Anxiety and Depression Symptoms in Hepatic Encephalopathy: Are They Psychiatric or Organic?

Gut-derived systemic inflammation as a driver of depression in chronic liver disease

Depression and chronic liver disease (CLD) are important causes of disability, morbidity and mortality worldwide and their prevalence continues to rise. The rate of depression in CLD is high compared to that of the general population and is comparable to the increased rates observed in other medical comorbidities and chronic inflammatory conditions. Notably, a comorbid diagnosis of depression has a detrimental effect on outcomes in cirrhosis. Systemic inflammation is pivotal in cirrhosis-associated immune dysfunction - a phenomenon present in advanced CLD (cirrhosis) and implicated in the development of complications, organ failure, disease progression, increased infection rates and poor outcome. The presence of systemic inflammation is also well-documented in a cohort of patients with depression; peripheral cytokine signals can result in neuroinflammation, behavioural change and depressive symptoms via neural mechanisms, cerebral endothelial cell and circumventricular organ signalling, and peripheral immune cell-to-brain signalling. Gut dysbiosis has been observed in both patients with cirrhosis and depression. It leads to intestinal barrier dysfunction resulting in increased bacterial translocation, in turn activating circulating immune cells, leading to cytokine production and systemic inflammation. A perturbed gut-liver-brain axis may therefore explain the high rates of depression in patients with cirrhosis. The underlying mechanisms explaining the critical relationship between depression and cirrhosis remain to be fully elucidated. Several other psychosocial and biological factors are likely to be involved, and therefore the cause is probably multifactorial. However, the role of the dysfunctional gut-liver-brain axis as a driver of gut-derived systemic inflammation requires further exploration and consideration as a target for the treatment of depression in patients with cirrhosis.

Possible Association Between DHEA and PKCε in Hepatic Encephalopathy Amelioration: A Pilot Study

Objective: Hepatic encephalopathy (HE) is a neuropsychiatric syndrome caused by liver failure and by an impaired neurotransmission and neurological function caused by hyperammonemia (HA). HE, in turn, decreases the phosphorylation of protein kinase C epsilon (PKCε), contributing to the impairment of neuronal functions. Dehydroepiandrosterone (DHEA) exerts a neuroprotective effect by increasing the GABAergic tone through GABA_A receptor stimulation. Therefore, we investigated the protective effect of DHEA in an animal model of HE, and the possible modulation of PKCε expression in different brain area.

Methods: Fulminant hepatic failure was induced in 18 male, Sprague–Dawley rats by i.p. administration of 3 g/kg D-galactosamine, and after 30 min, a group of animals received a subcutaneous injection of 25 mg/kg (DHEA) repeated twice a day (3 days). Exploratory behavior and general activity were evaluated 24 h and 48 h after the treatments by the open field test. Then, brain cortex and cerebellum were used for immunoblotting analysis of PKCε level.

Results: DHEA administration showed a significant improvement of locomotor activity both 24 and 48 h after D-galactosamine treatment (^****p < 0.0001) but did not ameliorate liver parenchymal degeneration. Western blot analysis revealed a reduced immunoreactivity of PKCε (^*p < 0.05) following D-galactosamine treatment in rat cortex and cerebellum. After the addition of DHEA, PKCε increased in the cortex in comparison with the D-galactosamine-treated (^***p < 0.001) and control group (^*p < 0.05), but decreased in the cerebellum (^*p < 0.05) with respect to the control group. PKCε decreased after treatment with NH₄Cl alone and in combination with DHEA in both cerebellum and cortex (^****p < 0.0001). MTS assay demonstrated the synergistic neurotoxic action of NH₄Cl and glutamate pretreatment in cerebellum and cortex along with an increased cell survival after DHEA pretreatment, which was significant only in the cerebellum (^*p < 0.05).

Conclusion: An association between the DHEA-mediated increase of PKCε expression and the improvement of comatose symptoms was observed. PKCε activation and expression in the brain could inhibit GABA-ergic tone counteracting HE symptoms. In addition, DHEA seemed to ameliorate the symptoms of HE and to increase the expression of PKCε in cortex and cerebellum.

