- Department of Critical Care Medicine, School of Anesthesiology, Naval Medical University, Shanghai 200433, China
| | - Xin Wei
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yabin Ma
- Department of Pharmacy, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai 200092, China.
| | - Ye Tu
- Department of Pharmacy, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai 200092, China.
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Meurisse N, Mertens M, Fieuws S, Gilbo N, Jochmans I, Pirenne J, Monbaliu D. Effect of a Combined Drug Approach on the Severity of Ischemia-Reperfusion Injury During Liver Transplant: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e230819. [PMID: 36853611 PMCID: PMC9975910 DOI: 10.1001/jamanetworkopen.2023.0819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
IMPORTANCE In a porcine model of liver transplant, a combined drug approach that targeted the donor graft and graft recipient reduced ischemia-reperfusion injury, a major hurdle to the success of liver transplant. OBJECTIVE To assess the effect of a clinical form of a perioperative combined drug approach delivered immediately before implantation to the procured liver and to the liver recipient on the degree of ischemia-reperfusion injury. DESIGN, SETTING, AND PARTICIPANTS This unicentric, investigator-driven, open-label randomized clinical trial with 2 parallel arms was conducted in Belgium from September 2013 through February 2018, with 1-year follow-up. Adults wait-listed for a first solitary full-size liver transplant were screened for eligibility. Exclusion criteria were acute liver failure, kidney failure, contraindication to treatment, participation in another trial, refusal, technical issues, and death while awaiting transplant. Included patients were enrolled and randomized at the time of liver offer. Data were analyzed from May 20, 2019, to May 27, 2020. INTERVENTIONS Participants were randomized to a combined drug approach with standard of care (static cold storage) or standard of care only (control group). In the combined drug approach group, following static cold preservation, donor livers were infused with epoprostenol (ex situ, portal vein); recipients were given oral α-tocopherol and melatonin prior to anesthesia and intravenous antithrombin III, infliximab, apotransferrin, recombinant erythropoietin-β, C1-inhibitor, and glutathione during the anhepatic and reperfusion phase. MAIN OUTCOMES AND MEASURES The primary outcome was the posttransplant peak serum aspartate aminotransferase (AST) level within the first 72 hours. Secondary end points were the frequencies of postreperfusion syndrome, ischemia-reperfusion injury score, early allograft dysfunction, surgical complications, ischemic cholangiopathy, acute kidney injury, acute cellular rejection, and graft and patient survival. RESULTS Of 93 randomized patients, 21 were excluded, resulting in 72 patients (36 per study arm) in the per protocol analysis (median recipient age, 60 years [IQR, 51.7-66.2 years]; 52 [72.2%] men). Peak AST serum levels were not different in the combined drug approach and control groups (geometric mean, 1262.9 U/L [95% CI, 946.3-1685.4 U/L] vs 1451.2 U/L [95% CI, 1087.4-1936.7 U/L]; geometric mean ratio, 0.87 [95% CI, 0.58-1.31]; P = .49) (to convert AST to μkat/L, multiply by 0.0167). There also were no significant differences in the secondary end points between the groups. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, the combined drug approach targeting the post-cold storage graft and the recipient did not decrease ischemic-reperfusion injury. The findings suggest that in addition to a downstream strategy that targets the preimplantation liver graft and the graft recipient, a clinically effective combined drug approach may need to include an upstream strategy that targets the donor graft during preservation. Dynamic preservation strategies may provide an appropriate delivery platform. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02251041.
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Affiliation(s)
- Nicolas Meurisse
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
- Department of Abdominal Surgery and Transplantation, CHU de Liège, University of Liège, Liège, Belgium
| | - Markoen Mertens
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Steffen Fieuws
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, KU Leuven—University of Leuven, Leuven, Belgium
| | - Nicholas Gilbo
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Ina Jochmans
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Jacques Pirenne
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
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Gao F, Qiu X, Wang K, Shao C, Jin W, Zhang Z, Xu X. Targeting the Hepatic Microenvironment to Improve Ischemia/Reperfusion Injury: New Insights into the Immune and Metabolic Compartments. Aging Dis 2022; 13:1196-1214. [PMID: 35855339 PMCID: PMC9286916 DOI: 10.14336/ad.2022.0109] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 01/09/2022] [Indexed: 12/12/2022] Open
Abstract
Hepatic ischemia/reperfusion injury (IRI) is mainly characterized by high activation of immune inflammatory responses and metabolic responses. Understanding the molecular and metabolic mechanisms underlying development of hepatic IRI is critical for developing effective therapies for hepatic IRI. Recent advances in research have improved our understanding of the pathogenesis of IRI. During IRI, hepatocyte injury and inflammatory responses are mediated by crosstalk between the immune cells and metabolic components. This crosstalk can be targeted to treat or reverse hepatic IRI. Thus, a deep understanding of hepatic microenvironment, especially the immune and metabolic responses, can reveal new therapeutic opportunities for hepatic IRI. In this review, we describe important cells in the liver microenvironment (especially non-parenchymal cells) that regulate immune inflammatory responses. The role of metabolic components in the diagnosis and prevention of hepatic IRI are discussed. Furthermore, recent updated therapeutic strategies based on the hepatic microenvironment, including immune cells and metabolic components, are highlighted.
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Affiliation(s)
- Fengqiang Gao
- 1Department of Hepatobiliary and Pancreatic Surgery, The Center for Integrated Oncology and Precision Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,6Zhejiang University School of Medicine, Hangzhou, China
| | - Xun Qiu
- 1Department of Hepatobiliary and Pancreatic Surgery, The Center for Integrated Oncology and Precision Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,6Zhejiang University School of Medicine, Hangzhou, China
| | - Kai Wang
- 1Department of Hepatobiliary and Pancreatic Surgery, The Center for Integrated Oncology and Precision Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chuxiao Shao
- 7Department of Hepatobiliary and Pancreatic Surgery, Affiliated Lishui Hospital, Zhejiang University School of Medicine, Lishui, China
| | - Wenjian Jin
- 8Department of Hepatobiliary Surgery, the Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Zhen Zhang
- 6Zhejiang University School of Medicine, Hangzhou, China
| | - Xiao Xu
- 1Department of Hepatobiliary and Pancreatic Surgery, The Center for Integrated Oncology and Precision Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,2Zhejiang University Cancer Center, Hangzhou, China.,3Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,4NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou, China.,5Institute of Organ Transplantation, Zhejiang University, Hangzhou, China
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Guan Y, Yao W, Yi K, Zheng C, Lv S, Tao Y, Hei Z, Li M. Nanotheranostics for the Management of Hepatic Ischemia-Reperfusion Injury. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2021; 17:e2007727. [PMID: 33852769 DOI: 10.1002/smll.202007727] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/21/2021] [Indexed: 06/12/2023]
Abstract
Hepatic ischemia-reperfusion injury (IRI), in which an insufficient oxygen supply followed by reperfusion leads to an inflammatory network and oxidative stress in disease tissue to cause cell death, always occurs after liver transplantations and sections. Although pharmacological treatments favorably prevent or protect the liver against experimental IRI, there have been few successes in clinical applications for patient benefits because of the incomprehension of complicated IRI-induced signaling events as well as short blood circulation time, poor solubility, and severe side reactions of most antioxidants and anti-inflammatory drugs. Nanomaterials can achieve targeted delivery and controllable release of contrast agents and therapeutic drugs in desired hepatic IRI regions for enhanced imaging sensitivity and improved therapeutic effects, emerging as novel alternative approaches for hepatic IRI diagnosis and therapy. In this review, the application of nanotechnology is summarized in the management of hepatic IRI, including nanomaterial-assisted hepatic IRI diagnosis, nanoparticulate systems-mediated remission of reactive oxygen species-induced tissue injury, and nanoparticle-based targeted drug delivery systems for the alleviation of IRI-related inflammation. The current challenges and future perspectives of these nanoenabled strategies for hepatic IRI treatment are also discussed.
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Affiliation(s)
- Yu Guan
- Laboratory of Biomaterials and Translational Medicine, Center for Nanomedicine, Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510630, China
| | - Weifeng Yao
- Laboratory of Biomaterials and Translational Medicine, Center for Nanomedicine, Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510630, China
| | - Ke Yi
- Laboratory of Biomaterials and Translational Medicine, Center for Nanomedicine, Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510630, China
| | - Chunxiong Zheng
- Laboratory of Biomaterials and Translational Medicine, Center for Nanomedicine, Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510630, China
- Guangdong Provincial Key Laboratory of Liver Disease Research, Guangzhou, 510630, China
| | - Shixian Lv
- Department of Bioengineering, University of Washington, Seattle, WA, 98195, USA
| | - Yu Tao
- Laboratory of Biomaterials and Translational Medicine, Center for Nanomedicine, Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510630, China
- Guangdong Provincial Key Laboratory of Liver Disease Research, Guangzhou, 510630, China
| | - Ziqing Hei
- Laboratory of Biomaterials and Translational Medicine, Center for Nanomedicine, Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510630, China
| | - Mingqiang Li
- Laboratory of Biomaterials and Translational Medicine, Center for Nanomedicine, Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510630, China
- Guangdong Provincial Key Laboratory of Liver Disease Research, Guangzhou, 510630, China
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Violet PC, Ebenuwa IC, Wang Y, Niyyati M, Padayatty SJ, Head B, Wilkins K, Chung S, Thakur V, Ulatowski L, Atkinson J, Ghelfi M, Smith S, Tu H, Bobe G, Liu CY, Herion DW, Shamburek RD, Manor D, Traber MG, Levine M. Vitamin E sequestration by liver fat in humans. JCI Insight 2020; 5:133309. [PMID: 31821172 PMCID: PMC7030816 DOI: 10.1172/jci.insight.133309] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/26/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUNDWe hypothesized that obesity-associated hepatosteatosis is a pathophysiological chemical depot for fat-soluble vitamins and altered normal physiology. Using α-tocopherol (vitamin E) as a model vitamin, pharmacokinetics and kinetics principles were used to determine whether excess liver fat sequestered α-tocopherol in women with obesity-associated hepatosteatosis versus healthy controls.METHODSCustom-synthesized deuterated α-tocopherols (d3- and d6-α-tocopherols) were administered to hospitalized healthy women and women with hepatosteatosis under investigational new drug guidelines. Fluorescently labeled α-tocopherol was custom-synthesized for cell studies.RESULTSIn healthy subjects, 85% of intravenous d6-α-tocopherol disappeared from the circulation within 20 minutes but reappeared within minutes and peaked at 3-4 hours; d3- and d6-α-tocopherols localized to lipoproteins. Lipoprotein redistribution occurred only in vivo within 1 hour, indicating a key role of the liver in uptake and re-release. Compared with healthy subjects who received 2 mg, subjects with hepatosteatosis had similar d6-α-tocopherol entry rates into liver but reduced initial release rates (P < 0.001). Similarly, pharmacokinetics parameters were reduced in hepatosteatosis subjects, indicating reduced hepatic d6-α-tocopherol output. Reductions in kinetics and pharmacokinetics parameters in hepatosteatosis subjects who received 2 mg were echoed by similar reductions in healthy subjects when comparing 5- and 2-mg doses. In vitro, fluorescent-labeled α-tocopherol localized to lipid in fat-loaded hepatocytes, indicating sequestration.CONCLUSIONSThe unique role of the liver in vitamin E physiology is dysregulated by excess liver fat. Obesity-associated hepatosteatosis may produce unrecognized hepatic vitamin E sequestration, which might subsequently drive liver disease. Our findings raise the possibility that hepatosteatosis may similarly alter hepatic physiology of other fat-soluble vitamins.TRIAL REGISTRATIONClinicalTrials.gov, NCT00862433.FUNDINGNational Institute of Diabetes and Digestive and Kidney Diseases and NIH grants DK053213-13, DK067494, and DK081761.
