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Pun CK, Huang HC, Chang CC, Hsu SJ, Huang YH, Hou MC, Lee FY. Hepatic encephalopathy: From novel pathogenesis mechanism to emerging treatments. J Chin Med Assoc 2024; 87:245-251. [PMID: 38109364 DOI: 10.1097/jcma.0000000000001041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
Hepatic encephalopathy (HE) is one of the major complications of liver disease and significantly affects the quality of life (QOL) of patients. HE is common and frequently relapses in cirrhotic patients. The management of HE is supportive, and precipitating conditions should be eliminated. Most drugs used to treat HE are conventional and include nonabsorbable disaccharides such as lactulose, and antibiotics such as rifaximin. However, their therapeutic efficacy is still suboptimal, and novel therapeutic agents are urgently needed. In addition, the optimal management and diagnosis of minimal HE/covert HE are under debate. In this review, we focus on novel pathogenetic mechanisms such as central nervous system clearance, and emerging therapeutic targets of HE, such as fecal material transplantation. We also discuss different classifications and etiologies of HE.
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Affiliation(s)
- Chon Kit Pun
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Hui-Chun Huang
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Ching-Chih Chang
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
- Division of Holistic and Multidisciplinary Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shao-Jung Hsu
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yi-Hsiang Huang
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Ming-Chih Hou
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Fa-Yauh Lee
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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Czarnecka AM, Obara-Michlewska M, Wesół-Kucharska D, Greczan M, Kaczor M, Książyk J, Rokicki D, Zielińska M. S100B Protein but Not 3-Nitrotyrosine Positively Correlates with Plasma Ammonia in Patients with Inherited Hyperammonemias: A New Promising Diagnostic Tool? J Clin Med 2023; 12:jcm12062411. [PMID: 36983411 PMCID: PMC10056255 DOI: 10.3390/jcm12062411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/15/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023] Open
Abstract
Individuals with inherited hyperammonemias often present developmental and intellectual deficiencies which are likely to be exaggerated by hyperammonemia episodes in long-term outcomes. In order to find a new, systemic marker common to the course of congenital hyperammonemias, we decided to measure the plasma level of S100 calcium-binding protein B (S100B), which is associated with cerebral impairment. Further, we analyzed three mechanistically diverged but linked with oxidative-nitrosative stress biochemical parameters: 3-nitrotyrosine (3-NT), a measure of plasma proteins' nitration; advanced oxidation protein products (AOPP), a measure of protein oxidation; and glutathione peroxidase (GPx) activity, a measure of anti-oxidative enzymatic capacity. The plasma biomarkers listed above were determined for the first time in congenital hyperammonemia. Also, the level of pro- and anti-inflammatory mediators (i.e., IL-12, IL-6, IL-8, TNF-α, IL-1β, and IL-10) and chemokines (IP-10, MCP-1, MIG, and RANTES) were quantified. S100B was positively correlated with plasma ammonia level, while noticeable levels of circulating 3-NT in some of the patients' plasma did not correlate with ammonia concentration. Overall, the linear correlation between ammonia and S100B but not standard oxidative stress-related markers offers a unique perspective for the future identification and monitoring of neurological deficits risk-linked with hyperammonemia episodes in patients with inherited hyperammonemias. The S100B measure may support the development of therapeutic targets and clinical monitoring in these disorders.
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Affiliation(s)
- Anna Maria Czarnecka
- Department of Neurotoxicology, Mossakowski Medical Research Institute Polish Academy of Sciences, Pawińskiego 5, 02-106 Warsaw, Poland
| | - Marta Obara-Michlewska
- Department of Neurotoxicology, Mossakowski Medical Research Institute Polish Academy of Sciences, Pawińskiego 5, 02-106 Warsaw, Poland
| | - Dorota Wesół-Kucharska
- Department of Pediatrics, Nutrition, and Metabolic Diseases, Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Milena Greczan
- Department of Pediatrics, Nutrition, and Metabolic Diseases, Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Magdalena Kaczor
- Department of Pediatrics, Nutrition, and Metabolic Diseases, Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Janusz Książyk
- Department of Pediatrics, Nutrition, and Metabolic Diseases, Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Dariusz Rokicki
- Department of Pediatrics, Nutrition, and Metabolic Diseases, Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Magdalena Zielińska
- Department of Neurotoxicology, Mossakowski Medical Research Institute Polish Academy of Sciences, Pawińskiego 5, 02-106 Warsaw, Poland
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Lopes FF, Lamberty Faverzani J, Hammerschmidt T, Aguilar Delgado C, Ferreira de Oliveira J, Wajner M, Regla Vargas C. Evaluation of oxidative damage to biomolecules and inflammation in patients with urea cycle disorders. Arch Biochem Biophys 2023; 736:109526. [PMID: 36702451 DOI: 10.1016/j.abb.2023.109526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/11/2023] [Accepted: 01/22/2023] [Indexed: 01/26/2023]
Abstract
Urea cycle disorders (UCD) are inborn errors of metabolism that occur due to a loss of function in enzymes and transporters involved in the urea cycle, causing an intoxication by hyperammonemia and accumulation of metabolites. Patients can develop hepatic encephalopathy (HE), severe neurological and motor disabilities, and often death. The mechanisms involved in the pathophysiology of UCD are many and complex, but there are strong indications that oxidative stress and inflammation are present, being responsible for at least part of the cellular damage that occurs in these diseases. The aim of this study was to evaluate oxidative and nitrosative damage and inflammation in UCD, to better understand the pathophysiology mechanisms of these diseases. We evaluated the nitrite and nitrate content, thiobarbituric acid-reactive substances (TBARS), carbonyl protein content and a panel of cytokines in plasma sample of 14 patients. The UCD patients group consisted of individuals affected with ornithine transcarbamylase deficiency (n = 8), carbamoyl phosphate synthetase deficiency (n = 2), argininosuccinate synthetase deficiency (n = 2); arginase 1 deficiency (n = 1) and argininosuccinate lyase deficiency (n = 1). Patients mean age at diagnosis was 5.25 ± 9.86 years-old and mean concentrations were compared with healthy individuals of matched age and gender. We found a significant reduction in nitrogen reactive species in patients when compared to controls. TBARS was increased in patients, indicating lipid peroxidation. To evaluate protein oxidative damage in UCD, the carbonyl content was measured, and the results also demonstrated an increase in this biomarker. Finally, we found that UCD patients have enhanced concentrations of cytokines, with pro-inflammatory interleukins IL-6, IL-8, interferon-γ and TNF-α, and anti-inflammatory IL-10 being increased when compared to the control group. In conclusion, our results demonstrate that oxidative stress and inflammation occurs in UCD and probably contribute to the severe brain damage present in patients.
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Affiliation(s)
- Franciele Fátima Lopes
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, UFRGS, Brazil; Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.
| | - Jéssica Lamberty Faverzani
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, UFRGS, Brazil; Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Tatiane Hammerschmidt
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, UFRGS, Brazil; Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Camila Aguilar Delgado
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Julia Ferreira de Oliveira
- Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, UFRGS, Brazil; Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Moacir Wajner
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Carmen Regla Vargas
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, UFRGS, Brazil; Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.
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Cellular Pathogenesis of Hepatic Encephalopathy: An Update. Biomolecules 2023; 13:biom13020396. [PMID: 36830765 PMCID: PMC9953810 DOI: 10.3390/biom13020396] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/01/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
Hepatic encephalopathy (HE) is a neuropsychiatric syndrome derived from metabolic disorders due to various liver failures. Clinically, HE is characterized by hyperammonemia, EEG abnormalities, and different degrees of disturbance in sensory, motor, and cognitive functions. The molecular mechanism of HE has not been fully elucidated, although it is generally accepted that HE occurs under the influence of miscellaneous factors, especially the synergistic effect of toxin accumulation and severe metabolism disturbance. This review summarizes the recently discovered cellular mechanisms involved in the pathogenesis of HE. Among the existing hypotheses, ammonia poisoning and the subsequent oxidative/nitrosative stress remain the mainstream theories, and reducing blood ammonia is thus the main strategy for the treatment of HE. Other pathological mechanisms mainly include manganese toxicity, autophagy inhibition, mitochondrial damage, inflammation, and senescence, proposing new avenues for future therapeutic interventions.
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Phillips RK, Steiner JM, Suchodolski JS, Lidbury JA. Urinary 15-F 2t-Isoprostane Concentrations in Dogs with Liver Disease. Vet Sci 2023; 10:vetsci10020082. [PMID: 36851386 PMCID: PMC9958836 DOI: 10.3390/vetsci10020082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 01/25/2023] Open
Abstract
Isoprostanes are stable end products of lipid peroxidation that can be used as markers of oxidative stress. It was previously reported that a cohort of dogs with various liver diseases had increased urinary isoprostane concentrations compared to healthy control (HC) dogs. The aim of this study was to measure and report urinary isoprostane concentrations in dogs with different types of liver diseases. Urine was collected from 21 HC dogs and from 40 dogs with liver disease, including 25 with chronic hepatitis (CH), 7 with steroid hepatopathy (SH), and 8 with a congenital portosystemic shunt (CPSS). In this prospective, observational study, urinary 15-F2t-isoprostane (F2-IsoP) concentrations were measured by liquid chromatography/mass spectrometry and normalized to urinary creatinine concentrations. Concentrations were compared between groups using a Kruskal-Wallis test followed by Dunn's multiple comparisons tests. Significance was set at p < 0.05. The median (range) urinary F2-IsoP to creatinine ratios (ng/mg UCr) were 3.6 (2.2-12.4) for HC dogs, 5.7 (2.4-11.3) for dogs with CH, 4.8 (2.4-8.6) for dogs with SH, and 12.5 (2.9-22.9) for dogs with CPSS. CPSS dogs had significantly higher urinary F2-IsoP concentrations than HC dogs (p = 0.004), suggesting increased oxidative stress among this cohort.