Psychometric properties the of Brazilian Portuguese version of Snaith-Hamilton Pleasure Scale (SHAPS)

INTRODUCTION

Anhedonia is defined as the reduced ability to feel pleasure and is a core symptom of various psychiatric disorders such as depression and schizophrenia. The Snaith-Hamilton Pleasure Scale (SHAPS) was developed to assess the presence of anhedonia. The objective of this study was to assess the psychometric properties of the Brazilian Portuguese version of the SHAPS.

METHODS

In this study, the SHAPS (14 items) was translated into Brazilian Portuguese and validated using data obtained from 228 subjects within a clinical sample. Psychometric properties were assessed using item response theory (logistic models) and classical test theory (Cronbach's alpha). We checked for external validity using a non-parametric correlation with an independent scale: Hospital Anxiety and Depression Scale - Depression subscale (HAD-D).

RESULTS

The SHAPS presented good internal consistency, with a Cronbach's α coefficient of 0.759 and adequacy to an IRT 1 parameter logistic (Rasch) model. The SHAPS presented significant correlation with the external measure HAD-D, with Spearman's ρ = 0.249 (S = 1368914; p < 0.001).

CONCLUSION

These results suggest that the Brazilian Portuguese version of the SHAPS is a reliable and valid instrument to assess hedonic tone.

1H NMR-Based Metabolic Signatures in the Liver and Brain in a Rat Model of Hepatic Encephalopathy

Hepatic encephalopathy (HE) is a debilitating neuropsychiatric complication associated with acute and chronic liver failure. It is characterized by diverse symptoms with variable severity that includes cognitive and motor deficits. The aim of the study is to assess metabolic alterations in the brain and liver using nuclear magnetic resonance (NMR) spectroscopy and subsequent multivariate analyses to characterize metabolic signatures associated with HE. HE was developed by bile duct ligation (BDL) that resulted in hepatic dysfunctions and cirrhosis as shown by liver function tests. Metabolic profiles from control and BDL rats indicated increased levels of lactate, branched-chain amino acids (BCAAs), glutamate, and choline in the liver, whereas levels of glucose, phenylalanine, and pyridoxine were decreased. In brain, the levels of lactate, acetate, succinate, citrate, and malate were increased, while glucose, creatine, isoleucine, leucine, and proline levels were decreased. Furthermore, neurotransmitters such as glutamate and GABA were increased, whereas choline and myo-inositol were decreased. The alterations in neurotransmitter levels resulted in cognitive and motor defects in BDL rats. A significant correlation was found among alterations in NAA/choline, choline/creatine, and NAA/creatine with behavioral deficits. Thus, the data suggests impairment in metabolic pathways such as the tricarboxylic acid (TCA) cycle, glycolysis, and ketogenesis in the liver and brain of animals with HE. The study highlights that metabolic signatures could be potential markers to monitor HE progression and to assess therapeutic interventions.

Anxiety in rats with bile duct ligation is associated with activation of JNK3 mitogen-activated protein kinase in the hippocampus

We examine the anxiety-like behaviors in rats with bile duct ligation (BDL), as well as its relationship with the expression of JNK3 and P38 MAPKs in rat hippocampus. Male Wistar rats undergo either sham operation or BDL as a rat model of cirrhotic HE. The anxiety-like behaviors are determined using a light/dark box test two hours befor the surgery on day 1 and on days 7, 14, 21 and 28 of BDL. The gene and protein expression levels of JNK3 and p38 in the hippocampus were examined respectively with qPCR and western blotting methods on day 28 of BDL. The results revealed that anxiety was increased in the cirrhotic HE model rats during 28 days of BDL. The molecular data indicated that the gene expression of Jnk3 and protein levels of JNK3, as well as phospho-JNK3, significantly increased in the hippocampus of the cirrhotic HE model rats compared to the sham control group. However, the results revealed no significant changes in the gene expression and the protein levels of p38 as well as phospho-p38 in the hippocampus of the cirrhotic HE model rats compared to the sham control group. We conclude that the increases in the expression and activation of JNK3 MAPK in the hippocampus may underlie, at least partly, the anxiety-like behaviors in rats with cirrhotic HE.