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Affiliation(s)
- Pierre-Christian Violet
- Molecular and Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - Ifechukwude C. Ebenuwa
- Molecular and Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - Yu Wang
- Molecular and Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - Mahtab Niyyati
- Molecular and Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - Sebastian J. Padayatty
- Molecular and Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - Brian Head
- Linus Pauling Institute, Oregon State University, Corvallis, Oregon, USA
| | - Kenneth Wilkins
- Office of the Director, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - Stacey Chung
- Department of Pharmacology and Department of Nutrition, School of Medicine, Case Western Reserve University and the Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Varsha Thakur
- Department of Pharmacology and Department of Nutrition, School of Medicine, Case Western Reserve University and the Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Lynn Ulatowski
- Department of Pharmacology and Department of Nutrition, School of Medicine, Case Western Reserve University and the Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Jeffrey Atkinson
- Department of Chemistry, Brock University, Saint Catharines, Ontario, Canada
| | - Mikel Ghelfi
- Department of Chemistry, Brock University, Saint Catharines, Ontario, Canada
| | - Sheila Smith
- Molecular and Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - Hongbin Tu
- Molecular and Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - Gerd Bobe
- Linus Pauling Institute, Oregon State University, Corvallis, Oregon, USA
| | | | - David W. Herion
- Clinical Research Informatics, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Robert D. Shamburek
- Cardiovascular Branch, Intramural Research Program, National Heart, Lung, and Blood Institute, NIH, Bethesda, Maryland, USA
| | - Danny Manor
- Department of Pharmacology and Department of Nutrition, School of Medicine, Case Western Reserve University and the Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Maret G. Traber
- Linus Pauling Institute, Oregon State University, Corvallis, Oregon, USA
| | - Mark Levine
- Molecular and Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
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Yang L, Zhang Z, Kong J, Wang W. Systematic Review and Meta-Analysis of the Benefit and Safety of Preoperative Administration of Steroid in Patients Undergoing Liver Resection. Front Pharmacol 2019; 10:1442. [PMID: 31849683 PMCID: PMC6894012 DOI: 10.3389/fphar.2019.01442] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 11/12/2019] [Indexed: 02/05/2023] Open
Abstract
Objective: To evaluate the benefit and safety of preoperative administration of steroid in patients undergoing liver resection. Methods: Randomized controlled trials (RCTs) which comparing preoperative administration of steroid in patients undergoing liver resection with control group were identified through a systematic literature search in PubMed, Embase, and Cochrane Library Central databases. This meta-analysis was carried out to assess the liver function, inflammatory response, and postoperative complications after liver surgery. Results: Six RCTs including 411 patients were reviewed. The pooled result showed that there was no significant difference in the incidence of overall complications between the steroid group and the control group (OR, 0.57; 95% CI, 0.27–1.17; P = 0.13). With respect to specific complications, no significant difference was detected between the two groups in infection complications (OR, 0.95; 95% CI, 0.13–6.95; P = 0.96), wound complications (OR, 0.65; 95% CI, 0.32–1.33; P = 0.24), liver failure (OR, 0.41; 95% CI, 0.10–1.64; P = 0.21), bile leakage (OR, 0.57; 95% CI, 0.17–1.89; P = 0.36), and pleural effusion (OR, 1.24; 95% CI, 0.55–2.78; P = 0.60). For liver function, the level of serum total bilirubin (TB) on postoperative day 1 (POD 1) was significantly decreased associated with the intervention of steroid (MD, −0.54; 95% CI, −0.94 to −0.15; P = 0.007). However, no significant difference was found in the level of alanine aminotransferase (ALT) (MD, −69.39; 95% CI, −226.52 to 87.75; P = 0.39) and aspartate aminotransferase (AST) (MD, −93.44; 95% CI, −275.68 to 88.80; P = 0.31) on POD 1 between the two groups. Serum IL-6 level on POD 1 (MD, −57.98; 95% CI, −73.04 to −42.91; P < 0.00001) and CRP level on POD 3 (MD, −4.83; 95% CI, −6.07 to −3.59; P < 0.00001) were significantly reduced in the steroid group comparing to the control group. Compared with the control group, the level of early postoperative IL-10 was significant higher in the steroid group (MD, 17.89; 95% CI, 3.89 to 31.89; P = 0.01). Conclusion: Preoperative administration of steroid in liver resection can promote the recovery of liver function and inhibit the inflammatory response without increasing postoperative complications. Further studies should focus on determining which patients would benefit most from the steroid.
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Affiliation(s)
- Lingpeng Yang
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, China
| | - Zifei Zhang
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, China.,Department of General Surgery, The Affiliated Hospital of Xizang Minzu University, Xianyang, China
| | - Junjie Kong
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, China
| | - Wentao Wang
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, China
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10
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Traber MG, Leonard SW, Ebenuwa I, Violet PC, Wang Y, Niyyati M, Padayatty S, Tu H, Courville A, Bernstein S, Choi J, Shamburek R, Smith S, Head B, Bobe G, Ramakrishnan R, Levine M. Vitamin E absorption and kinetics in healthy women, as modulated by food and by fat, studied using 2 deuterium-labeled α-tocopherols in a 3-phase crossover design. Am J Clin Nutr 2019; 110:1148-1167. [PMID: 31495886 PMCID: PMC6821549 DOI: 10.1093/ajcn/nqz172] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/05/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Determining the human vitamin E [α-tocopherol (α-T)] requirement is difficult, and novel approaches to assess α-T absorption and trafficking are needed. OBJECTIVE We hypothesized that the dual-isotope technique, using 2 deuterium-labeled [intravenous (IV) d6- and oral d3-] α-T, would be effective in determining α-T fractional absorption. Further, defined liquid meal (DLM) fat or fasting would modulate α-T fractional absorption and lipoprotein transport. METHODS A 3-phase cr ossover design was used. At 0 h, participants received IV d6-α-T and consumed d3-α-T with a 600-kcal DLM (40% or 0% fat) followed by controlled meals or by the 0% fat DLM, a 12-h fast, and then controlled meals. Blood samples and fecal samples were collected at intervals and analyzed by LC-MS. Pharmacokinetic parameters were calculated from plasma tracer concentrations and enrichments. Fractional absorption was calculated from d3- to d6-α-T areas under the curve, from a novel mathematical model, and from the balance method (oral d3-α-T minus fecal d3-α-T excreted). RESULTS Estimated α-T fractional absorption during the 40% fat intervention was 55% ± 3% (mean ± SEM; n = 10), which was 9% less than during the 0% fat intervention (64% ± 3%, n = 10; P < 0.02). Fasting had no apparent effect (56% ± 3%, n = 7), except it slowed plasma oral d3-α-T appearance. Both balance data and model outcomes confirmed that the DLM fat did not potentiate d3-α-T absorption. During the IV emulsion clearance, HDL rapidly acquired d6-α-T (21 ± 2 nmol/L plasma per minute). During the first 8 h postdosing, triglyceride-rich lipoproteins (TRLs) were preferentially d3-α-T enriched relative to LDL or HDL, showing the TRL precursor role. CONCLUSIONS Quantitatively, α-T absorption is not limited by fat absence or by fasting. However, α-T leaves the intestine by a process that is prolonged during fasting and potentiated by eating, suggesting that α-T absorption is highly dependent on chylomicron assembly processes. This trial was registered at clinicaltrials.gov as NCT00862433.
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Affiliation(s)
- Maret G Traber
- Linus Pauling Institute, Oregon State University, Corvallis, OR, USA,School of Biological and Population Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA,Address correspondence to MGT (e-mail: )
| | - Scott W Leonard
- Linus Pauling Institute, Oregon State University, Corvallis, OR, USA
| | - Ifechukwude Ebenuwa
- Molecular and Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Pierre-Christian Violet
- Molecular and Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Yu Wang
- Molecular and Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Mahtab Niyyati
- Molecular and Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Sebastian Padayatty
- Molecular and Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Hongbin Tu
- Molecular and Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Amber Courville
- Clinical Center Nutrition Department, Oregon State University, Corvallis, OR, USA
| | - Shanna Bernstein
- Clinical Center Nutrition Department, Oregon State University, Corvallis, OR, USA
| | - Jaewoo Choi
- Linus Pauling Institute, Oregon State University, Corvallis, OR, USA
| | - Robert Shamburek
- Cardiovascular Branch, Intramural Research Program, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Sheila Smith
- Molecular and Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Brian Head
- Linus Pauling Institute, Oregon State University, Corvallis, OR, USA
| | - Gerd Bobe
- Linus Pauling Institute, Oregon State University, Corvallis, OR, USA
| | - Rajasekhar Ramakrishnan
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Mark Levine
- Molecular and Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
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11
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Propofol intravenous anaesthesia with desflurane compared with desflurane alone on postoperative liver function after living-donor liver transplantation. Eur J Anaesthesiol 2019; 36:656-666. [DOI: 10.1097/eja.0000000000001018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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12
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Elke G, Hartl WH, Kreymann KG, Adolph M, Felbinger TW, Graf T, de Heer G, Heller AR, Kampa U, Mayer K, Muhl E, Niemann B, Rümelin A, Steiner S, Stoppe C, Weimann A, Bischoff SC. Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM). Clin Nutr ESPEN 2019; 33:220-275. [PMID: 31451265 DOI: 10.1016/j.clnesp.2019.05.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. METHODS The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process. RESULTS In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices. CONCLUSION The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).
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Affiliation(s)
- Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 12, 24105, Kiel, Germany.
| | - Wolfgang H Hartl
- Department of Surgery, University School of Medicine, Grosshadern Campus, Ludwig-Maximilian University, Marchioninistr. 15, 81377 Munich, Germany.
| | | | - Michael Adolph
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany.
| | - Thomas W Felbinger
- Department of Anesthesiology, Critical Care and Pain Medicine, Neuperlach and Harlaching Medical Center, The Munich Municipal Hospitals Ltd, Oskar-Maria-Graf-Ring 51, 81737, Munich, Germany.
| | - Tobias Graf
- Medical Clinic II, University Heart Center Lübeck, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Geraldine de Heer
- Center for Anesthesiology and Intensive Care Medicine, Clinic for Intensive Care Medicine, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Axel R Heller
- Clinic for Anesthesiology and Surgical Intensive Care Medicine, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany.
| | - Ulrich Kampa
- Clinic for Anesthesiology, Lutheran Hospital Hattingen, Bredenscheider Strasse 54, 45525, Hattingen, Germany.
| | - Konstantin Mayer
- Department of Internal Medicine, Justus-Liebig University Giessen, University of Giessen and Marburg Lung Center, Klinikstr. 36, 35392, Gießen, Germany.
| | - Elke Muhl
- Eichhörnchenweg 7, 23627, Gross Grönau, Germany.
| | - Bernd Niemann
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Rudolf-Buchheim-Str. 7, 35392, Gießen, Germany.
| | - Andreas Rümelin
- Clinic for Anesthesia and Surgical Intensive Care Medicine, HELIOS St. Elisabeth Hospital Bad Kissingen, Kissinger Straße 150, 97688, Bad Kissingen, Germany.
| | - Stephan Steiner
- Department of Cardiology, Pneumology and Intensive Care Medicine, St Vincenz Hospital Limburg, Auf dem Schafsberg, 65549, Limburg, Germany.
| | - Christian Stoppe
- Department of Intensive Care Medicine and Intermediate Care, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, Klinikum St. Georg, Delitzscher Straße 141, 04129, Leipzig, Germany.
| | - Stephan C Bischoff
- Department for Nutritional Medicine, University of Hohenheim, Fruwirthstr. 12, 70599, Stuttgart, Germany.
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13
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Oliva-Vilarnau N, Hankeova S, Vorrink SU, Mkrtchian S, Andersson ER, Lauschke VM. Calcium Signaling in Liver Injury and Regeneration. Front Med (Lausanne) 2018; 5:192. [PMID: 30023358 PMCID: PMC6039545 DOI: 10.3389/fmed.2018.00192] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 06/11/2018] [Indexed: 12/12/2022] Open
Abstract
The liver fulfills central roles in metabolic control and detoxification and, as such, is continuously exposed to a plethora of insults. Importantly, the liver has a unique ability to regenerate and can completely recoup from most acute, non-iterative insults. However, multiple conditions, including viral hepatitis, non-alcoholic fatty liver disease (NAFLD), long-term alcohol abuse and chronic use of certain medications, can cause persistent injury in which the regenerative capacity eventually becomes dysfunctional, resulting in hepatic scaring and cirrhosis. Calcium is a versatile secondary messenger that regulates multiple hepatic functions, including lipid and carbohydrate metabolism, as well as bile secretion and choleresis. Accordingly, dysregulation of calcium signaling is a hallmark of both acute and chronic liver diseases. In addition, recent research implicates calcium transients as essential components of liver regeneration. In this review, we provide a comprehensive overview of the role of calcium signaling in liver health and disease and discuss the importance of calcium in the orchestration of the ensuing regenerative response. Furthermore, we highlight similarities and differences in spatiotemporal calcium regulation between liver insults of different etiologies. Finally, we discuss intracellular calcium control as an emerging therapeutic target for liver injury and summarize recent clinical findings of calcium modulation for the treatment of ischemic-reperfusion injury, cholestasis and NAFLD.