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Oliveira MM, Monnet-Aimard A, Bosoi CR, Tremblay M, Rose CF. Sex is associated with differences in oxidative stress and susceptibility to severe hepatic encephalopathy in bile-duct ligated rats. J Neurochem 2022; 162:337-351. [PMID: 35771118 DOI: 10.1111/jnc.15661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 06/23/2022] [Accepted: 06/26/2022] [Indexed: 11/29/2022]
Abstract
Hepatic encephalopathy (HE) is a debilitating neurological complication of chronic liver disease (CLD). Hyperammonemia plays an important role in HE's pathogenesis, acting synergistically with systemic oxidative stress. During CLD, muscle plays a compensatory role in detoxifying ammonia, and therefore muscle loss leads to an increase in the risk of developing HE. With most animal studies involving males, sex's impact on the development of CLD and associated complications such as HE and muscle loss remains unknown. Therefore, we aimed to identify the impact of sex on CLD, HE, and muscle mass loss in a rodent model of CLD. Liver injury markers, hyperammonemia, oxidative stress, muscle mass and ammonia clearance were measured in female and male bile-duct ligated (BDL) rats. In addition, covert HE was assessed in females while ammonia-precipitated severe HE was assessed in female and male BDL rats, and male BDL rats treated with allopurinol (100mg/kg), an antioxidant (xanthine oxidase inhibitor). Female BDL developed CLD and HE (impaired motor-coordination and night activity) compared to respective SHAM. Hyperammonemia and muscle ammonia clearance were similar between female and male BDL. However, only female BDL rats did not develop muscle loss, brain edema, and short-term memory impairment (vs. female SHAM) and systemic oxidative stress and decreased albumin levels (vs. male BDL). Furthermore, both female BDL and allopurinol-treated male BDL rats were protected against ammonia-induced overt HE. In conclusion, female and male BDL rats develop distinct features of CLD and HE, with systemic oxidative stress playing a pivotal role in the susceptibility to ammonia precipitated overt HE.
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Affiliation(s)
- Mariana M Oliveira
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montreal, Canada
| | - Alexis Monnet-Aimard
- Institut de Neurosciences de la Timone, Équipe inVibe, Université Aix-Marseille, France
| | - Cristina R Bosoi
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montreal, Canada
| | - Mélanie Tremblay
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montreal, Canada
| | - Christopher F Rose
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montreal, Canada
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Häussinger D, Dhiman RK, Felipo V, Görg B, Jalan R, Kircheis G, Merli M, Montagnese S, Romero-Gomez M, Schnitzler A, Taylor-Robinson SD, Vilstrup H. Hepatic encephalopathy. Nat Rev Dis Primers 2022; 8:43. [PMID: 35739133 DOI: 10.1038/s41572-022-00366-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2022] [Indexed: 01/18/2023]
Abstract
Hepatic encephalopathy (HE) is a prognostically relevant neuropsychiatric syndrome that occurs in the course of acute or chronic liver disease. Besides ascites and variceal bleeding, it is the most serious complication of decompensated liver cirrhosis. Ammonia and inflammation are major triggers for the appearance of HE, which in patients with liver cirrhosis involves pathophysiologically low-grade cerebral oedema with oxidative/nitrosative stress, inflammation and disturbances of oscillatory networks in the brain. Severity classification and diagnostic approaches regarding mild forms of HE are still a matter of debate. Current medical treatment predominantly involves lactulose and rifaximin following rigorous treatment of so-called known HE precipitating factors. New treatments based on an improved pathophysiological understanding are emerging.
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Affiliation(s)
- Dieter Häussinger
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
| | - Radha K Dhiman
- Department of Hepatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, (Uttar Pradesh), India
| | - Vicente Felipo
- Laboratory of Neurobiology, Centro de Investigación Principe Felipe, Valencia, Spain
| | - Boris Görg
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Rajiv Jalan
- Liver Failure Group ILDH, Division of Medicine, UCL Medical School, Royal Free Campus, London, UK.,European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Gerald Kircheis
- Department of Gastroenterology, Diabetology and Hepatology, University Hospital Brandenburg an der Havel, Brandenburg Medical School, Brandenburg an der Havel, Germany
| | - Manuela Merli
- Department of Translational and Precision Medicine, Universita' degli Studi di Roma - Sapienza, Roma, Italy
| | | | - Manuel Romero-Gomez
- UCM Digestive Diseases, Virgen del Rocío University Hospital, Institute of Biomedicine of Seville (HUVR/CSIC/US), University of Seville, Seville, Spain
| | - Alfons Schnitzler
- Institute of Clinical Neuroscience and Medical Psychology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Simon D Taylor-Robinson
- Department of Surgery and Cancer, St. Mary's Hospital Campus, Imperial College London, London, UK
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Arjunan A, Sah DK, Jung YD, Song J. Hepatic Encephalopathy and Melatonin. Antioxidants (Basel) 2022; 11:antiox11050837. [PMID: 35624703 PMCID: PMC9137547 DOI: 10.3390/antiox11050837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 04/06/2022] [Accepted: 04/24/2022] [Indexed: 11/25/2022] Open
Abstract
Hepatic encephalopathy (HE) is a severe metabolic syndrome linked with acute/chronic hepatic disorders. HE is also a pernicious neuropsychiatric complication associated with cognitive decline, coma, and death. Limited therapies are available to treat HE, which is formidable to oversee in the clinic. Thus, determining a novel therapeutic approach is essential. The pathogenesis of HE has not been well established. According to various scientific reports, neuropathological symptoms arise due to excessive accumulation of ammonia, which is transported to the brain via the blood–brain barrier (BBB), triggering oxidative stress and inflammation, and disturbing neuronal-glial functions. The treatment of HE involves eliminating hyperammonemia by enhancing the ammonia scavenging mechanism in systemic blood circulation. Melatonin is the sole endogenous hormone linked with HE. Melatonin as a neurohormone is a potent antioxidant that is primarily synthesized and released by the brain’s pineal gland. Several HE and liver cirrhosis clinical studies have demonstrated impaired synthesis, secretion of melatonin, and circadian patterns. Melatonin can cross the BBB and is involved in various neuroprotective actions on the HE brain. Hence, we aim to elucidate how HE impairs brain functions, and elucidate the precise molecular mechanism of melatonin that reverses the HE effects on the central nervous system.
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Affiliation(s)
- Archana Arjunan
- Department of Anatomy, Chonnam National University Medical School, Hwasun 58128, Korea;
| | - Dhiraj Kumar Sah
- Department of Biochemistry, Chonnam National University Medical School, Hwasun 58128, Korea;
| | - Young Do Jung
- Department of Biochemistry, Chonnam National University Medical School, Hwasun 58128, Korea;
- Correspondence: (Y.D.J.); (J.S.); Tel.: +82-61-379-2706 (J.S.)
| | - Juhyun Song
- Department of Anatomy, Chonnam National University Medical School, Hwasun 58128, Korea;
- BioMedical Sciences Graduate Program (BMSGP), Chonnam National University, 264 Seoyangro, Hwasun 58128, Korea
- Correspondence: (Y.D.J.); (J.S.); Tel.: +82-61-379-2706 (J.S.)
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Hansen MKG, Kjærgaard K, Eriksen LL, Grønkjær LL, Mikkelsen ACD, Sandahl TD, Vilstrup H, Thomsen KL, Lauridsen MME. Psychometric methods for diagnosing and monitoring minimal hepatic encephalopathy -current validation level and practical use. Metab Brain Dis 2022; 37:589-605. [PMID: 35102491 DOI: 10.1007/s11011-022-00913-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/14/2022] [Indexed: 02/07/2023]
Abstract
Hepatic encephalopathy (HE) is cerebral dysfunction caused by liver failure and inflicts 30-40% of patients with liver cirrhosis during their disease course. Clinically manifest HE is often preceded by minimal HE (MHE) - a clinically undetectable cognitive disturbance closely associated with loss of quality of life. Accordingly, detecting and treating MHE improve the patients' daily functioning and prevent HE-related hospital admissions. The scope of this review article is to create an overview of the validation level and usage of psychometric tests used to detect MHE: Portosystemic hepatic encephalopathy test, continuous reaction time test, Stroop EncephalApp, animal naming test, critical flicker frequency test, and inhibitory control test. Our work is aimed at the clinician or scientist who is about to decide on which psychometric test would fit best in their clinic, cohort, or study. First, we outline psychometric test validation obstacles and requirements. Then, we systematically approach the literature on each test and select well-conducted studies to answer the following questions:• Which percentage of patients with cirrhosis does the test deem as having MHE?• Is the test able to predict clinically manifest HE?• Is there a well-known test-retest variation and inter-observer variation?• Is the test able to detect a treatment response?• Is the test result affected by age, educational level, gender, or comorbidities?
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Affiliation(s)
- Mads Kingo Guldberg Hansen
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark.
| | - Kristoffer Kjærgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Lotte Lindgreen Eriksen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Lea Ladegaard Grønkjær
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark
| | - Anne Catrine Daugaard Mikkelsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Thomas Damgaard Sandahl
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Karen Louise Thomsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Mette Munk Enok Lauridsen
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark
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Bonanno JA, Shyam R, Choi M, Ogando DG. The H + Transporter SLC4A11: Roles in Metabolism, Oxidative Stress and Mitochondrial Uncoupling. Cells 2022; 11:197. [PMID: 35053313 PMCID: PMC8773465 DOI: 10.3390/cells11020197] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 12/23/2022] Open
Abstract
Solute-linked cotransporter, SLC4A11, a member of the bicarbonate transporter family, is an electrogenic H+ transporter activated by NH3 and alkaline pH. Although SLC4A11 does not transport bicarbonate, it shares many properties with other members of the SLC4 family. SLC4A11 mutations can lead to corneal endothelial dystrophy and hearing deficits that are recapitulated in SLC4A11 knock-out mice. SLC4A11, at the inner mitochondrial membrane, facilitates glutamine catabolism and suppresses the production of mitochondrial superoxide by providing ammonia-sensitive H+ uncoupling that reduces glutamine-driven mitochondrial membrane potential hyperpolarization. Mitochondrial oxidative stress in SLC4A11 KO also triggers dysfunctional autophagy and lysosomes, as well as ER stress. SLC4A11 expression is induced by oxidative stress through the transcription factor NRF2, the master regulator of antioxidant genes. Outside of the corneal endothelium, SLC4A11's function has been demonstrated in cochlear fibrocytes, salivary glands, and kidneys, but is largely unexplored overall. Increased SLC4A11 expression is a component of some "glutamine-addicted" cancers, and is possibly linked to cells and tissues that rely on glutamine catabolism.