The association between hepatic encephalopathy/minimal hepatic encephalopathy and depressive and anxiety disorders: a systematic review

OBJECTIVES

This review examined the currently available evidence of the association between liver encephalopathy and mood/anxiety disorders.

METHOD

English-language studies using the keywords "hepatic encephalopathy," "depression," and "anxiety" were searched through PubMed, Medline, Cochrane Library, and PsycINFO databases. A total of 135 articles were considered for this review, of which 9 were qualitative and quantitative research papers regarding depression and anxiety in hepatic encephalopathy (HE).

RESULTS

There is a significant discrepancy between the research method of the studies and their outcomes. The number of studies suggesting a relationship between HE and mood/anxiety disorders is slightly higher than that of studies with opposite results; however, based on the current evidence, it is difficult to conclude a significant association between these two conditions.

CONCLUSION

More longitudinal studies that include face-to-face psychiatric assessments are required to highlight any possible association between depressive/anxiety disorders and HE.

Preventive Effects of Escitalopram Against Anxiety-Like Depressive Behaviors in Monosodium Glutamate-Teated Rats Subjected to Partial Hepatectomy

The reasons for the relationship between depression and chronic liver disease (CLD) are complex and multifactorial. Further research is needed to decipher the etiology and establish an optimal management approach for depression in patients, including the potential role of non-pharmacological treatments. monosodium glutamate (MSG)-treated rats are more likely to develop anxiogenic- and depressive-like behaviors, which could be related to the dysfunction of serotonergic system. In this study, partial hepatectomy (PH) was performed in MSG-treated rats and the histopathological changes were observed in orbitofrontal cortex (OFC) and liver. The effect of escitalopram, a widely used antidepressant, on neural and liver injury in this model was also examined. The MSG + PH-treated rats displayed decreased distances traveled in total, in center arena, and in the left side of arena in inner open field test (OFT), as compared to saline, saline + PH, and MSG-treated animals. The present study established that PH aggravated anxiety-like depressive behaviors in MSG-treated rats, concordant with damaged Nissl bodies (and neurites), decreased IBA-1 and Sox-2 expression in OFC and neurotransmitter disorder. Escitalopram treatment could alleviate these pathological changes as well as reduce hepatic steatosis and lipid metabolism.

Ammonium induced dysfunction of 5-HT2B receptor in astrocytes

Previously we reported that gene expression of astrocytic 5-HT_2B receptors was decreased in brains of depressed animals exposed to chronic mild stress (CMS) (Li et al., 2012) and of Parkinson's disease (Song et al., 2018). Depression is also one of the psychiatric symptoms in hyperammonemia, and astrocyte is a primary target of ammonium in brain in vivo. In the present study, we have used preparations of the brains of urease-treated mice and ammonium-treated astrocytes in culture to study gene expression and function of 5-HT_2B receptors. The urease-treated mice showed depressive behaviour. Both mRNA and protein of 5-HT_2B receptors were increased in the brains of urease-treated mice and in ammonium-treated cultured astrocytes. Further study revealed that mRNA and protein expression of adenosine deaminase acting on RNA 2 (ADAR2), an enzyme catalyze RNA deamination of adenosine to inosine was increased in the brains of urease-treated mice and in ammonium-treated cultured astrocytes. This increase in ADAR2 induced RNA editing of 5-HT_2B receptors. Cultured astrocytes treated with ammonium lost 5-HT induced Ca²⁺ signalling and ERK_1/2 phosphorylation, indicating dysfunction of 5-HT_2B receptors. This is in agreement with our previous observation that edited 5-HT_2B receptors no longer respond to 5-HT (Hertz et al., 2014). Ammonium effects are inhibited by ADAR2 siRNA in cultured astrocytes, suggesting that increased gene expression and editing and loss of function of 5-HT_2B receptors are results of increased activity of ADAR2. In summary, we have demonstrated that functional malfunction of astrocytic 5-HT_2B receptors occurs in animal models of major depression, Parkinson depression and hepatic encephalopathy albeit via different mechanisms. Understanding the role of astrocytic 5-HT_2B receptors in different pathological contexts may instigate development of novel therapeutic strategies for treating disease-specific depressive behaviour.