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Affiliation(s)
- Nuria Oliva-Vilarnau
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Simona Hankeova
- Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge, Sweden.,Faculty of Science, Institute of Experimental Biology, Masaryk University, Brno, Czechia
| | - Sabine U Vorrink
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Souren Mkrtchian
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Emma R Andersson
- Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge, Sweden.,Department of Cell and Molecular Biology, Karolinska Institutet, Stockholm, Sweden
| | - Volker M Lauschke
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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14
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Tsaroucha AK, Valsami G, Kostomitsopoulos N, Lambropoulou M, Anagnostopoulos C, Christodoulou E, Falidas E, Betsou A, Pitiakoudis M, Simopoulos CE. Silibinin Effect on Fas/FasL, HMGB1, and CD45 Expressions in a Rat Model Subjected to Liver Ischemia-Reperfusion Injury. J INVEST SURG 2017; 31:491-502. [DOI: 10.1080/08941939.2017.1360416] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Alexandra K. Tsaroucha
- Postgraduate Program in Hepatobiliary/Pancreatic Surgery, Faculty of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
- 2nd Department of Surgery and Laboratory of Experimental Surgery, Faculty of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Georgia Valsami
- School of Health Sciences, Department of Pharmacy, National and Kapodistrian University of Athens, Greece
| | | | - Maria Lambropoulou
- Laboratory of Histology-Embryology, Faculty of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | | | - Eirini Christodoulou
- School of Health Sciences, Department of Pharmacy, National and Kapodistrian University of Athens, Greece
| | - Evangelos Falidas
- Postgraduate Program in Hepatobiliary/Pancreatic Surgery, Faculty of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Afrodite Betsou
- Postgraduate Program in Hepatobiliary/Pancreatic Surgery, Faculty of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Michael Pitiakoudis
- Postgraduate Program in Hepatobiliary/Pancreatic Surgery, Faculty of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
- 2nd Department of Surgery and Laboratory of Experimental Surgery, Faculty of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Constantinos E. Simopoulos
- Postgraduate Program in Hepatobiliary/Pancreatic Surgery, Faculty of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
- 2nd Department of Surgery and Laboratory of Experimental Surgery, Faculty of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
- Department of Experimental Surgery, Bioresearch Foundation of the Academy of Athens, Athens, Greece
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15
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Maurer CA, Walensi M, Käser SA, Künzli BM, Lötscher R, Zuse A. Liver resections can be performed safely without Pringle maneuver: A prospective study. World J Hepatol 2016; 8:1038-1046. [PMID: 27648156 PMCID: PMC5002500 DOI: 10.4254/wjh.v8.i24.1038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 05/04/2016] [Accepted: 07/18/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate liver resections without Pringle maneuver, i.e., clamping of the portal triad.
METHODS Between 9/2002 and 7/2013, 175 consecutive liver resections (n = 101 major anatomical and n = 74 large atypical > 5 cm) without Pringle maneuver were performed in 127 patients (143 surgeries). Accompanying, 37 wedge resections (specimens < 5 cm) and 43 radiofrequency ablations were performed. Preoperative volumetric calculation of the liver remnant preceeded all anatomical resections. The liver parenchyma was dissected by water-jet. The median central venous pressure was 4 mmHg (range: 5-14). Data was collected prospectively.
RESULTS The median age of patients was 60 years (range: 16-85). Preoperative chemotherapy was used in 70 cases (49.0%). Liver cirrhosis was present in 6.3%, and liver steatosis of ≥ 10% in 28.0%. Blood loss was median 400 mL (range 50-5000 mL). Perioperative blood transfusions were given in 22/143 procedures (15%). The median weight of anatomically resected liver specimens was 525 g (range: 51-1850 g). One patient died postoperatively. Biliary leakages (n = 5) were treated conservatively. Temporary liver failure occurred in two patients.
CONCLUSION Major liver resections without Pringle maneuver are feasible and safe. The avoidance of liver inflow clamping might reduce liver damage and failure, and shorten the hospital stay.
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16
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Koekkoek WAC(K, van Zanten ARH. Antioxidant Vitamins and Trace Elements in Critical Illness. Nutr Clin Pract 2016; 31:457-74. [DOI: 10.1177/0884533616653832] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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17
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Simillis C, Robertson FP, Afxentiou T, Davidson BR, Gurusamy KS. A network meta-analysis comparing perioperative outcomes of interventions aiming to decrease ischemia reperfusion injury during elective liver resection. Surgery 2016; 159:1157-69. [DOI: 10.1016/j.surg.2015.10.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 09/05/2015] [Accepted: 10/01/2015] [Indexed: 12/12/2022]
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18
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Rodrigo R, Hasson D, Prieto JC, Dussaillant G, Ramos C, León L, Gárate J, Valls N, Gormaz JG. The effectiveness of antioxidant vitamins C and E in reducing myocardial infarct size in patients subjected to percutaneous coronary angioplasty (PREVEC Trial): study protocol for a pilot randomized double-blind controlled trial. Trials 2014; 15:192. [PMID: 24885600 PMCID: PMC4050098 DOI: 10.1186/1745-6215-15-192] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 05/09/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute myocardial infarction (AMI) is the leading cause of mortality worldwide. Oxidative stress has been involved in the ischemia-reperfusion injury in AMI. It has been suggested that reperfusion accounts for up to 50% of the final size of a myocardial infarct, a part of the damage likely to be prevented.Therefore, we propose that antioxidant reinforcement through vitamins C and E supplementation should protect against the ischemia-reperfusion damage, thus decreasing infarct size.The PREVEC Trial (Prevention of reperfusion damage associated with percutaneous coronary angioplasty following acute myocardial infarction) seeks to evaluate whether antioxidant vitamins C and E reduce infarct size in patients subjected to percutaneous coronary angioplasty after AMI. METHODS/DESIGN This is a randomized, 1:1, double-blind, placebo-controlled clinical trial.The study takes place at two centers in Chile: University of Chile Clinical Hospital and San Borja Arriarán Clinical Hospital.The subjects will be 134 adults with acute myocardial infarction with indication for percutaneous coronary angioplasty.This intervention is being performed as a pilot study, involving high-dose vitamin C infusion plus oral administration of vitamin E (Vitamin-treatment group) or placebo (Control group) during the angioplasty procedure. Afterward, the Vitamin-treatment group receives oral doses of vitamins C and E, and the Control group receives placebo for 84 days after coronary angioplasty.Primary outcome is infarct size, assessed by cardiac magnetic resonance (CMR), measured 6 and 84 days after coronary angioplasty.Secondary outcomes are ejection fraction, measured 6 and 84 days after coronary angioplasty with CMR, and biomarkers for oxidative stress, antioxidant status, heart damage, and inflammation, which will be measured at baseline, at the onset of reperfusion, 6 to 8 hours after revascularization, and at hospital discharge. DISCUSSION The ischemia-reperfusion event occurring during angioplasty is known to increase myocardial infarct size. The cardioprotective benefits of high doses of vitamin C combined with vitamin E have not been fully explored. The PREVEC Trial seeks to determine the suitability of the therapeutic use of vitamins C and E against the reperfusion damage produced during angioplasty.Patient recruitment opened in February 2013. The trial is scheduled to end in March 2016. TRIAL REGISTRATION ISRCTN56034553.
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Affiliation(s)
- Ramón Rodrigo
- Molecular and Clinical Pharmacology Program, Institute of Biomedical Sciences, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Daniel Hasson
- Molecular and Clinical Pharmacology Program, Institute of Biomedical Sciences, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Juan C Prieto
- Molecular and Clinical Pharmacology Program, Institute of Biomedical Sciences, Faculty of Medicine, University of Chile, Santiago, Chile
- Cardiovascular Department, University of Chile Clinical Hospital, Santiago, Chile
| | - Gastón Dussaillant
- Cardiovascular Department, University of Chile Clinical Hospital, Santiago, Chile
| | - Cristóbal Ramos
- Department of Radiology, University of Chile Clinical Hospital, Santiago, Chile
| | - Lucio León
- Cardiovascular Center, San Borja Arriarán Clinical Hospital, Santiago, Chile
| | - Javier Gárate
- Cardiovascular Center, San Borja Arriarán Clinical Hospital, Santiago, Chile
| | - Nicolás Valls
- Molecular and Clinical Pharmacology Program, Institute of Biomedical Sciences, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Juan G Gormaz
- Molecular and Clinical Pharmacology Program, Institute of Biomedical Sciences, Faculty of Medicine, University of Chile, Santiago, Chile
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Pandey CK, Nath SS, Pandey VK, Karna ST, Tandon M. Perioperative ischaemia-induced liver injury and protection strategies: An expanding horizon for anaesthesiologists. Indian J Anaesth 2013; 57:223-9. [PMID: 23983278 PMCID: PMC3748674 DOI: 10.4103/0019-5049.115576] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Liver resection is an effective modality of treatment in patients with primary liver tumour, metastases from colorectal cancers and selected benign hepatic diseases. Its aim is to resect the grossly visible tumour with clear margins and to ensure that the remnant liver mass has sufficient function which is adequate for survival. With the advent of better preoperative imaging, surgical techniques and perioperative management, there is an improvement in the outcome with decreased mortality. This decline in postoperative mortality after hepatic resection has encouraged surgeons for more radical liver resections, leaving behind smaller liver remnants in a bid to achieve curative surgeries. But despite advances in diagnostic, imaging and surgical techniques, postoperative liver dysfunction of varied severity including death due to liver failure is still a serious problem in such patients. Different surgical and non-surgical techniques like reducing perioperative blood loss and consequent decreased transfusions, vascular occlusion techniques (intermittent portal triad clamping and ischaemic preconditioning), administration of pharmacological agents (dextrose, intraoperative use of methylprednisolone, trimetazidine, ulinastatin and lignocaine) and inhaled anaesthetic agents (sevoflurane) and opioids (remifentanil) have demonstrated the potential benefit and minimised the adverse effects of surgery. In this article, the authors reviewed the surgical and non-surgical measures that could be adopted to minimise the risk of postoperative liver failure following liver surgeries with special emphasis on ischaemic and pharmacological preconditioning which can be easily adapted clinically.
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Affiliation(s)
- Chandra Kant Pandey
- Department of Anaesthesiology and Critical Care Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
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20
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Molecular basis of cardioprotective effect of antioxidant vitamins in myocardial infarction. BIOMED RESEARCH INTERNATIONAL 2013; 2013:437613. [PMID: 23936799 PMCID: PMC3726017 DOI: 10.1155/2013/437613] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 06/18/2013] [Indexed: 02/07/2023]
Abstract
Acute myocardial infarction (AMI) is the leading cause of mortality worldwide. Major advances in the treatment of acute coronary syndromes and myocardial infarction, using cardiologic interventions, such as thrombolysis or percutaneous coronary angioplasty (PCA) have improved the clinical outcome of patients. Nevertheless, as a consequence of these procedures, the ischemic zone is reperfused, giving rise to a lethal reperfusion event accompanied by increased production of reactive oxygen species (oxidative stress). These reactive species attack biomolecules such as lipids, DNA, and proteins enhancing the previously established tissue damage, as well as triggering cell death pathways. Studies on animal models of AMI suggest that lethal reperfusion accounts for up to 50% of the final size of a myocardial infarct, a part of the damage likely to be prevented. Although a number of strategies have been aimed at to ameliorate lethal reperfusion injury, up to date the beneficial effects in clinical settings have been disappointing. The use of antioxidant vitamins could be a suitable strategy with this purpose. In this review, we propose a systematic approach to the molecular basis of the cardioprotective effect of antioxidant vitamins in myocardial ischemia-reperfusion injury that could offer a novel therapeutic opportunity against this oxidative tissue damage.
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Akhtar M, Henderson T, Sutherland A, Vogel T, Friend P. Novel Approaches to Preventing Ischemia-Reperfusion Injury During Liver Transplantation. Transplant Proc 2013; 45:2083-92. [DOI: 10.1016/j.transproceed.2013.04.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 04/23/2013] [Indexed: 12/25/2022]
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Mpabanzi L, Mierlo KMC, Malagó M, Dejong CHC, Lytras D, Olde Damink SWM. Surrogate endpoints in liver surgery related trials: a systematic review of the literature. HPB (Oxford) 2013; 15:327-36. [PMID: 23323939 PMCID: PMC3633033 DOI: 10.1111/j.1477-2574.2012.00590.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 08/30/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although the safety of liver surgery has improved enormously, hepatic surgery continues to face challenging complications. Therefore, improvements supported by evidence-based guidelines are still required. The conduct of randomized controlled trials in liver surgery using dichotomous outcomes requires a large sample size. The use of surrogate endpoints (SEPs) reduces sample size but SEPs should be validated before use. AIM The aim of this review was to summarize the SEPs used in hepatic surgery related trials, their definitions and recapitulating the evidence validating their use. METHOD A systematic computerized literature search in the biomedical database PubMed using the MeSH terms 'hepatectomy' or 'liver resection' or 'liver transection' was conducted. Search was limited to papers written in the English language and published between 1 January 2000 and 1 January 2010. RESULTS A total of 593 articles met the search terms and 49 articles were included in the final selection. Standard biochemical liver functions tests were the most frequently used SEP (32 of 49 the studies). The used definitions of SEPs varied greatly among the studies. Most studies referred to earlier published material to justify their choice of SEP. However, no validating studies were found. CONCLUSION Many SEPs are used in liver surgery trials however there is little evidence validating them.