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Affiliation(s)
- Joseph A. Bonanno
- Vision Science Program, School of Optometry, Indiana University, Bloomington, IN 47405, USA; (R.S.); (M.C.).; (D.G.O.)
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11
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Murad H, Tayeb H, Mosli M, Rafeeq M, Basheikh M. Blood Levels of Glutamine and Nitrotyrosine in Patients with Chronic Viral Hepatitis. Int J Gen Med 2021; 14:8753-8762. [PMID: 34858046 PMCID: PMC8631182 DOI: 10.2147/ijgm.s337909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/02/2021] [Indexed: 12/16/2022] Open
Abstract
Purpose Oxidative stress is involved in pathogenesis of chronic viral hepatitis. Glutamine is an antioxidant, but there is a controversy about its risk-benefits. Nitrotyrosine is an oxidative stress marker. This observational cross-sectional study was designed to compare blood levels of glutamine and nitrotyrosine in treated versus untreated chronic viral hepatitis patients. Patients and Methods Five groups (n = 250) were included: hepatitis B untreated (HBV), hepatitis C untreated (HCV), HBV treated (HBVT), and HCV treated (HCVT) groups plus a normal control group. Liver function tests and blood levels of glutamine, nitrotyrosine, viral loads, and HBsAg were measured. Results Blood levels of glutamine and nitrotyrosine in all patient groups significantly increased compared with normal controls with non-significant differences in-between. Both tests showed significant large correlations with HBV-DNA or HCV-RNA test positivity, high accuracies, and cutoff scores with high sensitivities and specificities. The viral loads and HBsAg levels were significantly lower in treated versus untreated groups. However, they poorly correlated with levels of glutamine and nitrotyrosine in all patient groups. Conclusion Blood levels of glutamine and nitrotyrosine significantly increased in treated and untreated chronic viral hepatitis B and C patients compared with normal controls. Both tests showed high accuracies and cutoff scores with high sensitivities and specificities. However, they did not differ significantly in treated versus untreated patients. To our knowledge, this is the first data showing elevation of glutamine and nitrotyrosine in treated and untreated chronic viral hepatitis. A prospective longitudinal study with repeated measurements of glutamine and nitrotyrosine is recommended to verify if they can predict response to treatment. Study of other oxidative stress markers is also advised to clarify if the elevated nitrotyrosine could be an oxidative stress marker in these patients, and whether the increased glutamine could act as an antioxidant or as a predictive agent for deleterious consequences.
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Affiliation(s)
- Hussam Murad
- Department of Pharmacology, Faculty of Medicine, Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia.,Department of Pharmacology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Haythum Tayeb
- Department of Medicine, Division of Neurology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mahmoud Mosli
- Department of Medicine, Division of Gastroenterology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Misbahuddin Rafeeq
- Department of Pharmacology, Faculty of Medicine, Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammed Basheikh
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Salman T, Elsabaawy M, Omar M, Afify M, Elezawy H, Ghanem S, Abdelraouf O, Rewisha E, Shebl N. Evaluation of different diagnostic modalities of minimal hepatic encephalopathy in cirrhotic patients: case-control study. Clin Exp Hepatol 2021; 7:312-319. [PMID: 34712834 PMCID: PMC8527340 DOI: 10.5114/ceh.2021.109292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/13/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Minimal hepatic encephalopathy (MHE) represents one of the most overlooked complications of liver cirrhosis. AIM OF THE STUDY To compare the utility and efficacy of different MHE diagnostic modalities. MATERIAL AND METHODS This case-control study was conducted on hepatitis C virus (HCV)-related compensated cirrhotic patients. The Psychometric Hepatic Encephalopathy Score (PHES) was used to assign patients to MHE and controls. All patients were subjected to plasma ammonia, serum 3-nitrotyrosine (3-NT), critical flicker frequency (CFF), and the modified inhibitory control test (ICT). RESULTS CFF was significantly lower in the control group (38.5, 40 Hz, p = 0.003). The unweighted lures on ICT were 8.7, 4.9 in MHE and controls (p < 0.001). Moreover, ammonia was higher in the MHE group (89, 61.5 µmol/l, p < 0.001). 3-NT was also higher in the MHE group (31.5, 13.7 nmol/l, p < 0.001) respectively. CFF at cutoff < 39 Hz had sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 57.5%, 77.5%, 71.9% and 64.6%, respectively; in modified ICT, at cutoff > 5 unweighted lures the values were 87.5%, 80%, 81.4% and 86.5%, respectively; in ammonia, at cutoff ≥ 76.45 µmol/l the values were 65%, 72.5%, 70.3% and 67.4%, respectively; for 3-NT at cutoff ≥ 14.15 nmol/l the values were 85%, 82.5%, 82.9% and 84.6%, respectively. The accuracy for MHE diagnosis was 67.5%, 83.3%, 68.8%, 83.8% relying on CFF, 3-NT, ammonia, and ICT respectively. On multivariate analysis, CFF < 39 Hz (OR = 10.2, p = 0.04), modified ICT > 5 unweighted lures (OR = 43.2, p = 0.002), and serum 3-NT levels ≥ 14.15 nmol/l (OR = 50.4, p < 0.001) were independent predictors of MHE. CONCLUSIONS 3-NT and ICT are advantageous to reveal MHE in compensated liver cirrhosis, while CFF can be only used as adjuncts, with humble merits of ammonia.
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Affiliation(s)
- Tary Salman
- National Liver Institute, Menoufia University, Egypt
| | | | - Mahmoud Omar
- National Liver Institute, Menoufia University, Egypt
| | - Mohamed Afify
- National Liver Institute, Menoufia University, Egypt
| | | | - Samar Ghanem
- National Liver Institute, Menoufia University, Egypt
| | - Osama Abdelraouf
- Faculty of Computers and Information, Menoufia University, Egypt
| | - Eman Rewisha
- National Liver Institute, Menoufia University, Egypt
| | - Nashwa Shebl
- National Liver Institute, Menoufia University, Egypt
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13
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Häussinger D, Butz M, Schnitzler A, Görg B. Pathomechanisms in hepatic encephalopathy. Biol Chem 2021; 402:1087-1102. [PMID: 34049427 DOI: 10.1515/hsz-2021-0168] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/12/2021] [Indexed: 02/06/2023]
Abstract
Hepatic encephalopathy (HE) is a frequent neuropsychiatric complication in patients with acute or chronic liver failure. Symptoms of HE in particular include disturbances of sensory and motor functions and cognition. HE is triggered by heterogeneous factors such as ammonia being a main toxin, benzodiazepines, proinflammatory cytokines and hyponatremia. HE in patients with liver cirrhosis is triggered by a low-grade cerebral edema and cerebral oxidative/nitrosative stress which bring about a number of functionally relevant alterations including posttranslational protein modifications, oxidation of RNA, gene expression changes and senescence. These alterations are suggested to impair astrocyte/neuronal functions and communication. On the system level, a global slowing of oscillatory brain activity and networks can be observed paralleling behavioral perceptual and motor impairments. Moreover, these changes are related to increased cerebral ammonia, alterations in neurometabolite and neurotransmitter concentrations and cortical excitability in HE patients.
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Affiliation(s)
- Dieter Häussinger
- Clinic for Gastroenterology, Hepatology, and Infectious Diseases, Heinrich Heine University, Moorenstr. 5, D-40225 Düsseldorf, Germany
| | - Markus Butz
- Department of Neurology/Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University, Moorenstr. 5, D-40225 Düsseldorf, Germany
| | - Alfons Schnitzler
- Department of Neurology/Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University, Moorenstr. 5, D-40225 Düsseldorf, Germany
| | - Boris Görg
- Clinic for Gastroenterology, Hepatology, and Infectious Diseases, Heinrich Heine University, Moorenstr. 5, D-40225 Düsseldorf, Germany
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14
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Milewski K, Czarnecka AM, Albrecht J, Zielińska M. Decreased Expression and Uncoupling of Endothelial Nitric Oxide Synthase in the Cerebral Cortex of Rats with Thioacetamide-Induced Acute Liver Failure. Int J Mol Sci 2021; 22:6662. [PMID: 34206365 PMCID: PMC8268495 DOI: 10.3390/ijms22136662] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/16/2021] [Accepted: 06/18/2021] [Indexed: 02/04/2023] Open
Abstract
Acute liver failure (ALF) is associated with deregulated nitric oxide (NO) signaling in the brain, which is one of the key molecular abnormalities leading to the neuropsychiatric disorder called hepatic encephalopathy (HE). This study focuses on the effect of ALF on the relatively unexplored endothelial NOS isoform (eNOS). The cerebral prefrontal cortices of rats with thioacetamide (TAA)-induced ALF showed decreased eNOS expression, which resulted in an overall reduction of NOS activity. ALF also decreased the content of the NOS cofactor, tetrahydro-L-biopterin (BH4), and evoked eNOS uncoupling (reduction of the eNOS dimer/monomer ratio). The addition of the NO precursor L-arginine in the absence of BH4 potentiated ROS accumulation, whereas nonspecific NOS inhibitor L-NAME or EDTA attenuated ROS increase. The ALF-induced decrease of eNOS content and its uncoupling concurred with, and was likely causally related to, both increased brain content of reactive oxidative species (ROS) and decreased cerebral cortical blood flow (CBF) in the same model.
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Affiliation(s)
| | | | | | - Magdalena Zielińska
- Department of Neurotoxicology, Mossakowski Medical Research Institute, Polish Academy of Sciences, 5 Pawińskiego Str, 02-106 Warsaw, Poland; (K.M.); (A.M.C.); (J.A.)