Protective Effects of Liu Wei Di Huang Wan on the Liver, Orbitofrontal Cortex Nissl Bodies, and Neurites in MSG+PH-Induced Liver Regeneration Rat Model

Introduction. To examine the protective effects of Liu Wei Di Huang Wan formula (LWDH) on liver and orbitofrontal cortex (OFC) injuries in monosodium glutamate (MSG) and partial hepatectomy (PH) rat model. Methods. Neonatal Wistar rats were given MSG or saline on postnatal days 2, 4, 6, 8, and 10. The rats were caged into five groups and treated accordingly at six weeks old as follows: Saline group, Saline+PH group, MSG group, MSG+PH group, and LWDH group (MSG+PH+LWDH). The PH was performed during week 8 by excision of the left and median hepatic lobes (occupying about 68% of whole liver).On day 8 after the PH, the rats were subjected to an inner OFT before being sacrificed. The liver and OFC were stained using H&E, ORO, or Nissl staining. The expression of neurotrophic factors (β-NGF, BDNF) was examined in the OFC lysates by ELISA. Serum levels of cytokines (IL-1β, VEGF) were examined using the Bio-Plex suspension array. Results. LWDH increased the total distance traveled by the animals (p<0.05), and LWDH improved the integrity of the Nissl bodies in the OFC (mean area of the Nissl bodies, p<0.01; mean diameter, p<0.05; mean density, p<0.05; and IOD, p<0.01). There were less white area in the liver (p>0.05) and decreased hepatic steatosis (p<0.01) in LWDH group. LWDH administration decreased the expression of serum levels of IL-1β (p>0.05), while it increased VEGF (p>0.05) expression. LWDH administration increased the expression of BDNF (p>0.05) and β-NGF (p>0.05) in the OFC, all as compared to the MSG+PH group. Conclusion. LWDH partly protected the animals from depressive-like behaviors in the MSG+PH-induced liver regeneration neonatal rat model. LWDH alleviated hepatic injury and steatosis and, furthermore, protected the Nissl body integrity and the growth of neurites.

Post-Liver Transplant Delirium Increases Mortality and Length of Stay

BACKGROUND

Incidence of delirium after liver transplantation (LT) has been reported to occur in 10%-47% of patients and is associated with increased hospital and intensive care unit lengths of stay and poor outcomes.

METHODS

Our primary objective was to evaluate the incidence and predisposing risk factors for developing delirium after LT. Our secondary objectives were to describe how delirium is managed in patients after LT, to examine the utilization of resources associated with delirium after LT, and to analyze the outcomes of patients who were treated for delirium after LT.

RESULTS

In a population of 181 consecutive patients who received an LT, 38 (21.0%) developed delirium. In the multivariate analysis, delirium was associated with pretransplant use of antidepressants (odds ratio [OR] 3.34, 95% confidence interval [CI] 1.29-8.70) and pretransplant hospital admission for encephalopathy (OR 4.39, 95% CI 1.77-10.9). Patients with delirium spent more time on mechanical ventilation (2.0 vs 1.3 days, P=0.008) and had longer intensive care unit stays (4.6 vs 2.7 days, P=0.008), longer hospital stays (27.6 vs 11.2 days, P=0.003), and higher 6-month mortality (13.2% vs 1.4%, P=0.003) than patients who did not develop delirium.

CONCLUSION

The presence of delirium is common after LT and is associated with high morbidity and mortality within the first 6 months posttransplant. Pretransplant factors independently associated with developing delirium after LT include prior use of antidepressants and pretransplant hospital admission for encephalopathy. Efforts should be made to identify patients at risk for delirium, as protocol-based management may improve outcomes in a cost-effective manner.