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Affiliation(s)
- Liliane Mpabanzi
- Department of Surgery, Maastricht University Medical Centre, and NUTRIM School of Nutrition, Toxicology and Metabolism, Maastricht UniversityMaastricht, the Netherlands,Hepato-Pancreato-Biliary and Liver Transplant Surgery, Royal Free Hospital, University College LondonLondon, UK
| | - Kim MC Mierlo
- Department of Surgery, Maastricht University Medical Centre, and NUTRIM School of Nutrition, Toxicology and Metabolism, Maastricht UniversityMaastricht, the Netherlands
| | - Massimo Malagó
- Hepato-Pancreato-Biliary and Liver Transplant Surgery, Royal Free Hospital, University College LondonLondon, UK
| | - Cornelis HC Dejong
- Department of Surgery, Maastricht University Medical Centre, and NUTRIM School of Nutrition, Toxicology and Metabolism, Maastricht UniversityMaastricht, the Netherlands
| | - Dimitrios Lytras
- Hepato-Pancreato-Biliary and Liver Transplant Surgery, Royal Free Hospital, University College LondonLondon, UK
| | - Steven WM Olde Damink
- Department of Surgery, Maastricht University Medical Centre, and NUTRIM School of Nutrition, Toxicology and Metabolism, Maastricht UniversityMaastricht, the Netherlands,Hepato-Pancreato-Biliary and Liver Transplant Surgery, Royal Free Hospital, University College LondonLondon, UK,Correspondence Steven W.M. Olde Damink, Department of Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands. Tel: 31 43 387 74 89. Fax: 31 43 387 54 73. E-mail:
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Morsy MD, Bashir SO. Alpha-tocopherol ameliorates oxidative renal insult associated with spinal cord reperfusion injury. J Physiol Biochem 2013; 69:487-96. [PMID: 23345003 DOI: 10.1007/s13105-013-0236-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 01/07/2013] [Indexed: 02/06/2023]
Abstract
Ischemic-reperfusion procedures targeting a specific organ often results in remote multiple organ injuries mediated possibly by heightened oxidative stress levels. As the kidney is one of the most vulnerable organs for ischemic oxidative stress, the aim of the present study was to confirm the occurrence of renal complication secondary to spinal cord ischemic-reperfusion injury (SC-IRI) induced by aortic clamping. The study also investigated the possible prophylactic effect of long-term administration of α-tocopherol (α-TOL) against high level of renal oxidative stress and inflammatory processes induced by SC-IRI. In this study, a total of 60 male Sprague-Dawley rats were randomly divided into five equal groups: C group underwent no surgery; CE group received α-TOL 600 mg/kg intramuscular twice weekly for 6 weeks; S group were subjected to laparotomy without clamping of the aorta; SE group were handled as S group and treated with α-TOL as group CE; SC-IRI group were subjected to laparotomy with clamping of the aorta just above the bifurcation of the aorta for 45 min, then the clamp was released for 48 h for reperfusion. SC-IRIE group was subjected to IRI as in group SC-IRI and was injected with α-TOL in the same dose and route as α-TOL-treated control group. SC-IRI resulted in increases in serum creatinine, blood urea nitrogen, plasma nitrite/nitrate level, serum tumor necrosis factor alpha, renal tissue homogenate level for malondialdehyde, superoxide dismutase and prostaglandin E2. Long-term prophylactic treatment with α-TOL resulted in amelioration of the renal functional disturbances and all measured parameters of oxidative stress and inflammation. Ischemic reperfusion injury of the spinal cord induced some remote renal functional disturbances although some of the observed changes may have resulted from decreased renal blood flow due to the hypotension induced during the procedure. Prophylactic long-term α-TOL administration guards against the renal function disturbances an effect that can be attributed, at least partially, to improvement of the renal pro-oxidant/antioxidant balance and inhibition of the inflammatory processes.
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Affiliation(s)
- Mohamed D Morsy
- Physiology Department, Faculty of Medicine, King Khalid University, Abha, Saudi Arabia.
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Manzanares W, Dhaliwal R, Jiang X, Murch L, Heyland DK. Antioxidant micronutrients in the critically ill: a systematic review and meta-analysis. Crit Care 2012; 16:R66. [PMID: 22534505 PMCID: PMC3681395 DOI: 10.1186/cc11316] [Citation(s) in RCA: 143] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 03/13/2012] [Accepted: 04/25/2012] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Critical illness is characterized by oxidative stress, which is a major promoter of systemic inflammation and organ failure due to excessive free radical production, depletion of antioxidant defenses, or both. We hypothesized that exogenous supplementation of trace elements and vitamins could restore antioxidant status, improving clinical outcomes. METHODS We searched computerized databases, reference lists of pertinent articles and personal files from 1980 to 2011. We included randomized controlled trials (RCTs) conducted in critically ill adult patients that evaluated relevant clinical outcomes with antioxidant micronutrients (vitamins and trace elements) supplementation versus placebo. RESULTS A total of 21 RCTs met inclusion criteria. When the results of these studies were statistically aggregated (n = 20), combined antioxidants were associated with a significant reduction in mortality (risk ratio (RR) = 0.82, 95% confidence interval (CI) 0.72 to 0.93, P = 0.002); a significant reduction in duration of mechanical ventilation (weighed mean difference in days = -0.67, 95% CI -1.22 to -0.13, P = 0.02); a trend towards a reduction in infections (RR= 0.88, 95% CI 0.76 to 1.02, P = 0.08); and no overall effect on ICU or hospital length of stay (LOS). Furthermore, antioxidants were associated with a significant reduction in overall mortality among patients with higher risk of death (>10% mortality in control group) (RR 0.79, 95% CI 0.68 to 0.92, P = 0.003) whereas there was no significant effect observed for trials of patients with a lower mortality in the control group (RR = 1.14, 95% 0.72 to 1.82, P = 0.57). Trials using more than 500 μg per day of selenium showed a trend towards a lower mortality (RR = 0.80, 95% CI 0.63 to 1.02, P = 0.07) whereas trials using doses lower than 500 μg had no effect on mortality (RR 0.94, 95% CI 0.67 to 1.33, P = 0.75). CONCLUSIONS Supplementation with high dose trace elements and vitamins may improve outcomes of critically ill patients, particularly those at high risk of death.
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Affiliation(s)
- William Manzanares
- Intensive Care Unit, Department of Critical Care Medicine, Universidad de la República, Hospital de Clínicas (University Hospital), Faculty of Medicine, Avda Italia s/n 14th Floor, Montevideo, 11600, Uruguay
| | - Rupinder Dhaliwal
- Clinical Evaluation Research Unit, Kingston General Hospital, Angada 4, Kingston General Hospital, 76 Stuart Street, Kingston ON, K7L 2V7, Canada
| | - Xuran Jiang
- Clinical Evaluation Research Unit, Kingston General Hospital, Angada 4, Kingston General Hospital, 76 Stuart Street, Kingston ON, K7L 2V7, Canada
| | - Lauren Murch
- Clinical Evaluation Research Unit, Kingston General Hospital, Angada 4, Kingston General Hospital, 76 Stuart Street, Kingston ON, K7L 2V7, Canada
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Angada 4, Kingston General Hospital, 76 Stuart Street, Kingston ON, K7L 2V7, Canada
- Department of Medicine, Queen's University Kingston, Angada 4, Kingston General Hospital, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada
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van den Heuvel M, Bast A, Haenen G, Ambergen A, Mermans J, van der Hulst R. The role of antioxidants in ischaemia-reperfusion in a human DIEP flap model. J Plast Reconstr Aesthet Surg 2012; 65:1706-11. [DOI: 10.1016/j.bjps.2012.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Revised: 04/29/2012] [Accepted: 06/11/2012] [Indexed: 02/04/2023]
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Cardioprotection against ischaemia/reperfusion by vitamins C and E plus n-3 fatty acids: molecular mechanisms and potential clinical applications. Clin Sci (Lond) 2012; 124:1-15. [PMID: 22963444 DOI: 10.1042/cs20110663] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The role of oxidative stress in ischaemic heart disease has been thoroughly investigated in humans. Increased levels of ROS (reactive oxygen species) and RNS (reactive nitrogen species) have been demonstrated during ischaemia and post-ischaemic reperfusion in humans. Depending on their concentrations, these reactive species can act either as benevolent molecules that promote cell survival (at low-to-moderate concentrations) or can induce irreversible cellular damage and death (at high concentrations). Although high ROS levels can induce NF-κB (nuclear factor κB) activation, inflammation, apoptosis or necrosis, low-to-moderate levels can enhance the antioxidant response, via Nrf2 (nuclear factor-erythroid 2-related factor 2) activation. However, a clear definition of these concentration thresholds remains to be established. Although a number of experimental studies have demonstrated that oxidative stress plays a major role in heart ischaemia/reperfusion pathophysiology, controlled clinical trials have failed to prove the efficacy of antioxidants in acute or long-term treatments of ischaemic heart disease. Oral doses of vitamin C are not sufficient to promote ROS scavenging and only down-regulate their production via NADPH oxidase, a biological effect shared by vitamin E to abrogate oxidative stress. However, infusion of vitamin C at doses high enough to achieve plasma levels of 10 mmol/l should prevent superoxide production and the pathophysiological cascade of deleterious heart effects. In turn, n-3 PUFA (polyunsaturated fatty acid) exposure leads to enhanced activity of antioxidant enzymes. In the present review, we present evidence to support the molecular basis for a novel pharmacological strategy using these antioxidant vitamins plus n-3 PUFAs for cardioprotection in clinical settings, such as post-operative atrial fibrillation, percutaneous coronary intervention following acute myocardial infarction and other events that are associated with ischaemia/reperfusion.
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Jaeschke H, Woolbright BL. Current strategies to minimize hepatic ischemia-reperfusion injury by targeting reactive oxygen species. Transplant Rev (Orlando) 2012; 26:103-14. [PMID: 22459037 DOI: 10.1016/j.trre.2011.10.006] [Citation(s) in RCA: 212] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 10/17/2011] [Indexed: 12/15/2022]
Abstract
Ischemia-reperfusion is a major component of injury in vascular occlusion both during liver surgery and during liver transplantation. The pathophysiology of hepatic ischemia-reperfusion includes a number of mechanisms including oxidant stress that contribute to various degrees to the overall organ damage. A large volume of recent research has focused on the use of antioxidants to ameliorate this injury, although results in experimental models have not translated well to the clinic. This review focuses on critical sources and mediators of oxidative stress during hepatic ischemia-reperfusion, the status of current antioxidant interventions, and emerging mechanisms of protection by preconditioning. While recent advances in regulation of antioxidant systems by Nrf2 provide interesting new potential therapeutic targets, an increased focus must be placed on more in-depth mechanistic investigations in hepatic ischemia-reperfusion injury and translational research in order to refine current strategies in disease management.
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Affiliation(s)
- Hartmut Jaeschke
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, KS 66160, USA.