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15
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Rose CF, Amodio P, Bajaj JS, Dhiman RK, Montagnese S, Taylor-Robinson SD, Vilstrup H, Jalan R. Hepatic encephalopathy: Novel insights into classification, pathophysiology and therapy. J Hepatol 2020; 73:1526-1547. [PMID: 33097308 DOI: 10.1016/j.jhep.2020.07.013] [Citation(s) in RCA: 204] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023]
Abstract
Hepatic encephalopathy (HE) is a frequent and serious complication of both chronic liver disease and acute liver failure. HE manifests as a wide spectrum of neuropsychiatric abnormalities, from subclinical changes (mild cognitive impairment) to marked disorientation, confusion and coma. The clinical and economic burden of HE is considerable, and it contributes greatly to impaired quality of life, morbidity and mortality. This review will critically discuss the latest classification of HE, as well as the pathogenesis and pathophysiological pathways underlying the neurological decline in patients with end-stage liver disease. In addition, management strategies, diagnostic approaches, currently available therapeutic options and novel treatment strategies are discussed.
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Affiliation(s)
- Christopher F Rose
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montreal, Canada.
| | - Piero Amodio
- Department of Medicine, University of Padova, Padova, Italy
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - Radha Krishan Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Simon D Taylor-Robinson
- Department of Surgery and Cancer, St. Mary's Hospital Campus, Imperial College London, London, United Kingdom
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom; European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.
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16
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Alsebaey A. Prediction of minimal encephalopathy in patients with HCV-related cirrhosis using albumin-bilirubin, platelets-albumin-bilirubin score, albumin-bilirubin-platelets grade and ammonia level. EGYPTIAN LIVER JOURNAL 2020. [DOI: 10.1186/s43066-020-0023-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Abstract
Background
Minimal hepatic encephalopathy (MHE) is a complication of liver cirrhosis causing low quality of life, driving skills and higher traffic violation. The neuro-psychometric tests are the gold standard but difficult clinically and time-consuming. The aim was to assess albumin-bilirubin (ALBI), platelets-albumin-bilirubin (PALBI) score, albumin-bilirubin-platelets (ALBI-PLT) grade and ammonia level as MHE predictors. All the patients (n = 257) underwent critical flicker frequency number connection, serial dotting and digit symbol test for MHE diagnosis (n = 166, 64.6%). Liver function, INR, CBC and arterial ammonia were measured.
Results
There was statistically significant difference (p < 0.05) between MHE patients and those without as regards ammonia (86.59 ± 23.25 vs. 63.56 ± 24.2 μmol/L), ALBI score (−2.13 ± 0.53 vs. −2.49 ± 0.38), PALBI score (−2.33 ± 0.39 vs. −2.55 ± 0.26) and ALBI-PLT (3.98 ± 0.49 vs. 3.70 ± 0.56). Patients with MHE were mainly Child-Pugh B and C and also ALBI grade 2 and 3. For MHE discrimination, ALBI, PALBI, ALBI-PLT and ammonia had the following cutoffs >−2.36 (57.23% sensitivity, 77.78% specificity), >−2.5 (60.84% sensitivity, 67.9% specificity), > 3 (87.35% sensitivity, 27.16% specificity) and > 76.5 (69% sensitivity, 72.5% specificity) respectively (p = 0.001). On comparison of the area under the curve, ALBI is comparable to PALBI (p = 0.245) and ammonia (p = 0.603). The ALBI-PLT is inferior to ALBI (p = 0.018) and ammonia (p = 0.021) but comparable to PALBI (p = 0.281). ALBI (odds = 5.64), PALBI (odds = 7.86), ALBI-PLT (odds = 2.86), ammonia (odds = 1.05), Child-Pugh score (odds = 2.13), MELD (odds = 1.26) are independent predictors of MHE.
Conclusion
ALBI, PALBI and ammonia are clinical useful model for MHE prediction.
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Verdelho Machado M. Liquid Diagnosis of Hepatic Encephalopathy: Are We There Already? GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 27:378-382. [PMID: 33251286 PMCID: PMC7670371 DOI: 10.1159/000510059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 06/18/2020] [Indexed: 06/12/2023]
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18
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Interplay of cardiovascular mediators, oxidative stress and inflammation in liver disease and its complications. Nat Rev Cardiol 2020; 18:117-135. [PMID: 32999450 DOI: 10.1038/s41569-020-0433-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2020] [Indexed: 12/11/2022]
Abstract
The liver is a crucial metabolic organ that has a key role in maintaining immune and endocrine homeostasis. Accumulating evidence suggests that chronic liver disease might promote the development of various cardiac disorders (such as arrhythmias and cardiomyopathy) and circulatory complications (including systemic, splanchnic and pulmonary complications), which can eventually culminate in clinical conditions ranging from portal and pulmonary hypertension to pulmonary, cardiac and renal failure, ascites and encephalopathy. Liver diseases can affect cardiovascular function during the early stages of disease progression. The development of cardiovascular diseases in patients with chronic liver failure is associated with increased morbidity and mortality, and cardiovascular complications can in turn affect liver function and liver disease progression. Furthermore, numerous infectious, inflammatory, metabolic and genetic diseases, as well as alcohol abuse can also influence both hepatic and cardiovascular outcomes. In this Review, we highlight how chronic liver diseases and associated cardiovascular effects can influence different organ pathologies. Furthermore, we explore the potential roles of inflammation, oxidative stress, vasoactive mediator imbalance, dysregulated endocannabinoid and autonomic nervous systems and endothelial dysfunction in mediating the complex interplay between the liver and the systemic vasculature that results in the development of the extrahepatic complications of chronic liver disease. The roles of ageing, sex, the gut microbiome and organ transplantation in this complex interplay are also discussed.
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San Martín-Valenzuela C, Borras-Barrachina A, Gallego JJ, Urios A, Mestre-Salvador V, Correa-Ghisays P, Ballester MP, Escudero-García D, Tosca J, Montón C, Ríos MP, Kosenko E, Felipo V, Tabares-Seisdedos R, Selva-Vera G, Montoliu C. Motor and Cognitive Performance in Patients with Liver Cirrhosis with Minimal Hepatic Encephalopathy. J Clin Med 2020; 9:E2154. [PMID: 32650464 PMCID: PMC7408738 DOI: 10.3390/jcm9072154] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/01/2020] [Accepted: 07/06/2020] [Indexed: 12/28/2022] Open
Abstract
Minimal hepatic encephalopathy (MHE) is associated with mild cognitive impairment and frailty. This study aims to identify cognitive and motor differences in cirrhotic patients with and without MHE, and the correlations between motor signs and cognitive performance. Gait, balance, hand strength and motor speed performance were evaluated in 66 cirrhotic patients (38 without and 28 with MHE, according to the Psychometric Hepatic Encephalopathy Score (PHES). Cognitive performance was measured with the Mini-Mental State Examination, Verbal Fluency Test, Aprendizaje Verbal España-Complutense Test (TAVEC), Wechsler Adult Intelligence Scale III, Hamilton Depression and Anxiety Rating Scale and Functioning Assessment Short Test (FAST). MHE patients performed worse than patients without MHE in cognitive and autonomous functioning, learning and long-term memory, and verbal fluency. The same pattern was found in gait, center of pressure movement, variability of hand strength performance and hand motor speed. In MHE patients, high correlations were found between balance and FAST test, gait velocity and verbal skills, hand strength variability and anxiety and depression, and motor speed and FAST and TAVEC. MHE patients showed worse motor and cognitive performance than patients without MHE. MHE patients could have impaired movement control expressed as bradykinesia, and this reduced motor performance could correlate with cognitive performance.
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Affiliation(s)
- Constanza San Martín-Valenzuela
- Unit of Personal Autonomy, Dependency and Mental Disorder Assessment, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain; (C.S.M.-V.); (A.B.-B.); (V.M.-S.); (R.T.-S.)
- Department of Physiotherapy, Faculty of Physiotherapy, University of Valencia, 46010 Valencia, Spain
- Centro Investigación Biomédica en Red de Salud Mental, CIBERSAM, 28029 Madrid, Spain;
| | - Aroa Borras-Barrachina
- Unit of Personal Autonomy, Dependency and Mental Disorder Assessment, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain; (C.S.M.-V.); (A.B.-B.); (V.M.-S.); (R.T.-S.)
| | - Juan-José Gallego
- INCLIVA, Health Research Institute, 46010 Valencia, Spain; (J.-J.G.); (A.U.); (M.-P.B.)
| | - Amparo Urios
- INCLIVA, Health Research Institute, 46010 Valencia, Spain; (J.-J.G.); (A.U.); (M.-P.B.)
| | - Víctor Mestre-Salvador
- Unit of Personal Autonomy, Dependency and Mental Disorder Assessment, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain; (C.S.M.-V.); (A.B.-B.); (V.M.-S.); (R.T.-S.)
| | - Patricia Correa-Ghisays
- Centro Investigación Biomédica en Red de Salud Mental, CIBERSAM, 28029 Madrid, Spain;
- Faculty of Psychology, University of Valencia, 46010 Valencia, Spain
| | - María-Pilar Ballester
- INCLIVA, Health Research Institute, 46010 Valencia, Spain; (J.-J.G.); (A.U.); (M.-P.B.)
- Digestive Medicine Unit, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.)
| | - Desamparados Escudero-García
- Digestive Medicine Unit, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.)
- Department of Medicine, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain
| | - Joan Tosca
- Digestive Medicine Unit, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.)
| | - Cristina Montón
- Digestive Medicine Unit, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.)
| | - María-Pilar Ríos
- Digestive Service, Arnau de Vilanova Hospital, 46015 Valencia, Spain;
| | - Elena Kosenko
- Institute of Theoretical and Experimental Biophysics of Russian Academy of Sciences, 142290 Pushchino, Russia;
| | - Vicente Felipo
- Laboratory of Neurobiology, Príncipe Felipe Research Center, 46012 Valencia, Spain;
| | - Rafael Tabares-Seisdedos
- Unit of Personal Autonomy, Dependency and Mental Disorder Assessment, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain; (C.S.M.-V.); (A.B.-B.); (V.M.-S.); (R.T.-S.)
- Centro Investigación Biomédica en Red de Salud Mental, CIBERSAM, 28029 Madrid, Spain;
- Department of Medicine, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain
| | - Gabriel Selva-Vera
- Unit of Personal Autonomy, Dependency and Mental Disorder Assessment, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain; (C.S.M.-V.); (A.B.-B.); (V.M.-S.); (R.T.-S.)
- Centro Investigación Biomédica en Red de Salud Mental, CIBERSAM, 28029 Madrid, Spain;
- Unit of Psychiatry and Psychological Medicine, Hospital Clinico Universitario de Valencia, 46010 Valencia, Spain
| | - Carmina Montoliu
- INCLIVA, Health Research Institute, 46010 Valencia, Spain; (J.-J.G.); (A.U.); (M.-P.B.)
- Department of Pathology, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain
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Karanfilian BV, Cheung M, Dellatore P, Park T, Rustgi VK. Laboratory Abnormalities of Hepatic Encephalopathy. Clin Liver Dis 2020; 24:197-208. [PMID: 32245527 DOI: 10.1016/j.cld.2020.01.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Currently, there is no gold standard serologic or imaging modality to detect hepatic encephalopathy (HE). It is a clinical diagnosis gathered from the history and physical. Imaging is nonspecific; however, PET and MRI have shown areas of utility, but are not widely available, cost-efficient, or necessary for diagnosis. Electroencephalogram has shown promise as it can be used in conjunction with the Portal Systemic Hepatic Encephalopathy Score test to diagnose minimal HE. Further research on these techniques would need to be performed to identify strict criteria and cutoffs for diagnosing HE as well as associated sensitivities and specificities.
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Affiliation(s)
- Briette Verken Karanfilian
- Department of Internal Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA; Department of Medicine, 125 Paterson Street, New Brunswick, NJ 08901, USA
| | - Maggie Cheung
- Department of Internal Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA; Department of Medicine, 125 Paterson Street, New Brunswick, NJ 08901, USA
| | - Peter Dellatore
- Department of Internal Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA; Department of Medicine, 125 Paterson Street, New Brunswick, NJ 08901, USA
| | - Taeyang Park
- Department of Internal Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA; Department of Medicine, 125 Paterson Street, New Brunswick, NJ 08901, USA
| | - Vinod K Rustgi
- Department Gastroenterology and Hepatology, Rutgers-Robert Wood Johnson Medical School, 125 Paterson Street, Suite 5100B, New Brunswick, NJ 08901, USA.
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21
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KASL clinical practice guidelines for liver cirrhosis: Varices, hepatic encephalopathy, and related complications. Clin Mol Hepatol 2020; 26:83-127. [PMID: 31918536 PMCID: PMC7160350 DOI: 10.3350/cmh.2019.0010n] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 02/06/2023] Open
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Liotta EM, Kimberly WT. Cerebral edema and liver disease: Classic perspectives and contemporary hypotheses on mechanism. Neurosci Lett 2020; 721:134818. [PMID: 32035166 DOI: 10.1016/j.neulet.2020.134818] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 02/01/2020] [Accepted: 02/03/2020] [Indexed: 02/07/2023]
Abstract
Liver disease is a growing public health concern. Hepatic encephalopathy, the syndrome of brain dysfunction secondary to liver disease, is a frequent complication of both acute and chronic liver disease and cerebral edema (CE) is a key feature. While altered ammonia metabolism is a key contributor to hepatic encephalopathy and CE in liver disease, there is a growing appreciation that additional mechanisms contribute to CE. In this review we will begin by presenting three classic perspectives that form a foundation for a discussion of CE in liver disease: 1) CE is unique to acute liver failure, 2) CE in liver disease is only cytotoxic, and 3) CE in liver disease is primarily an osmotically mediated consequence of ammonia and glutamine metabolism. We will present each classic perspective along with more recent observations that call in to question that classic perspective. After highlighting these areas of debate, we will explore the leading contemporary mechanisms hypothesized to contribute to CE during liver disease.
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Affiliation(s)
- Eric M Liotta
- Northwestern University-Feinberg School of Medicine, Department of Neurology, United States; Northwestern University-Feinberg School of Medicine, Department of Surgery, Division of Organ Transplantation, United States; Northwestern University Transplant Outcomes Research Collaboration, United States.
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cGMP signaling pathway in hepatic encephalopathy neuroinflammation and cognition. Int Immunopharmacol 2019; 79:106082. [PMID: 31869775 DOI: 10.1016/j.intimp.2019.106082] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/05/2019] [Accepted: 11/24/2019] [Indexed: 12/25/2022]
Abstract
Hepatic encephalopathy (HE) is a complex neuropsychiatric syndrome that results from liver failure and is characterized by a wide range of symptoms such as alteration in the sleep-waking cycle, neuromuscular coordination, mood, and cognition. The deregulation of nitric oxide (NO)/cyclic guanosine monophosphate (cGMP)/protein kinase G (PKG) signaling pathway is thought to play an important role in the etiology and progression of neurodegenerative diseases, and several studies pointed that the cGMP signaling is impaired in patients with HE and experimental models of chronic hyperammonemia. This review aimed to briefly present the current knowledge of the cGMP signaling pathways in neuroinflammation, neurogenesis, and memory in hepatic encephalopathy and its potential therapeutic role.
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Bai Z, Bernardi M, Yoshida EM, Li H, Guo X, Méndez-Sánchez N, Li Y, Wang R, Deng J, Qi X. Albumin infusion may decrease the incidence and severity of overt hepatic encephalopathy in liver cirrhosis. Aging (Albany NY) 2019; 11:8502-8525. [PMID: 31596729 PMCID: PMC6814610 DOI: 10.18632/aging.102335] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 09/22/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The role of human albumin infusion for the prevention and treatment of overt hepatic encephalopathy (HE) in liver cirrhosis remains unclear. RESULTS Among the 708 patients without pre-existing overt HE, albumin infusion significantly decreased the incidence of overt HE (4.20% versus 12.70%, P<0.001) and in-hospital mortality (1.70% versus 5.40%, P=0.008). Among the 182 patients with overt HE at admission or during hospitalization, albumin infusion significantly improved overt HE (84.60% versus 68.10%, P=0.009) and decreased in-hospital mortality (7.70% versus 19.80%, P=0.018). Meta-analysis of 6 studies found that albumin infusion might decrease the risk of overt HE (OR=1.63, P=0.07), but the difference was not statistically significant. Meta-analysis of 3 studies found that albumin infusion significantly improved overt HE (OR=2.40, P=0.04). CONCLUSIONS Based on the results of our retrospective study and meta-analysis, albumin infusion might prevent from the occurrence of overt HE and improve the severity of overt HE in cirrhosis. Our retrospective study also suggested that albumin infusion improved the outcomes of cirrhotic patients regardless of overt HE. METHODS Cirrhotic patients consecutively admitted between January 2010 and June 2014 were considered in a retrospective study. A 1:1 propensity score matching analysis was performed. Additionally, publications regarding albumin infusion for the management of overt HE were systematically searched. Meta-analyses were performed by random-effect model. Odds ratio (OR) was calculated.
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Affiliation(s)
- Zhaohui Bai
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, P.R. China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, P.R. China
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Eric M. Yoshida
- Division of Gastroenterology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Hongyu Li
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Nahum Méndez-Sánchez
- Liver Research Unit, Medica Sur Clinic and Foundation and Faculty of Medicine, National Autonomous University of Mexico, Mexico
| | - Yingying Li
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Ran Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Jiao Deng
- Department of Pharmacology, General Hospital of Northern Theater Command, (formerly called General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, P.R. China
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25
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Zheng W, Zhu WW, Feng ZC, Liang Q, Rong PF, Li LF, Liao YJ, Wang W. Increased serum malondialdehyde levels are associated with grey matter volume loss in patients with non-alcoholic cirrhosis. Quant Imaging Med Surg 2019; 9:230-237. [PMID: 30976547 DOI: 10.21037/qims.2018.12.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Grey matter volume (GMV) loss has been observed in patients with non-alcoholic cirrhosis, but the underlying mechanisms are unknown. Oxidative stress (OS) is a recognized feature and systemic phenomenon of cirrhosis. However, little is known about whether OS is associated with GMV loss in cirrhosis. This study aimed to assess the relationship between oxidative damage and GMV loss in patients with non-alcoholic cirrhosis. Methods Thirty-four patients with non-alcoholic cirrhosis and 27 age- and sex-matched healthy controls were enrolled in this prospective study. All subjects underwent brain magnetic resonance imaging (MRI), and voxel-based morphometry (VBM) was performed to assess normalized global GMV. As an OS marker, serum malondialdehyde (MDA) levels were determined in all subjects. In the patient group, a correlation analysis was used to investigate the relationship between serum MDA levels and normalized global GMV. Results Compared with healthy controls, cirrhotic patients displayed a significant decrease in normalized global GMV and a significant increase in serum MDA levels. In the patient group, serum MDA levels were negatively correlated with normalized global GMV adjusted for age, sex and Child-Pugh class. Conclusions Increased serum MDA levels were associated with GMV loss in patients with non-alcoholic cirrhosis, suggesting that oxidative damage may be involved in GMV loss observed in cirrhotic patients.