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Abstract
BACKGROUND Weight loss and muscle wasting are commonly found in patients with end-stage liver disease. Since there is an association between malnutrition and poor clinical outcome, such patients (or those at risk of becoming malnourished) are often given parenteral nutrition, enteral nutrition, or oral nutritional supplements. These interventions have costs and adverse effects, so it is important to prove that their use results in improved morbidity or mortality, or both. OBJECTIVES To assess the beneficial and harmful effects of parenteral nutrition, enteral nutrition, and oral nutritional supplements on the mortality and morbidity of patients with underlying liver disease. SEARCH METHODS The following computerised databases were searched: the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, and Science Citation Index Expanded (January 2012). In addition, reference lists of identified trials and review articles and Clinicaltrials.gov were searched. Trials identified in a previous systematic handsearch of Index Medicus were also considered. Handsearches of a number of medical journals, including abstracts from annual meetings, were done. Experts in the field and manufacturers of nutrient formulations were contacted for potential references. SELECTION CRITERIA Randomised clinical trials (parallel or cross-over design) comparing groups of patients with any underlying liver disease who received, or did not receive, enteral or parenteral nutrition or oral nutritional supplements were identified without restriction on date, language, or publication status. Six categories of trials were separately considered: medical or surgical patients receiving parenteral nutrition, enteral nutrition, or supplements. DATA COLLECTION AND ANALYSIS The following data were sought in each report: date of publication; geographical location; inclusion and exclusion criteria; the type of nutritional support and constitution of the nutrient formulation; duration of treatment; any nutrition provided to the controls; other interventions provided to the patients; number, sex, age of the study participants; hospital or outpatient status; underlying liver disease; risks of bias (sequence generation, allocation concealment, blinding, incomplete outcome reporting, intention-to-treat analysis, selective outcome reporting, others (vested interests, baseline imbalance, early stopping)); mortality; hepatic morbidity (development or resolution of ascites or hepatic encephalopathy, occurrence of gastrointestinal bleeding); quality of life scores; adverse events; infections; lengths of stay in the hospital or intensive care unit; costs; serum bilirubin; postoperative complications (surgical trials only); and nutritional outcomes (nitrogen balance, anthropometric measurements, body weight). The primary outcomes of this review were mortality, hepatic morbidity, quality of life, and adverse events. Data were extracted in duplicate; differences were resolved by consensus.Data for each outcome were combined in a meta-analysis (RevMan 5.1). Estimates were reported using risk ratios or mean differences, along with the 95% confidence intervals (CI). Both fixed-effect and random-effects models were employed; fixed-effect models were reported unless one model, but not the other, found a significant difference (in which case both were reported). Heterogeneity was assessed by the Chi(2) test and I(2) statistic. Subgroup analyses were planned to assess specific liver diseases (alcoholic hepatitis, cirrhosis, hepatocellular carcinoma), acute or chronic liver diseases, and trials employing standard or branched-chain amino acid formulations (for the hepatic encephalopathy outcomes). Sensitivity analyses were planned to compare trials at low and high risk of bias and trials reported as full papers. The following exploratory analyses were undertaken: 1) medical and surgical trials were combined for each nutritional intervention; 2) intention-to-treat analyses in which missing dichotomous data were imputed as best- and worst-case scenarios; 3) all trials were combined to assess mortality; 4) effects were estimated by absolute risk reductions. MAIN RESULTS Thirty-seven trials were identified; only one was at low risk of bias. Most of the analyses failed to find any significant differences. The significant findings that were found were the following: 1) icteric medical patients receiving parenteral nutrition had a reduced serum bilirubin (mean difference (MD) -2.86 mg%, 95% CI -3.82 mg% to -1.89 mg%, 3 trials) and better nitrogen balance (MD 3.60 g/day, 95% CI 0.86 g/day to 6.34 g/day, 1 trial); 2) surgical patients receiving parenteral nutrition had a reduced incidence of postoperative ascites only in the fixed-effect model (RR 0.65, 95% CI 0.48 to 0.87, 2 trials, I(2) = 70%) and one trial demonstrated a reduction in postoperative complications, especially infections (pneumonia in particular); 3) enteral nutrition may have improved nitrogen balance in medical patients (although a combination of the three trials was not possible); 4) one surgical trial of enteral nutrition found a reduction in postoperative complications; and 5) oral nutritional supplements had several effects in medical patients (reduced occurrence of ascites (RR 0.57, 95% CI 0.37 to 0.88, 3 trials), possibly (significant differences only seen in the fixed-effect model) reduced rates of infection (RR 0.49, 95% CI 0.24 to 0.99, 3 trials, I(2) = 14%), and improved resolution of hepatic encephalopathy (RR 3.75, 95% CI 1.15 to 12.18, 2 trials, I(2) = 79%). While there was no overall effect of the supplements on mortality in medical patients, the one low risk of bias trial found an increased risk of death in the recipients of the supplements. Three trials of supplements in surgical patients failed to show any significant differences. No new information was derived from the various subgroup or sensitivity analyses. The exploratory analyses were also unrevealing except for a logical conundrum. There was no difference in mortality when all of the trials were combined, but the trials of parenteral nutrition found that those recipients had better survival (RR 0.53, 95% CI 0.29 to 0.98, 10 trials). Either the former observation represents a type II error or the latter one a type I error. AUTHORS' CONCLUSIONS The data do not compellingly justify the routine use of parenteral nutrition, enteral nutrition, or oral nutritional supplements in patients with liver disease. The fact that all but one of these trials were at high risks of bias even casts doubt on the few benefits that were demonstrated. Data from well-designed and executed randomised trials that include an untreated control group are needed before any such recommendation can be made. Future trials have to be powered adequately to see small, but clinically important, differences.
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Koretz RL, Avenell A, Lipman TO. Nutritional support for liver disease. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [PMID: 22592729 DOI: 10.1002/14651858.cd008344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Weight loss and muscle wasting are commonly found in patients with end-stage liver disease. Since there is an association between malnutrition and poor clinical outcome, such patients (or those at risk of becoming malnourished) are often given parenteral nutrition, enteral nutrition, or oral nutritional supplements. These interventions have costs and adverse effects, so it is important to prove that their use results in improved morbidity or mortality, or both. OBJECTIVES To assess the beneficial and harmful effects of parenteral nutrition, enteral nutrition, and oral nutritional supplements on the mortality and morbidity of patients with underlying liver disease. SEARCH METHODS The following computerised databases were searched: the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, and Science Citation Index Expanded (January 2012). In addition, reference lists of identified trials and review articles and Clinicaltrials.gov were searched. Trials identified in a previous systematic handsearch of Index Medicus were also considered. Handsearches of a number of medical journals, including abstracts from annual meetings, were done. Experts in the field and manufacturers of nutrient formulations were contacted for potential references. SELECTION CRITERIA Randomised clinical trials (parallel or cross-over design) comparing groups of patients with any underlying liver disease who received, or did not receive, enteral or parenteral nutrition or oral nutritional supplements were identified without restriction on date, language, or publication status. Six categories of trials were separately considered: medical or surgical patients receiving parenteral nutrition, enteral nutrition, or supplements. DATA COLLECTION AND ANALYSIS The following data were sought in each report: date of publication; geographical location; inclusion and exclusion criteria; the type of nutritional support and constitution of the nutrient formulation; duration of treatment; any nutrition provided to the controls; other interventions provided to the patients; number, sex, age of the study participants; hospital or outpatient status; underlying liver disease; risks of bias (sequence generation, allocation concealment, blinding, incomplete outcome reporting, intention-to-treat analysis, selective outcome reporting, others (vested interests, baseline imbalance, early stopping)); mortality; hepatic morbidity (development or resolution of ascites or hepatic encephalopathy, occurrence of gastrointestinal bleeding); quality of life scores; adverse events; infections; lengths of stay in the hospital or intensive care unit; costs; serum bilirubin; postoperative complications (surgical trials only); and nutritional outcomes (nitrogen balance, anthropometric measurements, body weight). The primary outcomes of this review were mortality, hepatic morbidity, quality of life, and adverse events. Data were extracted in duplicate; differences were resolved by consensus.Data for each outcome were combined in a meta-analysis (RevMan 5.1). Estimates were reported using risk ratios or mean differences, along with the 95% confidence intervals (CI). Both fixed-effect and random-effects models were employed; fixed-effect models were reported unless one model, but not the other, found a significant difference (in which case both were reported). Heterogeneity was assessed by the Chi(2) test and I(2) statistic. Subgroup analyses were planned to assess specific liver diseases (alcoholic hepatitis, cirrhosis, hepatocellular carcinoma), acute or chronic liver diseases, and trials employing standard or branched-chain amino acid formulations (for the hepatic encephalopathy outcomes). Sensitivity analyses were planned to compare trials at low and high risk of bias and trials reported as full papers. The following exploratory analyses were undertaken: 1) medical and surgical trials were combined for each nutritional intervention; 2) intention-to-treat analyses in which missing dichotomous data were imputed as best- and worst-case scenarios; 3) all trials were combined to assess mortality; 4) effects were estimated by absolute risk reductions. MAIN RESULTS Thirty-seven trials were identified; only one was at low risk of bias. Most of the analyses failed to find any significant differences. The significant findings that were found were the following: 1) icteric medical patients receiving parenteral nutrition had a reduced serum bilirubin (mean difference (MD) -2.86 mg%, 95% CI -3.82 mg% to -1.89 mg%, 3 trials) and better nitrogen balance (MD 3.60 g/day, 95% CI 0.86 g/day to 6.34 g/day, 1 trial); 2) surgical patients receiving parenteral nutrition had a reduced incidence of postoperative ascites only in the fixed-effect model (RR 0.65, 95% CI 0.48 to 0.87, 2 trials, I(2) = 70%) and one trial demonstrated a reduction in postoperative complications, especially infections (pneumonia in particular); 3) enteral nutrition may have improved nitrogen balance in medical patients (although a combination of the three trials was not possible); 4) one surgical trial of enteral nutrition found a reduction in postoperative complications; and 5) oral nutritional supplements had several effects in medical patients (reduced occurrence of ascites (RR 0.57, 95% CI 0.37 to 0.88, 3 trials), possibly (significant differences only seen in the fixed-effect model) reduced rates of infection (RR 0.49, 95% CI 0.24 to 0.99, 3 trials, I(2) = 14%), and improved resolution of hepatic encephalopathy (RR 3.75, 95% CI 1.15 to 12.18, 2 trials, I(2) = 79%). While there was no overall effect of the supplements on mortality in medical patients, the one low risk of bias trial found an increased risk of death in the recipients of the supplements. Three trials of supplements in surgical patients failed to show any significant differences. No new information was derived from the various subgroup or sensitivity analyses. The exploratory analyses were also unrevealing except for a logical conundrum. There was no difference in mortality when all of the trials were combined, but the trials of parenteral nutrition found that those recipients had better survival (RR 0.53, 95% CI 0.29 to 0.98, 10 trials). Either the former observation represents a type II error or the latter one a type I error. AUTHORS' CONCLUSIONS The data do not compellingly justify the routine use of parenteral nutrition, enteral nutrition, or oral nutritional supplements in patients with liver disease. The fact that all but one of these trials were at high risks of bias even casts doubt on the few benefits that were demonstrated. Data from well-designed and executed randomised trials that include an untreated control group are needed before any such recommendation can be made. Future trials have to be powered adequately to see small, but clinically important, differences.
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Rodrigo R. Prevention of postoperative atrial fibrillation: novel and safe strategy based on the modulation of the antioxidant system. Front Physiol 2012; 3:93. [PMID: 22518106 PMCID: PMC3325031 DOI: 10.3389/fphys.2012.00093] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Accepted: 03/26/2012] [Indexed: 01/15/2023] Open
Abstract
Postoperative atrial fibrillation (AF) is the most common arrhythmia following cardiac surgery with extracorporeal circulation. The pathogenesis of postoperative AF is multifactorial. Oxidative stress, caused by the unavoidable ischemia-reperfusion event occurring in this setting, is a major contributory factor. Reactive oxygen species (ROS)-derived effects could result in lipid peroxidation, protein carbonylation, or DNA oxidation of cardiac tissue, thus leading to functional and structural myocardial remodeling. The vulnerability of myocardial tissue to the oxidative challenge is also dependent on the activity of the antioxidant system. High ROS levels, overwhelming this system, should result in deleterious cellular effects, such as the induction of necrosis, apoptosis, or autophagy. Nevertheless, tissue exposure to low to moderate ROS levels could trigger a survival response with a trend to reinforce the antioxidant defense system. Administration of n-3 polyunsaturated fatty acids (PUFA), known to involve a moderate ROS production, is consistent with a diminished vulnerability to the development of postoperative AF. Accordingly, supplementation of n-3 PUFA successfully reduced the incidence of postoperative AF after coronary bypass grafting. This response is due to an up-regulation of antioxidant enzymes, as shown in experimental models. In turn, non-enzymatic antioxidant reinforcement through vitamin C administration prior to cardiac surgery has also reduced the postoperative AF incidence. Therefore, it should be expected that a mixed therapy result in an improvement of the cardioprotective effect by modulating both components of the antioxidant system. We present novel available evidence supporting the hypothesis of an effective prevention of postoperative AF including a two-step therapeutic strategy: n-3 PUFA followed by vitamin C supplementation to patients scheduled for cardiac surgery with extracorporeal circulation. The present study should encourage the design of clinical trials aimed to test the efficacy of this strategy to offer new therapeutic opportunities to patients challenged by ischemia-reperfusion events not solely in heart, but also in other organs such as kidney or liver in transplantation surgeries.
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Affiliation(s)
- Ramón Rodrigo
- Molecular and Clinical Pharmacology Program, Institute of Biomedical Sciences, Faculty of Medicine, University of ChileSantiago, Chile
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Köhler HF, Delucca IMS, Sbragia Neto L. Antioxidantes enterais em lesões de isquemia e reperfusão em ratos. Rev Col Bras Cir 2011; 38:422-8. [DOI: 10.1590/s0100-69912011000600010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Accepted: 05/04/2011] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Avaliar o papel do pré-tratamento com antioxidantes dietéticos em um modelo experimental de lesão intestinal de isquemia-reperfusão (I/R) em ratos. MÉTODOS: Noventa ratos Wistar adultos machos foram utilizados. Um segmento intestinal foi isolado baseado em seu pedículo vascular. Uma biópsia controle foi realizada e o pedículo foi seccionado e anastomosado novamente, garantindo um tempo de isquemia de 60 minutos, seguido por reperfusão. Biópsias sequenciais foram realizadas ao término do período isquêmico e a cada 15 minutos, durante a reperfusão. O tratamento consistiu de solução salina ou vitamina C ou vitamina E ou a associação destas. Avaliações quantitativa e qualitativa das biópsias foram realizadas. RESULTADOS: Os grupos tratados com vitamina E isolada ou associada com vitamina C apresentaram uma atenuação estatisticamente significativa da lesão de isquemia-reperfusão, com diminuição da perda de altura dos vilos e menor infiltração neutrofílica ao final do estudo quando comparados ao grupo controle e vitamina C exclusiva. CONCLUSÃO: Neste modelo experimental de isquemia-reperfusão, o pré-tratamento com vitamina E atenuou a lesão de I/R no intestino delgado, demonstrado pela diminuição da perda de altura dos vilos e pela atenuação da infiltração neutrofílica.