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Affiliation(s)
- Wei Zheng
- Department of Radiology, The Third Xiangya Hospital, Central South University, Changsha 410013, China
| | - Wen-Wei Zhu
- Department of Radiology, The Third Xiangya Hospital, Central South University, Changsha 410013, China
| | - Zhi-Chao Feng
- Department of Radiology, The Third Xiangya Hospital, Central South University, Changsha 410013, China
| | - Qi Liang
- Department of Radiology, The Third Xiangya Hospital, Central South University, Changsha 410013, China
| | - Peng-Fei Rong
- Department of Radiology, The Third Xiangya Hospital, Central South University, Changsha 410013, China
| | - Li-Feng Li
- Department of Radiology, The Third Xiangya Hospital, Central South University, Changsha 410013, China
| | - Yun-Jie Liao
- Department of Radiology, The Third Xiangya Hospital, Central South University, Changsha 410013, China
| | - Wei Wang
- Department of Radiology, The Third Xiangya Hospital, Central South University, Changsha 410013, China
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Ochoa-Sanchez R, Rose CF. Pathogenesis of Hepatic Encephalopathy in Chronic Liver Disease. J Clin Exp Hepatol 2018; 8:262-271. [PMID: 30302043 PMCID: PMC6175755 DOI: 10.1016/j.jceh.2018.08.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 08/09/2018] [Indexed: 12/12/2022] Open
Abstract
Hepatic encephalopathy (HE) is a complex neuropsychiatric syndrome that occurs during chronic liver disease (CLD). While ammonia and other precipitating factors in liver disease including inflammation, bile acids, oxidative stress, and lactate play a role in the pathogenesis of HE, the exact mechanism that leads to HE is not fully understood. Notably, accumulating evidence points toward a synergic effect rather than independent actions among precipitating factors that contributes to the development and severity of HE in CLD. Hence, this review is aimed to briefly discuss the single and synergic interplay of pathological factors in the progression and severity of HE.
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Key Words
- AQP4, Aquaporin 4
- BAs, Bile Acids
- BBB, Blood-Brain Barrier
- BDL, Bile Duct Ligation
- CLD, Chronic Liver Disease
- CSF, Cerebrospinal Fluid
- GABA, Gamma-Aminobutyric Acid
- GAMSAs, GABAA Receptor Modulating Steroid Antagonists
- GFAP, Glial Fibrillary Acid Protein
- GLAST, Glial Glutamate-Aspartate Transporter
- GPR81, G-Protein-Coupled Receptor 81
- GS, Glutamine Synthetase
- HE, Hepatic Encephalopathy
- ICP, Intracranial Pressure
- ILs, Interleukins
- MRI, Magnetic Resonance Imaging
- NF-?B, Nuclear Factor Kappa B
- NMDA, N-Methyl-d-Aspartate Glutamate Receptor
- NO, Nitric Oxide
- PCA, Portacaval Anastomosis
- ROS, Reactive Oxygen Species
- TJ, Tight Junction
- TNF-a, Tumor Necrosis Alpha
- ammonia
- astrocyte swelling
- bile acids
- brain edema
- cGMP, Cyclic Guanosine Monophosphate
- cirrhosis
- hepatic encephalopathy
- inflammation
- lactate
- mGluR, Metabotropic Glutamate Receptor
- neurotransmission
- oxidative stress
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Affiliation(s)
| | - Christopher F. Rose
- Address for correspondence. Christopher F. Rose Professor, Dept. Medicine, Université de Montréal, CRCHUM, 900 Saint-Denis Street, Montréal, Québec, H2X 0A9, Canada.
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Montes-Cortés DH, Novelo-Del Valle JL, Olivares-Corichi IM, Rosas-Barrientos JV, Jara LJ, Cruz-Domínguez MP. Impact of intestinal mannitol on hyperammonemia, oxidative stress and severity of hepatic encephalopathy in the ED. Am J Emerg Med 2018; 36:1570-1576. [PMID: 29352675 DOI: 10.1016/j.ajem.2018.01.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 01/07/2018] [Accepted: 01/08/2018] [Indexed: 12/20/2022] Open
Abstract
Hyperammonemia results from hepatic inability to remove nitrogenous products generated by protein metabolism of intestinal microbiota, which leads to hepatic encephalopathy (HE) in chronic liver disease (CLD). In ammonium neurotoxicity, oxidative stress (OxS) plays a pathogenic role. Our objective was to evaluate if intestinal mannitol is as effective and safe as conventional treatment for diminishing hyperammonemia, OxS, and HE in patients with CLD. MATERIAL AND METHODS We included 30 patients with HE classified by "Haven Criteria for Hepatic Encephalopathy". They were randomized into two groups: 1) Mannitol Group (MG) with mannitol 20% administered into the intestine by an enema, 2) conventional group (CG) with lactulose 40 g enema both substances were diluted in 800 mL of double distilled solution every 6 h; all patients received neomycin. We evaluated ammonia concentration, plasma oxidative stress, HE severity, intestinal discomfort and adverse effects. RESULTS Hyperammonemia (171 ± 104 vs 79 ± 49 μmol ammonia/L, p < 0.01), and oxidative stress (MDA 29 vs 27%, formazan 15 vs 11%, carbonyls 16 vs 9% and dityrosines 10 vs 5%) were reduced in MG and CG respectively. The HE severity decreased by two degrees compared to baseline values in both groups. Intestinal discomfort and electrolyte plasma alterations were less frequent (p < 0.05) in MG than CG. CONCLUSIONS Intestinal mannitol is as effective and safe as conventional treatment for reducing hyperammonemia, oxidative stress, and hepatic encephalopathy of CLD patients in the emergency room. Likewise, mannitol is better tolerated than conventional treatment.
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Affiliation(s)
- Daniel H Montes-Cortés
- Urgencias Adultos. Hospital General, Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social, 02990 Ciudad de México, Mexico; Coordinación de Enseñanza e Investigación. Hospital Regional 1° de Octubre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, 07760 Ciudad de México, Mexico
| | - José L Novelo-Del Valle
- Urgencias Adultos. Hospital General, Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social, 02990 Ciudad de México, Mexico
| | - Ivonne M Olivares-Corichi
- Sección de Estudios y Posgrado en Investigación. Escuela Superior de Medicina, Instituto Politécnico Nacional, 11340 Ciudad de México, Mexico
| | - José V Rosas-Barrientos
- Coordinación de Enseñanza e Investigación. Hospital Regional 1° de Octubre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, 07760 Ciudad de México, Mexico
| | - Luis J Jara
- División de Investigación en Salud. Hospital Especialidades, Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social, 02990 Ciudad de México, Mexico
| | - María Pilar Cruz-Domínguez
- División de Investigación en Salud. Hospital Especialidades, Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social, 02990 Ciudad de México, Mexico.
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Giménez-Garzó C, Urios A, Agustí A, Mangas-Losada A, García-García R, Escudero-García D, Kosenko E, Ordoño JF, Tosca J, Giner-Durán R, Serra MA, Felipo V, Montoliu C. Cirrhotic patients with minimal hepatic encephalopathy have increased capacity to eliminate superoxide and peroxynitrite in lymphocytes, associated with cognitive impairment. Free Radic Res 2017; 52:118-133. [PMID: 29262736 DOI: 10.1080/10715762.2017.1420183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Patients with minimal hepatic encephalopathy (MHE) show increased oxidative stress in blood. We aimed to assess whether MHE patients show alterations in different types of blood cells in (a) basal reactive oxygen and nitrogen species levels; (b) capacity to metabolise these species. To assess the mechanisms involved in the altered capacity to metabolise these species we also analysed: (c) peroxynitrite formation and d) peroxynitrite reaction with biological molecules. Levels of reactive oxygen and nitrogen species were measured by flow cytometry in blood cell populations from cirrhotic patients with and without MHE and controls, under basal conditions and after adding generators of superoxide (plumbagin) or nitric oxide (NOR-1) to assess the capacity to eliminate them. Under basal conditions, MHE patients show reduced superoxide and peroxynitrite levels and increased nitric oxide (NO) and nitrotyrosine levels. In patients without MHE plumbagin strongly increases cellular superoxide, moderately peroxynitrite and reduces NO levels. In MHE patients, plumbagin increases slightly superoxide and strongly peroxynitrite levels and affects slightly NO levels. NOR-1 increases NO levels much less in patients with than without MHE. These data show that the mechanisms and the capacity to eliminate cellular superoxide, NO and peroxynitrite are enhanced in MHE patients. Superoxide elimination is enhanced through reaction with NO to form peroxynitrite which, in turn, is eliminated by enhanced reaction with biological molecules, which could contribute to cognitive impairment in MHE. The data show that basal free radical levels do not reflect the oxidative stress status in MHE.
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Affiliation(s)
- Carla Giménez-Garzó
- a Laboratory of Neurobiology , Centro Investigación Príncipe Felipe de Valencia , Valencia , Spain
| | - Amparo Urios
- a Laboratory of Neurobiology , Centro Investigación Príncipe Felipe de Valencia , Valencia , Spain.,b Fundación Investigación Hospital Clínico de Valencia, Instituto de Investigación Sanitaria-INCLIVA , Valencia , Spain
| | - Ana Agustí
- b Fundación Investigación Hospital Clínico de Valencia, Instituto de Investigación Sanitaria-INCLIVA , Valencia , Spain
| | - Alba Mangas-Losada
- b Fundación Investigación Hospital Clínico de Valencia, Instituto de Investigación Sanitaria-INCLIVA , Valencia , Spain
| | - Raquel García-García
- a Laboratory of Neurobiology , Centro Investigación Príncipe Felipe de Valencia , Valencia , Spain
| | - Desamparados Escudero-García
- c Unidad de Digestivo, Hospital Clínico de Valencia , Departamento de Medicina, Universidad de Valencia , Valencia , Spain
| | - Elena Kosenko
- d Laboratory of Modeling and Bioinformatics , Institute of Theoretical and Experimental Biophysics, Russian Academy of Sciences , Pushchino , Russia
| | - Juan Fermín Ordoño
- e Servicio Neurofisiología , Hospital Arnau de Vilanova , Valencia , Spain.,f Psychopatology and Neurophysiology Unit , Paterna Mental Health Center, CIBERSAM , Valencia , Spain
| | - Joan Tosca
- c Unidad de Digestivo, Hospital Clínico de Valencia , Departamento de Medicina, Universidad de Valencia , Valencia , Spain
| | | | - Miguel Angel Serra
- c Unidad de Digestivo, Hospital Clínico de Valencia , Departamento de Medicina, Universidad de Valencia , Valencia , Spain
| | - Vicente Felipo
- a Laboratory of Neurobiology , Centro Investigación Príncipe Felipe de Valencia , Valencia , Spain
| | - Carmina Montoliu
- b Fundación Investigación Hospital Clínico de Valencia, Instituto de Investigación Sanitaria-INCLIVA , Valencia , Spain.,h Departamento de Patología, Facultad de Medicina , Universidad de Valencia , Valencia , Spain
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29
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Rose CF. What's new in our understanding of the pathogenesis of hepatic encephalopathy? Clin Liver Dis (Hoboken) 2017; 10:29-31. [PMID: 30992755 PMCID: PMC6467112 DOI: 10.1002/cld.648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 05/08/2017] [Accepted: 05/20/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Christopher F. Rose
- Laboratory Hepato‐Neuro, CRCHUM, Department of MedicineUniversité de Montréal900 St‐DenisH2X 0A9MontrealQuebecCanada
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30
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Urios A, Mangas-Losada A, Gimenez-Garzó C, González-López O, Giner-Durán R, Serra MA, Noe E, Felipo V, Montoliu C. Altered postural control and stability in cirrhotic patients with minimal hepatic encephalopathy correlate with cognitive deficits. Liver Int 2017; 37:1013-1022. [PMID: 27988985 DOI: 10.1111/liv.13345] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 12/07/2016] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Cognitive dysfunction in cirrhotic patients with minimal hepatic encephalopathy (MHE) is associated with falls. Alterations in postural control and stability could contribute to increase falls risk in these patients. We aimed to assess whether postural control and direction-specific limits of stability are altered in cirrhotic patients with MHE compared to patients without MHE and controls. We also assessed if alterations in postural control correlate with neurological impairment and/or blood biomarkers. METHODS Posturography analysis, attention Stroop test and bimanual and visuo-motor coordination tests were performed in 18 controls, 19 patients with cirrhosis without MHE and 17 with MHE, diagnosed by PHES. Posturography was assessed by NedSVE® /IBV system under four sensory conditions. Limits of stability and rhythmic weight-shifting tests were also performed. Blood ammonia and serum interleukins were also measured. Falls were assessed after 12-24 months follow-up. RESULTS MHE patients show impaired balance, mainly on unstable surface with eyes open, with longer reaction and confinement times and lower success in Limits of Stability test compared to patients without MHE. Performance in attention and motor coordination tests correlated with most posturography parameters alterations. Logistic regression analysis shows that posturography parameters and bimanual coordination test are good predictors of falls. CONCLUSION Balance patterns and limits of stability in MHE patients are impaired compared to patients without MHE and controls. This seems to contribute to a higher falls risk. Attention and motor coordination deficits could contribute to balance impairment in patients with MHE.
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Affiliation(s)
- Amparo Urios
- Instituto de Investigación Sanitaria-INCLIVA, Valencia, Spain.,Laboratory of Neurobiology, Centro Investigación Príncipe Felipe de Valencia, Valencia, Spain
| | | | - Carla Gimenez-Garzó
- Instituto de Investigación Sanitaria-INCLIVA, Valencia, Spain.,Laboratory of Neurobiology, Centro Investigación Príncipe Felipe de Valencia, Valencia, Spain
| | | | | | - Miguel A Serra
- Unidad de Digestivo, Hospital Clínico de Valencia, Departamento Medicina, Universidad de Valencia, Valencia, Spain
| | - Enrique Noe
- Servicio de Daño, Cerebral del Hospital Valencia al Mar, Valencia, Spain
| | - Vicente Felipo
- Laboratory of Neurobiology, Centro Investigación Príncipe Felipe de Valencia, Valencia, Spain
| | - Carmina Montoliu
- Instituto de Investigación Sanitaria-INCLIVA, Valencia, Spain.,Departamento de Patología, Facultad de Medicina, Universidad de Valencia, Valencia, Spain
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31
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Zhang W, Li H, Ogando DG, Li S, Feng M, Price FW, Tennessen JM, Bonanno JA. Glutaminolysis is Essential for Energy Production and Ion Transport in Human Corneal Endothelium. EBioMedicine 2017; 16:292-301. [PMID: 28117276 PMCID: PMC5474426 DOI: 10.1016/j.ebiom.2017.01.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 01/03/2017] [Accepted: 01/04/2017] [Indexed: 12/23/2022] Open
Abstract
Corneal endothelium (CE) is among the most metabolically active tissues in the body. This elevated metabolic rate helps the CE maintain corneal transparency by its ion and fluid transport properties, which when disrupted, leads to visual impairment. Here we demonstrate that glutamine catabolism (glutaminolysis) through TCA cycle generates a large fraction of the ATP needed to maintain CE function, and this glutaminolysis is severely disrupted in cells deficient in NH3:H+ cotransporter Solute Carrier Family 4 Member 11 (SLC4A11). Considering SLC4A11 mutations leads to corneal endothelial dystrophy and sensorineural deafness, our results indicate that SLC4A11-associated developmental and degenerative disorders result from altered glutamine catabolism. Overall, our results describe an important metabolic mechanism that provides CE cells with the energy required to maintain high level transport activity, reveal a direct link between glutamine metabolism and developmental and degenerative neuronal diseases, and suggest an approach for protecting the CE during ophthalmic surgeries. Glutamine contributes half of TCA cycle intermediates in human corneal endothelium. Glutamine catabolism supplies significant ATP that fuels the endothelial pump function. SLC4A11 (NH3:2H+ cotransporter) knockout shows ammonia related oxidative damage. Loss of SLC4A11 transporter disrupts expression of glutaminolysis enzymes.
The corneal endothelium (CE) is responsible for maintaining corneal transparency through the action of active transport processes. We report that CE metabolizes the amino acid glutamine producing ATP in support of active transport. In the mouse model of CHED (Congenital Hereditary Endothelial Dystrophy), which manifests corneal edema and loss of transparency, glutamine metabolism is disrupted due to loss of SLC4A11, an NH3:2H+ transporter. This work sheds light on potential clinical therapies to facilitate CE function, the pathogenesis of CHED and Fuchs' Endothelial Corneal Dystrophy, and suggests that the ammonia handling capacity of SLC4A11 is essential for efficient metabolism of glutamine.
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Affiliation(s)
- Wenlin Zhang
- School of Optometry, Indiana University, Bloomington, IN 47405, USA.
| | - Hongde Li
- Department of Biology, Indiana University, Bloomington, IN 47405, USA
| | - Diego G Ogando
- School of Optometry, Indiana University, Bloomington, IN 47405, USA
| | - Shimin Li
- School of Optometry, Indiana University, Bloomington, IN 47405, USA
| | | | | | - Jason M Tennessen
- Department of Biology, Indiana University, Bloomington, IN 47405, USA
| | - Joseph A Bonanno
- School of Optometry, Indiana University, Bloomington, IN 47405, USA.
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Patel VC, White H, Støy S, Bajaj JS, Shawcross DL. Clinical science workshop: targeting the gut-liver-brain axis. Metab Brain Dis 2016; 31:1327-1337. [PMID: 26446022 DOI: 10.1007/s11011-015-9743-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Accepted: 10/02/2015] [Indexed: 02/08/2023]
Abstract
A clinical science workshop was held at the ISHEN meeting in London on Friday 11th September 2014 with the aim of thrashing out how we might translate what we know about the central role of the gut-liver-brain axis into targets which we can use in the treatment of hepatic encephalopathy (HE). This review summarises the integral role that inter-organ ammonia metabolism plays in the pathogenesis of HE with specific discussion of the roles that the small and large intestine, liver, brain, kidney and muscle assume in ammonia and glutamine metabolism. Most recently, the salivary and gut microbiome have been shown to underpin the pathophysiological changes which culminate in HE and patients with advanced cirrhosis present with enteric dysbiosis with small bowel bacterial overgrowth and translocation of bacteria and their products across a leaky gut epithelial barrier. Resident macrophages within the liver are able to sense bacterial degradation products initiating a pro-inflammatory response within the hepatic parenchyma and release of cytokines such as tumour necrosis factor alpha (TNF-α) and interleukin-8 into the systemic circulation. The endotoxemia and systemic inflammatory response that are generated predispose both to the development of infection as well as the manifestation of covert and overt HE. Co-morbidities such as diabetes and insulin resistance, which commonly accompany cirrhosis, may promote slow gut transit, promote bacterial overgrowth and increase glutaminase activity and may need to be acknowledged in HE risk stratification assessments and therapeutic regimens. Therapies are discussed which target ammonia production, utilisation or excretion at an individual organ level, or which reduce systemic inflammation and endotoxemia which are known to exacerbate the cerebral effects of ammonia in HE. The ideal therapeutic strategy would be to use an agent that can reduce hyperammonemia and reduce systemic inflammation or perhaps to adopt a combination of therapies that can address both.
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Affiliation(s)
- Vishal C Patel
- Institute of Liver Studies, King's College London School of Medicine, King's College Hospital, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Helen White
- Institute of Liver Studies, King's College London School of Medicine, King's College Hospital, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Sidsel Støy
- Institute of Liver Studies, King's College London School of Medicine, King's College Hospital, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Jasmohan S Bajaj
- McGuire VA Medical Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Debbie L Shawcross
- Institute of Liver Studies, King's College London School of Medicine, King's College Hospital, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
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Yoshimura E, Ichikawa T, Miyaaki H, Taura N, Miuma S, Shibata H, Honda T, Takeshima F, Nakao K. Screening for minimal hepatic encephalopathy in patients with cirrhosis by cirrhosis-related symptoms and a history of overt hepatic encephalopathy. Biomed Rep 2016; 5:193-198. [PMID: 27446540 DOI: 10.3892/br.2016.702] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 05/30/2016] [Indexed: 02/06/2023] Open
Abstract
The diagnosis of minimal hepatic encephalopathy (MHE) is more difficult in comparison to the diagnosis of overt hepatic encephalopathy (OHE), as patients with MHE do not exhibit overt neurological deficits and must be diagnosed using specialized equipment. However, identifying MHE is critical for patients with cirrhosis, and a simple screening test is required. The present study aimed to evaluate the associations between MHE, clinical characteristics and questionnaire items regarding sleep disturbances and cirrhosis-related symptom score (CSS). A total of 91 patients who had cirrhosis without OHE were evaluated using various questionnaires [i.e., CSS, Epworth Sleepiness Scale, the Japanese version of the Pittsburgh Sleep Quality Index (PSQI) and the Japanese 36-item short-form health survey (SF-36)]. MHE was diagnosed using the neuropsychological test. MHE was associated with severe liver damage, which was indicated by liver damage markers and a history of OHE. In addition, MHE was associated with the CSS, PSQI and SF-36 results. The multivariate analyses revealed that a history of OHE was the factor that was the most strongly associated with MHE. Among patients without a history of OHE, MHE was most strongly associated with CSS, although it was also associated with severe liver damage and platelet counts. A prediction score (calculated using a history of OHE and CSS) provided an area under the receiver operating characteristic curve of 0.738 and a sensitivity of 0.671 for identifying MHE. In conclusion, a history of OHE and CSS may be useful for identifying MHE in patients with cirrhosis.