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Oral preoperative antioxidants in pancreatic surgery: a double-blind, randomized, clinical trial. Nutrition 2011; 28:160-4. [PMID: 21890323 DOI: 10.1016/j.nut.2011.05.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2010] [Revised: 05/23/2011] [Accepted: 05/25/2011] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Oxidative stress due to ischemia/reperfusion injury increases systemic inflammation and impairs immune defenses. Much interest has developed for the administration of antioxidant substrates in surgical patients. The purpose of this study was to perform a pilot evaluation of the impact of a carbohydrate- containing preconditioning oral nutritional supplement (pONS) enriched with glutamine, antioxidants, and green tea extract on postoperative oxidative stress. METHODS We performed a double-blind placebo-controlled randomized clinical trial, involving 36 cancer patients undergoing pancreaticoduodenectomy. Patients were randomized to receive either pONS or placebo twice the day before surgery and once 3 hours before surgery. Total endogenous antioxidant capacity (TEAC), plasma levels of vitamin C, vitamin E, selenium, zinc, F2-isoprostanes, and C-reactive protein were measured at baseline and on postoperative day (POD) 1, 3, and 7. RESULTS At surgery, the mean gastric residual volume (mL) was 54.2 in the pONS group versus 51.3 in the placebo group (P = NS). On POD 1 plasma levels of vitamin C (P = 0.001), selenium (P = 0.07), and zinc (P = 0.06) were higher in the pONS group compared to placebo. TEAC was improved on POD 1, 3, and 7 in the pONS group compared to placebo (P = 0.01). No difference was found in plasma C-reactive protein levels after surgery in both groups. CONCLUSIONS Perioperative pONS administration positively affected plasma vitamin C levels and improved TEAC shortly after surgery, but did not reduce oxidative stress and systemic inflammation markers.
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Shokeir AA, Barakat N, Hussein AAM, Awadalla A, Abdel-Aziz A, Abo-Elenin H. Role of combination of L-arginine and α-tocopherol in renal transplantation ischaemia/reperfusion injury: a randomized controlled experimental study in a rat model. BJU Int 2011; 108:612-8. [PMID: 21592301 DOI: 10.1111/j.1464-410x.2010.09943.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
UNLABELLED What's known on the subject? and What does the study add? Renal ischaemia/reperfusion (I/R) injury is an inevitable consequence of kidney transplantation. It contributes to delayed graft function (DGF), acute renal failure and graft rejection. The present study investigates for the first time the impact of a combination of L-arginine and alpha tocopherol on the renal ischemia/reperfusion injury in a rodent model of kidney transplantation. We found that concomitant administration of L-arginine and α-tocopherol has a more protective effect and synergistic antioxidant effect on ischaemia/reperfusion injury in transplanted rat kidneys. OBJECTIVES To investigate the role of L-arginine and α-tocopherol in ischaemia/reperfusion injury in a kidney transplanted rat model. MATERIALS AND METHODS In total, 40 male Sprague-Dawley rats subjected to renal transplantation received FK506 (tacrolimus) to overcome early acute rejection episodes. Animals were divided randomly into four groups (ten rats each). Group I were treated with FK506 (2 mg/kg/bw/day) and served as the control group. Group II were treated with L-arginine 300 mg/kg/bw. Group III were treated with α-tocopherol 30 mg/kg/bw. Group IV were treated with L-arginine and α-tocopherol. Urine and blood samples were taken at 0 (before operation), 2, 7 and 14 days post-transplantation for estimation of urine sodium, creatinine, fractional excretion of sodium, serum creatinine, sodium and blood urea nitrogen. Histological examination and measurement of malondialdehyde in kidney tissues were also performed. RESULTS Serum creatinine and blood urea nitrogen significantly decreased in L-arginine and α-tocopherol, as well as combination groups, compared to the control group. Malondialdehyde was significantly decreased in the combination group compared to L-arginine and α-tocopherol alone. Histological examination of the control group showed that acute tubular necrosis was markedly decreased in transplanted kidneys treated with a combination of both L-arginine and α-tocopherol. CONCLUSIONS Concomitant administration of l-arginine and α-tocopherol has a more protective effect and synergistic antioxidant effect on ischaemia/reperfusion injury in transplanted rat kidneys.
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Affiliation(s)
- Ahmed A Shokeir
- Urology and Nephrology Center Physiology Department Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
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Nickkholgh A, Schneider H, Sobirey M, Venetz WP, Hinz U, Pelzl LH, Gotthardt DN, Cekauskas A, Manikas M, Mikalauskas S, Mikalauskene L, Bruns H, Zorn M, Weigand MA, Büchler MW, Schemmer P. The use of high-dose melatonin in liver resection is safe: first clinical experience. J Pineal Res 2011; 50:381-8. [PMID: 21480979 DOI: 10.1111/j.1600-079x.2011.00854.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Experimental data suggest that melatonin decreases inflammatory changes after major liver resection, thus positively influencing the postoperative course. To assess the safety of a preoperative single dose of melatonin in patients undergoing major liver resection, a randomized controlled double-blind pilot clinical trial with two parallel study arms was designed at the Department of General and Transplantation Surgery, Ruprecht-Karls-University, Heidelberg. A total of 307 patients, who were referred for liver surgery, were screened. One hundred and thirteen patients, for whom a major liver resection (≥3 segments) was scheduled, were eligible. Sixty-three eligible patients refused to participate, and therefore, 50 patients were randomized. A preoperative single dose of melatonin (50 mg/kg BW) dissolved in 250 mL of milk was administered through the gastric tube after the intubation for general anesthesia. Controls were given the same amount of microcrystalline cellulose. Primary endpoint was safety. Secondary endpoints were postoperative complications. Melatonin was effectively absorbed with serum concentrations of 1142.8 ± 7.2 ng/mL (mean ± S.E.M.) versus 0.3 ± 7.8 ng/mL in controls (P < 0.0001). Melatonin treatment resulted in lower postoperative transaminases over the study period (P = 0.6). There was no serious adverse event in patients after melatonin treatment. A total of three infectious complications occurred in either group. A total of eight noninfectious complications occurred in five control patients, whereas three noninfectious complications occurred in three patients receiving preoperative melatonin (P = 0.3). There was a trend toward shorter ICU stay and total hospital stay after melatonin treatment. Therefore, a single preoperative enteral dose of melatonin is effectively absorbed and is safe and well tolerated in patients undergoing major liver surgery.
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Affiliation(s)
- Arash Nickkholgh
- Department of General and Transplantation Surgery, Ruprecht-Karls-University, Heidelberg, Germany
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Ischemia/reperfusion injury in liver resection: a review of preconditioning methods. Surg Today 2011; 41:620-9. [PMID: 21533932 DOI: 10.1007/s00595-010-4444-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Accepted: 10/18/2010] [Indexed: 02/06/2023]
Abstract
Ischemic preconditioning is one of the therapeutic interventions aiming at preventing ischemia/reperfusion-related injury. Numerous experimental studies and a few clinical series have shown that during liver resections, ischemic preconditioning is a promising strategy for optimizing the postoperative outcome. Moreover, various types of pharmacological intervention as well as different types of preconditioning, such as remote preconditioning, the use of heat shock, and hyperbaric oxygen, have been developed to attenuate the functional impairment accompanying ischemia/reperfusion injury. This review summarizes the various forms of preconditioning, thus suggesting that close cooperation between surgeons and anesthesiologists paves the way to apply novel strategies to improve the outcome of liver resection.
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Vitamin E derivative ETS-GS reduces liver ischemia-reperfusion injury in rats. J Surg Res 2011; 175:118-22. [PMID: 21529839 DOI: 10.1016/j.jss.2011.02.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Revised: 01/28/2011] [Accepted: 02/24/2011] [Indexed: 11/20/2022]
Abstract
BACKGROUND Ischemic liver injury is often the result of surgical procedures such as liver transplantation and hepatic resection. Liver damage occurs after reperfusion, leading to increased systemic inflammation. Recent studies have reported that vitamin E and glutathione can ameliorate ischemia-reperfusion (I/R) injury. In the present study, we evaluated the ability of a new vitamin E derivative, ETS-GS, to improve liver I/R injury. MATERIALS AND METHODS Male Wistar received a subcutaneous injection of ETS-GS (10 mg/kg) or saline before experimentally-induced liver I/R injury or sham treatment. The rats were sacrificed after the 60-min ischemia and 24-h reperfusion. Histology and serum levels of cytokines [tumor necrosis factor (TNF)-α, interleukin (IL)-6, and high-mobility group box 1 (HMGB1) protein] and liver enzymes were determined to evaluate the protective effects of ETS-GS. RESULTS We found that ETS-GS treatment attenuated I/R-induced histologic alterations, reduced levels of liver enzymes aspartate aminotransferase (AST), alanine aminotransferase (ALT), and lactate dehydrogenase (LDH). In addition, ETS-GS treatment decreased serum cytokine levels. CONCLUSIONS Taken together, our results demonstrate that ETS-GS attenuates I/R injury in a rat model and suggests that ETS-GS may exert anti-inflammatory effects. Accordingly, ETS-GS may have therapeutic potential to treat various clinical conditions involving I/R injury.
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Bjelakovic G, Gluud LL, Nikolova D, Bjelakovic M, Nagorni A, Gluud C. Antioxidant supplements for liver diseases. Cochrane Database Syst Rev 2011:CD007749. [PMID: 21412909 DOI: 10.1002/14651858.cd007749.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several liver diseases have been associated with oxidative stress. Accordingly, antioxidants have been suggested as potential therapeutics for various liver diseases. The evidence supporting these suggestions is equivocal. OBJECTIVES To assess the benefits and harms of antioxidant supplements for patients with liver diseases. SEARCH STRATEGY We searched The Cochrane Library, MEDLINE, EMBASE, LILACS, the Science Citation Index Expanded, and Conference Proceedings Citation Index-Science to January 2011. We scanned bibliographies of relevant publications and asked experts and pharmaceutical companies for additional trials. SELECTION CRITERIA We considered for inclusion randomised trials that compared antioxidant supplements (beta-carotene, vitamin A, C, E, and selenium) versus placebo or no intervention for autoimmune liver diseases, viral hepatitis, alcoholic liver disease, and cirrhosis (any aetiology). DATA COLLECTION AND ANALYSIS Four authors independently selected trials for inclusion and extracted data. Outcome measures were all-cause mortality, liver-related mortality, liver-related morbidity, biochemical indices at maximum follow-up in the individual trials as well as adverse events, quality-of-life measures, and cost-effectiveness. For patients with hepatitis B or C we also considered end of treatment and sustained virological response. We conducted random-effects and fixed-effect meta-analyses. Results were presented as relative risks (RR) or mean differences (MD), both with 95% confidence intervals (CI). MAIN RESULTS Twenty randomised trials with 1225 participants were included. The trials assessed beta-carotene (3 trials), vitamin A (2 trials), vitamin C (9 trials), vitamin E (15 trials), and selenium (8 trials). The majority of the trials had high risk of bias and showed heterogeneity. Overall, the assessed antioxidant supplements had no significant effect on all-cause mortality (relative risk [RR] 0.84, 95% confidence interval [CI] 0.60 to 1.19, I(2) = 0%), or liver-related mortality (RR 0.89, 95% CI 0.39 to 2.05, I(2) = 37%). Stratification according to the type of liver disease did not affect noticeably the results. Antioxidant supplements significantly increased activity of gamma glutamyl transpeptidase (MD 24.21 IU/l, 95% CI 6.67 to 41.75, I(2) = 0%). AUTHORS' CONCLUSIONS We found no evidence to support or refute antioxidant supplements in patients with liver disease. Antioxidant supplements may increase liver enzyme activity.
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Affiliation(s)
- Goran Bjelakovic
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 3344, Rigshospitalet, Copenhagen University Hospital, and Department of Internal Medicine - Gastroenterology and Hepatology, Medical Faculty, University of Nis, Zorana Djindjica 81, Nis, Serbia, 18000
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Abstract
BACKGROUND Vascular occlusion to prevent haemorrhage during liver resection causes ischaemia-reperfusion (IR) injury. Insights into the mechanisms of IR injury gathered from experimental models have contributed to the development of therapeutic approaches, some of which have already been tested in randomized clinical trials. METHODS The review was based on a PubMed search using the terms 'ischemia AND hepatectomy', 'ischemia AND liver', 'hepatectomy AND drug treatment', 'liver AND intermittent clamping' and 'liver AND ischemic preconditioning'; only randomized controlled trials (RCTs) were included. RESULTS Twelve RCTs reported on ischaemic preconditioning and intermittent clamping. Both strategies seem to confer protection and allow extension of ischaemia time. Fourteen RCTs evaluating pharmacological interventions, including antioxidants, anti-inflammatory drugs, vasodilators, pharmacological preconditioning and glucose infusion, were identified. CONCLUSION Several strategies to prevent hepatic IR have been developed, but few have been incorporated into clinical practice. Although some pharmacological strategies showed promising results with improved clinical outcome there is not sufficient evidence to recommend them.
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Affiliation(s)
- R Bahde
- Surgical Research, Department of General and Visceral Surgery, Muenster University Hospital, Waldeyer Strasse 1, D-48149 Muenster, Germany
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Benko T, Frede S, Gu Y, Best J, Baba HA, Schlaak JF, de Groot H, Fandrey J, Rauen U. Glycine pretreatment ameliorates liver injury after partial hepatectomy in the rat. J INVEST SURG 2010; 23:12-20. [PMID: 20233000 DOI: 10.3109/08941930903469466] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Living donor liver transplantation subjects the donor to a major hepatectomy. Pharmacological or nutritive protection of the liver during the procedure is desirable to ensure that the remnant is able to maintain sufficient function. The aim of our study was to analyze the effects of pretreatments with alpha-tocopherol (vitamin E), the flavonoid silibinin and/or the amino acid L-glycine on the donor in a rat model. METHODS Male Wistar rats were pretreated with L-glycine (5% in chow, 5 days), alpha-tocopherol (100 mg/kg body weight by gavage, 3 days) and/or silibinin (100 mg/kg body weight, i.p., 5 days). Thereafter, 90% partial hepatectomy was performed without portal vein clamping. RESULTS Glycine pretreatment markedly decreased transaminase release (AST, 12 hr: glycine 1292 +/- 192 U/L, control 2311 +/- 556 U/L, p < .05; ALT, 12 hr: glycine 1013 +/- 278 U/L, control 2038 +/- 500 U/L, p < .05), serum ALP activity and serum bilirubin levels (p < .05). Prothrombin time was reduced, and histologically, liver injury was also decreased in the glycine group. Silibinin pretreatment was less advantageous and pretreatment with alpha-tocopherol at this very high dose showed some adverse effects. Combined, i.e., triple pretreatment was less advantageous than glycine alone. Liver resection induced HIF-1alpha accumulation and HIF-1alpha accumulation was also decreased by glycine pretreatment. CONCLUSION The decrease of liver injury and improvement of liver function after pretreatment with glycine suggests that glycine pretreatment might be beneficial for living liver donors as well as for patients subjected to partial hepatectomy for other reasons.
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Affiliation(s)
- Tamas Benko
- Department of Surgery and Transplantation, Semmelweis University, Budapest, Hungary
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Protective Effect of Parenteral Vitamin E on Ischemia-reperfusion Injury of Rabbit Kidney. Urology 2010; 75:858-61. [DOI: 10.1016/j.urology.2009.04.062] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2008] [Revised: 04/05/2009] [Accepted: 04/18/2009] [Indexed: 11/18/2022]
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Abu-Amara M, Gurusamy K, Hori S, Glantzounis G, Fuller B, Davidson BR. Systematic review of randomized controlled trials of pharmacological interventions to reduce ischaemia-reperfusion injury in elective liver resection with vascular occlusion. HPB (Oxford) 2010; 12:4-14. [PMID: 20495639 PMCID: PMC2814398 DOI: 10.1111/j.1477-2574.2009.00120.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2009] [Accepted: 07/09/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Vascular occlusion during liver resection results in ischaemia-reperfusion (IR) injury, which can lead to liver dysfunction. We performed a systematic review and meta-analysis to assess the benefits and harms of using various pharmacological agents to decrease IR injury during liver resection with vascular occlusion. METHODS Randomized clinical trials (RCTs) evaluating pharmacological agents in liver resections conducted under vascular occlusion were identified. Two independent reviewers extracted data on population characteristics and risk of bias in the trials, and on outcomes such as postoperative morbidity, hospital stay and liver function. RESULTS A total of 18 RCTs evaluating 17 different pharmacological interventions were identified. There was no significant difference in perioperative mortality, liver failure or postoperative morbidity between the intervention and control groups in any of the comparisons. A significant improvement in liver function was seen with methylprednisolone use. Hospital and intensive therapy unit stay were significantly shortened with trimetazidine and vitamin E use, respectively. Markers of liver parenchymal injury were significantly lower in the methylprednisolone, trimetazidine, dextrose and ulinastatin groups compared with their respective controls (placebo or no intervention). DISCUSSION Methylprednisolone, trimetazidine, dextrose and ulinastatin may have protective roles against IR injury in liver resection. However, based on the current evidence, they cannot be recommended for routine use and their application should be restricted to RCTs.
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Affiliation(s)
- Mahmoud Abu-Amara
- Hepatopancreatobiliary and Liver Transplant Surgery, University Department of Surgery, Royal Free and University College School of Medicine, Royal Free Hospital CampusLondon, UK
| | - Kurinchi Gurusamy
- Hepatopancreatobiliary and Liver Transplant Surgery, University Department of Surgery, Royal Free and University College School of Medicine, Royal Free Hospital CampusLondon, UK
| | - Satoshi Hori
- Department of Urology, Addenbrooke's HospitalCambridge, UK
| | - George Glantzounis
- Hepatopancreatobiliary and Liver Transplant Surgery, University Department of Surgery, Royal Free and University College School of Medicine, Royal Free Hospital CampusLondon, UK
| | - Barry Fuller
- Hepatopancreatobiliary and Liver Transplant Surgery, University Department of Surgery, Royal Free and University College School of Medicine, Royal Free Hospital CampusLondon, UK
| | - Brian R Davidson
- Hepatopancreatobiliary and Liver Transplant Surgery, University Department of Surgery, Royal Free and University College School of Medicine, Royal Free Hospital CampusLondon, UK
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Abu-Amara M, Gurusamy KS, Hori S, Glantzounis G, Fuller B, Davidson BR. Pharmacological interventions versus no pharmacological intervention for ischaemia reperfusion injury in liver resection surgery performed under vascular control. Cochrane Database Syst Rev 2009:CD007472. [PMID: 19821421 DOI: 10.1002/14651858.cd007472.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Vascular occlusion to reduce blood loss is used during elective liver resection but results in significant ischaemia reperfusion injury. This, in turn, might lead to significant postoperative liver dysfunction and morbidity. Various pharmacological drugs have been used with an intention to ameliorate the ischaemia reperfusion injury in liver resections. OBJECTIVES To assess the benefits and harms of different pharmacological agents versus no pharmacological interventions to decrease ischaemia reperfusion injury during liver resections where vascular occlusion was performed during the surgery. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until January 2009. SELECTION CRITERIA We included randomised clinical trials, irrespective of language or publication status, comparing any pharmacological agent versus placebo or no pharmacological agent during elective liver resections with vascular occlusion. DATA COLLECTION AND ANALYSIS Two authors independently identified trials for inclusion and independently extracted the data. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. We calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat analysis or available case analysis. MAIN RESULTS We identified a total of 15 randomised trials evaluating 11 different pharmacological interventions (methylprednisolone, multivitamin antioxidant infusion, vitamin E infusion, amrinone, prostaglandin E1, pentoxifylline, mannitol, trimetazidine, dextrose, allopurinol, and OKY 046 (a thromboxane A2 synthetase inhibitor)). All trials had high risk of bias. There were no significant differences between the groups in mortality, liver failure, or perioperative morbidity. The trimetazidine group had a significantly shorter hospital stay than control (MD -3.00 days; 95% CI -3.57 to -2.43). There were no significant differences in any of the clinically relevant outcomes in the remaining comparisons. Methylprednisolone improved the enzyme markers of liver function and trimetazidine, methylprednisolone, and dextrose reduced the enzyme markers of liver injury compared with controls. However, there is a high risk of type I and type II errors because of the few trials included, the small sample size in each trial, and the risk of bias. AUTHORS' CONCLUSIONS Trimetazidine, methylprednisolone, and dextrose may protect against ischaemia reperfusion injury in elective liver resections performed under vascular occlusion, but this is shown in trials with small sample sizes and high risk of bias. The use of these drugs should be restricted to well-designed randomised clinical trials before implementing them in clinical practice.
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Affiliation(s)
- Mahmoud Abu-Amara
- University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG
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Abu‐Amara M, Gurusamy KS, Glantzounis G, Fuller B, Davidson BR. Pharmacological interventions for ischaemia reperfusion injury in liver resection surgery performed under vascular control. Cochrane Database Syst Rev 2009; 2009:CD008154. [PMID: 19821445 PMCID: PMC7182152 DOI: 10.1002/14651858.cd008154] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Vascular occlusion used during elective liver resection to reduce blood loss results in significant ischaemia reperfusion (IR) injury. This in turn leads to significant postoperative liver dysfunction and morbidity. Various pharmacological drugs have been used in experimental settings to ameliorate the ischaemia reperfusion injury in liver resections. OBJECTIVES To assess the relative benefits and harms of using one pharmacological intervention versus another pharmacological intervention to decrease ischaemia reperfusion injury during liver resections where vascular occlusion was performed during the surgery. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until January 2009. SELECTION CRITERIA We included randomised clinical trials, irrespective of language or publication status, comparing one pharmacological agent versus another pharmacological agent during elective liver resections with vascular occlusion. DATA COLLECTION AND ANALYSIS Two authors independently identified trials for inclusion and independently extracted data. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. We planned to calculate the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat analysis or available case analysis. However, all outcomes were only reported on by single trials, and meta-analysis could not be performed. Therefore, we performed Fisher's exact test on dichotomous outcomes. MAIN RESULTS We identified a total of five randomised trials evaluating nine different pharmacological interventions (amrinone, prostaglandin E1, pentoxifylline, dopexamine, dopamine, ulinastatin, gantaile, sevoflurane, and propofol). All trials had high risk of bias. There was no significant difference between the groups in mortality, liver failure, or perioperative morbidity. The ulinastatin group had significantly lower postoperative enzyme markers of liver injury compared with the gantaile group. None of the other comparisons showed any difference in any of the other outcomes. However, there is a high risk of type I and type II errors because of the few trials included, the small sample size in each trial, and the risk of bias. AUTHORS' CONCLUSIONS Ulinastatin may have a protective effect against ischaemia reperfusion injury relative to gantaile in elective liver resections performed under vascular occlusion. The absolute benefit of this drug agent remains unknown. None of the drugs can be recommended for routine clinical practice. Considering that none of the drugs have proven to be useful to decrease ischaemia reperfusion injury, such trials should include a group of patients who do not receive any active intervention whenever possible to determine the pharmacological drug's absolute effects on ischaemia reperfusion injury in liver resections.
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Affiliation(s)
- Mahmoud Abu‐Amara
- Royal Free Hospital and University College School of MedicineUniversity Department of SurgeryLondonUK
| | - Kurinchi Selvan Gurusamy
- Royal Free Hospital and University College School of MedicineUniversity Department of SurgeryLondonUK
| | - George Glantzounis
- University of IoanninaDepartment of Surgery, School of MedicineIoanninaGreece45 110
| | - Barry Fuller
- Royal Free Hospital and University College School of MedicineUniversity Department of SurgeryLondonUK
| | - Brian R Davidson
- Royal Free Hospital and University College School of MedicineUniversity Department of SurgeryLondonUK
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Nouri-Majalan N, Ardakani EF, Forouzannia K, Moshtaghian H. Effects of allopurinol and vitamin E on renal function in patients with cardiac coronary artery bypass grafts. Vasc Health Risk Manag 2009; 5:489-94. [PMID: 19554089 PMCID: PMC2697583 DOI: 10.2147/vhrm.s5761] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Indexed: 11/23/2022] Open
Abstract
Background: Acute renal failure is a common complication of cardiac surgery, with oxidants found to play an important role in renal injury. We therefore assessed whether the supplemental antioxidant vitamin E and the inhibitor of xanthine oxidase allopurinol could prevent renal dysfunction after coronary artery bypass graft (CABG) surgery. Methods: Of 60 patients with glomerular filtration rate (GFR) < 60 mL/min scheduled to undergo CABG surgery, 30 were randomized to treatment with vitamin E and allopurinol for 3–5 days before surgery and 30 to no treatment. Serum creatinine levels and potassium and creatinine clearances were measured preoperatively and daily until day 5 after surgery. Results: The patients consisted of 31 males and 29 females, with a mean age of 63 ± 9 years. After surgery, there were no significant differences in mean serum creatinine (1.2 ± 0.33 vs 1.2 ± 0.4 mg/dL; p = 0.43) concentrations, or creatinine clearance (52 ± 12.8 vs 52 ± 12.8 mL/min; p = 0.9). The frequency of acute renal failure did not differ in treatment group compared with control (16% vs 13%; p = 0.5). Length of stay in the intensive care unit (ICU) was significantly longer in the control than in the treated group (3.9 ± 1.5 vs 2.6 ± 0.7 days; p < 0.001). Conclusion: Prophylactic treatment with vitamin E and allopurinol had no renoprotective effects in patients with pre-existing renal failure undergoing CABG surgery. Treatment with these agents, however, reduces the duration of ICU stay.
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Hoshida S, Hatano M, Furukawa M, Ito M. Neuroprotective effects of vitamin E on adult rat motor neurones following facial nerve avulsion. Acta Otolaryngol 2009; 129:330-6. [PMID: 18720077 DOI: 10.1080/00016480802210431] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
CONCLUSION The present study demonstrates the neuroprotective effect of vitamin E after peripheral facial nerve injury. Antioxidants may have therapeutic potential in traumatic facial nerve dysfunction resulting from traumatic temporal bone injury and ear surgery. OBJECTIVE We investigated the possible neuroprotective effect of vitamin E on the facial motor nucleus (FMN) motor neurones after peripheral nerve avulsion. METHODS In 36 adult rats, the right facial nerve was avulsed from the stylomastoid foramen. Following nerve avulsion, immunohistochemistry was used to investigate the effects of vitamin E on 4-hydroxynonenal (HNE) activity. FMN motor neurones and glial cells were counted bilaterally in sections stained with cresyl violet. RESULTS Rats administered vitamin E exhibited clear suppression of injury-induced neuronal HNE expression in the ipsilateral FMN as compared to non-treated controls. Following nerve avulsion, the number of surviving motor neurones in the ipsilateral FMN was significantly greater among vitamin E-treated rats than non-treated controls.
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Gurusamy KS, Sheth H, Kumar Y, Sharma D, Davidson BR. WITHDRAWN: Methods of vascular occlusion for elective liver resections. Cochrane Database Syst Rev 2009; 2009:CD006409. [PMID: 19160283 PMCID: PMC10654807 DOI: 10.1002/14651858.cd006409.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Vascular occlusion is used to reduce blood loss during liver resection surgery. There is considerable controversy regarding whether vascular occlusion should be used or not during elective liver resections. The method of vascular occlusion employed is also controversial. There is also considerable debate on the role of ischaemic preconditioning before vascular occlusion. OBJECTIVES To assess the advantages (decreased blood loss and peri-operative morbidity) and disadvantages (liver dysfunction from ischaemia) of vascular occlusion during liver resections. To compare the advantages (in decreasing blood loss or decreasing ischaemia-reperfusion injury) and disadvantages of different types of vascular occlusion versus total, continuous portal triad clamping. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until March 2007. SELECTION CRITERIA We included randomised clinical trials comparing vascular occlusion versus no vascular occlusion during elective liver resections (irrespective of language or publication status). We also included randomised clinical trials comparing the different methods of vascular occlusion and those investigating the role of ischaemic preconditioning in liver resection. DATA COLLECTION AND ANALYSIS We collected the data on the characteristics of the trial, methodological quality of the trials, mortality, morbidity, blood loss, blood transfusion requirements, liver function tests, markers of neutrophil activation, operating time, and hospital stay. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each binary outcome we calculated the odds ratio (OR) with 95% confidence intervals (CI) based on intention-to-treat analysis. For continuous outcomes, we calculated the weighted mean difference (WMD) with 95% confidence intervals. MAIN RESULTS We identified a total of 16 randomised trials. Five trials including 331 patients compared vascular occlusion (n = 166) versus no vascular occlusion (n = 165). Six trials including 521 patients compared different methods of vascular occlusion. Three trials including 210 patients compared ischaemic preconditioning before continuous portal triad clamping (n = 105) versus no ischaemic preconditioning (n = 105). Two trials including 127 patients compared ischaemic preconditioning before continuous portal triad clamping (n = 63) versus intermittent portal triad clamping (n = 64).The blood loss was significantly lower in vascular occlusion compared with no vascular occlusion. The liver enzymes were significantly elevated in the vascular occlusion group compared with no vascular occlusion. There was no difference in the mortality, liver failure, or other morbidities. Four of the five trials comparing vascular occlusion and no vascular occlusion used intermittent vascular occlusion. Trials comparing complete inflow and outflow occlusion to the liver, ie, hepatic vascular exclusion and portal triad clamping demonstrate significant detrimental haemodynamic changes in hepatic vascular exclusion compared to portal triad clamping. There was no significant difference in the number of units transfused and the number of patients needing transfusion. There was no difference in mortality, liver failure, or morbidity between total and selective methods of portal triad clamping. All four cases of mortality and liver failure in the comparison between the intermittent and continuous portal triad clamping occurred in the continuous portal triad clamping (statistically not significant). Intermittent portal triad clamping does not increase the total blood loss or operating time compared to continuous portal triad clamping.There was no statistically significant difference in the mortality, liver failure, morbidity, blood loss, or haemodynamic changes between ischaemic preconditioning versus no ischaemic preconditioning before continuous portal triad clamping. Liver enzymes used as markers of liver injury were significantly lower in the early post-operative period in the ischaemic preconditioning group. The intensive therapy unit stay and hospital stay were statistically significantly lower in the ischaemic preconditioning group than in the no ischaemic preconditioning group.There was no statistically significant difference in the mortality, liver failure, morbidity, intensive therapy unit stay, or hospital stay between ischaemic preconditioning before continuous portal triad clamping and intermittent portal triad clamping. The blood loss and transfusion requirements were lower in the ischaemic preconditioning group. Aspartate aminotransferase level was lower in the intermittent portal triad clamping group than the ischaemic preconditioning group on the third post-operative day. There was no difference in the peak aspartate aminotransferase levels or in the aspartate aminotransferase levels on first or sixth post-operative days of aspartate aminotransferase . AUTHORS' CONCLUSIONS Intermittent vascular occlusion seems safe in liver resection. However, it does not seem to decrease morbidity. Among the different methods of vascular occlusion, intermittent portal triad clamping has most evidence to support the clinical application. Hepatic vascular exclusion cannot be recommended routinely. Ischaemic preconditioning before continuous portal triad clamping may be of clinical benefit in reducing intensive therapy unit and hospital stay.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG.
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Abstract
BACKGROUND Vascular occlusion is used to reduce blood loss during liver resection surgery. There is considerable controversy regarding whether vascular occlusion should be used or not during elective liver resections. The method of vascular occlusion employed is also controversial. There is also considerable debate on the role of ischaemic preconditioning before vascular occlusion. OBJECTIVES To assess the advantages (decreased blood loss and peri-operative morbidity) and disadvantages (liver dysfunction from ischaemia) of vascular occlusion during liver resections. To compare the advantages (in decreasing blood loss or decreasing ischaemia-reperfusion injury) and disadvantages of different types of vascular occlusion versus total, continuous portal triad clamping. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until March 2007. SELECTION CRITERIA We included randomised clinical trials comparing vascular occlusion versus no vascular occlusion during elective liver resections (irrespective of language or publication status). We also included randomised clinical trials comparing the different methods of vascular occlusion and those investigating the role of ischaemic preconditioning in liver resection. DATA COLLECTION AND ANALYSIS We collected the data on the characteristics of the trial, methodological quality of the trials, mortality, morbidity, blood loss, blood transfusion requirements, liver function tests, markers of neutrophil activation, operating time, and hospital stay. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each binary outcome we calculated the odds ratio (OR) with 95% confidence intervals (CI) based on intention-to-treat analysis. For continuous outcomes, we calculated the weighted mean difference (WMD) with 95% confidence intervals. MAIN RESULTS We identified a total of 16 randomised trials. Five trials including 331 patients compared vascular occlusion (n = 166) versus no vascular occlusion (n = 165). Six trials including 521 patients compared different methods of vascular occlusion. Three trials including 210 patients compared ischaemic preconditioning before continuous portal triad clamping (n = 105) versus no ischaemic preconditioning (n = 105). Two trials including 127 patients compared ischaemic preconditioning before continuous portal triad clamping (n = 63) versus intermittent portal triad clamping (n = 64). The blood loss was significantly lower in vascular occlusion compared with no vascular occlusion. The liver enzymes were significantly elevated in the vascular occlusion group compared with no vascular occlusion. There was no difference in the mortality, liver failure, or other morbidities. Four of the five trials comparing vascular occlusion and no vascular occlusion used intermittent vascular occlusion. Trials comparing complete inflow and outflow occlusion to the liver, ie, hepatic vascular exclusion and portal triad clamping demonstrate significant detrimental haemodynamic changes in hepatic vascular exclusion compared to portal triad clamping. There was no significant difference in the number of units transfused and the number of patients needing transfusion. There was no difference in mortality, liver failure, or morbidity between total and selective methods of portal triad clamping. All four cases of mortality and liver failure in the comparison between the intermittent and continuous portal triad clamping occurred in the continuous portal triad clamping (statistically not significant). Intermittent portal triad clamping does not increase the total blood loss or operating time compared to continuous portal triad clamping. There was no statistically significant difference in the mortality, liver failure, morbidity, blood loss, or haemodynamic changes between ischaemic preconditioning versus no ischaemic preconditioning before continuous portal triad clamping. Liver enzymes used as markers of liver injury were significantly lower in the early post-operative period in the ischaemic preconditioning group. The intensive therapy unit stay and hospital stay were statistically significantly lower in the ischaemic preconditioning group than in the no ischaemic preconditioning group. There was no statistically significant difference in the mortality, liver failure, morbidity, intensive therapy unit stay, or hospital stay between ischaemic preconditioning before continuous portal triad clamping and intermittent portal triad clamping. The blood loss and transfusion requirements were lower in the ischaemic preconditioning group. Aspartate aminotransferase level was lower in the intermittent portal triad clamping group than the ischaemic preconditioning group on the third post-operative day. There was no difference in the peak aspartate aminotransferase levels or in the aspartate aminotransferase levels on first or sixth post-operative days of aspartate aminotransferase. AUTHORS' CONCLUSIONS Intermittent vascular occlusion seems safe in liver resection. However, it does not seem to decrease morbidity. Among the different methods of vascular occlusion, intermittent portal triad clamping has most evidence to support the clinical application. Hepatic vascular exclusion cannot be recommended routinely. Ischaemic preconditioning before continuous portal triad clamping may be of clinical benefit in reducing intensive therapy unit and hospital stay.
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Affiliation(s)
- K S Gurusamy
- Royal Free and University College School of Medicine, University Department of Surgery, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG.
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Harputluoglu MMM, Demirel U, Ciralik H, Temel I, Firat S, Ara C, Aladag M, Karincaoglu M, Hilmioglu F. Protective effects of Gingko biloba on thioacetamide-induced fulminant hepatic failure in rats. Hum Exp Toxicol 2007; 25:705-13. [PMID: 17286148 DOI: 10.1177/0960327106073827] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Gingko biloba (GB) has antioxidant and platelet-activating factor (PAF) antagonistic effects. We investigated the protective effects of GB on thioacetamide (TAA)-induced fulminant hepatic failure in rats. Fulminant hepatic failure was induced in treatment groups by three intraperitoneal (ip) injections of TAA (350 mg/kg) at 24-hour intervals. Treatments with GB (100 mg/kg per day, orally) and N-acetylcysteine (20 mg/kg twice daily, sc) were initiated 48 hours prior to TAA administration. The liver was removed for histopathological examinations. Serum and liver thiobarbituric acid-reactive substance (TBARS) levels were measured for assessment of oxidative stress. Liver necrosis and inflammation scores and serum and liver TBARS levels were significantly higher in the TAA group compared to the control group (P < 0.001, < 0.001, 0.001, < 0.001, respectively). Liver necrosis and inflammation scores and liver TBARS levels were significantly lower in the GB group compared to the TAA group (P < 0.001, < 0.001 and 0.01, respectively). GB ameliorated hepatic damage in TAA-induced fulminant hepatic failure. This may be due to the free radical-scavenging effects of GB.
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Affiliation(s)
- M M M Harputluoglu
- Department of Gastroenterology, Inonu University Medical Faculty, Malatya, Turkey.
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Constantinides PP, Han J, Davis SS. Advances in the use of tocols as drug delivery vehicles. Pharm Res 2006; 23:243-55. [PMID: 16421666 DOI: 10.1007/s11095-005-9262-9] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2005] [Accepted: 10/25/2005] [Indexed: 12/12/2022]
Abstract
There has been increasing interest in recent years in the drug delivery applications of tocols and their derivatives. Their biocompatibility and potential to deliver both poorly soluble and water-soluble drugs make tocols attractive as drug delivery vehicles. This review article will focus primarily on topical, oral, and parenteral drug administration using tocols, although other routes of delivery such as pulmonary and nasal will also be discussed. After an overview of the tocol structures, physicochemical properties with emphasis on their solvent properties, functions, and metabolism, specific case studies will be discussed where tocols have been successfully used in topical, oral, and parenteral drug formulations and marketed drug products. Case studies will be extended to those where tocol-based formulations were administered pulmonarily and nasally. As more clinical data and marketed drug products emerge, the utility and therapeutic value of tocols will certainly increase.
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