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Affiliation(s)
- Emi Yoshimura
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Science, Nagasaki 852-8501, Japan
| | - Tatsuki Ichikawa
- Department of Gastroenterology, Nagasaki Harbor Medical Center, City Hospital, Nagasaki 850-8555, Japan
| | - Hisamitsu Miyaaki
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Science, Nagasaki 852-8501, Japan
| | - Naota Taura
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Science, Nagasaki 852-8501, Japan
| | - Satoshi Miuma
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Science, Nagasaki 852-8501, Japan
| | - Hidataka Shibata
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Science, Nagasaki 852-8501, Japan
| | - Takuya Honda
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Science, Nagasaki 852-8501, Japan
| | - Fuminao Takeshima
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Science, Nagasaki 852-8501, Japan
| | - Kazuhiko Nakao
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Science, Nagasaki 852-8501, Japan
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Marano M, Vespasiani Gentilucci U, Altamura C, Siotto M, Squitti R, Bucossi S, Quintiliani L, Migliore S, Greco F, Scarciolla L, Quattrocchi CC, Picardi A, Vernieri F. Altered metal metabolism in patients with HCV-related cirrhosis and hepatic encephalopathy. Metab Brain Dis 2015; 30:1445-52. [PMID: 26307419 DOI: 10.1007/s11011-015-9721-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 08/21/2015] [Indexed: 12/13/2022]
Abstract
Dysfunctional metal homeostasis contributes to oxidative stress and neuronal damage. These have been implicated in hepatic encephalopathy pathogenesis. To investigate whether altered metal metabolism is associated with hepatic encephalopathy. Twenty-one controls and 34 HCV-cirrhotic patients (ENC/NEC patients according to presence/absence of previous overt episodes of hepatic encephalopathy) and a control group were studied. Serum iron, copper, ceruloplasmin, ceruloplasmin activity, transferrin, and ceruloplasmin/transferrin ratio were determined. Neuropsychological tests were performed by the repeatable battery of neuropsychological status. Magnetic resonance assessed basal ganglia volumes and metal deposition (pallidal index and T2*). Cirrhotic patients performed worse than controls at cognitive tests, especially ENC patients,. At biochemical analysis copper concentrations, ceruloplasmin activity and transferrin levels were lower in ENC than in NEC patients and controls (p < 0.05 and p < 0.01, respectively). Ceruloplasmin/transferrin ratio was higher in ENC compared to NEC patients (p < 0.05), and controls (p < 0.01). By brain magnetic resonance, ENC patients showed reduced caudate and globus pallidus volumes compared to controls (p < 0.05), and ENC and NEC patients an increased pallidal index compared to controls (p < 0.01). In ENC patients, ceruloplasmin activity correlated with caudate volume and pallidal index (ρ = 0.773 and ρ = -0.683, p < 0.05). Altered metal metabolism likely contributes to cirrhotic hepatic encephalopathy.
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Affiliation(s)
- Massimo Marano
- Neurology, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy.
| | - Umberto Vespasiani Gentilucci
- Internal Medicine and Hepatology, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Claudia Altamura
- Neurology, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | | | - Rosanna Squitti
- Fatebenefratelli Foundation, AFaR Division, Fatebenefratelli Hospital, Isola Tiberina, Rome, Italy
- Laboratorio di Neurodegenerazione, IRCCS San Raffaele Pisana, Rome, Italy
| | - Serena Bucossi
- Laboratorio di Neurodegenerazione, IRCCS San Raffaele Pisana, Rome, Italy
| | - Livia Quintiliani
- Clinical psychology, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Simone Migliore
- Clinical psychology, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Federico Greco
- Radiology, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Laura Scarciolla
- Radiology, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Carlo Cosimo Quattrocchi
- Radiology, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Antonio Picardi
- Internal Medicine and Hepatology, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Fabrizio Vernieri
- Neurology, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
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Tsipotis E, Shuja A, Jaber BL. Albumin Dialysis for Liver Failure: A Systematic Review. Adv Chronic Kidney Dis 2015; 22:382-90. [PMID: 26311600 DOI: 10.1053/j.ackd.2015.05.004] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 05/25/2015] [Accepted: 05/27/2015] [Indexed: 12/30/2022]
Abstract
Albumin dialysis is the best-studied extracorporeal nonbiologic liver support system as a bridge or destination therapy for patients with liver failure awaiting liver transplantation or recovery of liver function. We performed a systematic review to examine the efficacy and safety of 3 albumin dialysis systems (molecular adsorbent recirculating system [MARS], fractionated plasma separation, adsorption and hemodialysis [Prometheus system], and single-pass albumin dialysis) in randomized trials for supportive treatment of liver failure. PubMed, Ovid, EMBASE, Cochrane's Library, and ClinicalTrials.gov were searched. Two authors independently screened citations and extracted data on patient characteristics, quality of reports, efficacy, and safety end points. Ten trials (7 of MARS and 3 of Prometheus) were identified (620 patients). By meta-analysis, albumin dialysis achieved a net decrease in serum total bilirubin level relative to standard medical therapy of 8.0 mg/dL (95% confidence interval [CI], -10.6 to -5.4) but not in serum ammonia or bile acids. Albumin dialysis achieved an improvement in hepatic encephalopathy relative to standard medical therapy with a risk ratio of 1.55 (95% CI, 1.16-2.08) but had no effect survival with a risk ratio of 0.95 (95% CI, 0.84-1.07). Because of inconsistency in the reporting of adverse events, the safety analysis was limited but did not demonstrate major safety concerns. Use of albumin dialysis as supportive treatment for liver failure is successful at removing albumin-bound molecules, such as bilirubin and at improving hepatic encephalopathy. Additional experience is required to guide its optimal use and address safety concerns.
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Abstract
Minimal hepatic encephalopathy (mHE) is common among patients with cirrhotic liver disease and causes significant morbidity and mortality. It may present as cognitive impairment, behavioural changes and, less frequently, with neurological symptoms which make diagnosis of the disease challenging. A history of falls and accidents may also be suggestive of mHE. Diagnosis primarily relies on at least two positive psychometric tests of which the psychometric hepatic encephalopathy score (PHES) is essential. Alternatively, PHES and an electroencephalogram may be used to establish a diagnosis. Biochemical markers of encephalopathy currently have no role in the diagnosis of mHE. Treatment is not always advocated for a diagnosis of mHE but is dependent on the degree of impairment caused by the symptoms. After treatment of other metabolic abnormalities and co-morbidities associated with cirrhosis, more specific treatment for mHE largely relies on therapies used to lower ammonia levels. Laxatives and rifaximin are commonly used in treatment and work through decreasing ammonia absorption from the gut. Other therapies, such as BCAA, LOLA, L-carnitine and phenylbutyrate, modify responses to ammonia as well as enhancing metabolism and excretion. mHE resulting from spontaneous portosystemic shunts or transhepatic intraportal systemic shunts may require ablation or reduction of the shunt. Early detection and appropriate treatment of mHE is important to prevent significant cognitive impairments and progression to overt HE.
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Affiliation(s)
- Shamindra Direkze
- Royal Free Hospital NHS Foundation Trust, University College London, London, UK
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Jördens MS, Keitel V, Karababa A, Zemtsova I, Bronger H, Häussinger D, Görg B. Multidrug resistance-associated protein 4 expression in ammonia-treated cultured rat astrocytes and cerebral cortex of cirrhotic patients with hepatic encephalopathy. Glia 2015; 63:2092-2105. [PMID: 26102310 DOI: 10.1002/glia.22879] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 06/08/2015] [Indexed: 12/30/2022]
Abstract
Hepatic encephalopathy (HE) is a neuropsychiatric syndrome frequently accompanying liver cirrhosis and reflects the clinical manifestation of a low grade cerebral edema associated with cerebral oxidative/nitrosative stress. The multidrug resistance-associated protein (Mrp) 4 is an export pump which transports metabolites that were recently suggested to play a major role in the pathogenesis of HE such as neurosteroids and cyclic nucleotides. We therefore studied Mrp4 expression changes in ammonia-exposed cultured astrocytes and postmortem human brain samples of cirrhotic patients with HE. NH4 Cl increased Mrp4 mRNA and protein levels in astrocytes in a dose- and time-dependent manner up to threefold after 72 h of exposure and concurrently inhibited N-glycosylation of Mrp4 protein. Upregulation of Mrp4 mRNA and protein as well as impaired N-glycosylation of Mrp4 protein by ammonia were sensitive towards the glutamine-synthetase inhibitor l-methionine-S-sulfoximine and were not induced by CH3 NH3 Cl (5 mmol/L). Upregulation of Mrp4 mRNA required ammonia-induced activation of nitric oxide synthases or NADPH oxidase and p38MAPK -dependent activation of PPARα. Inhibition of Mrp4 by ceefourin 1 synergistically enhanced both, inhibition of astrocyte proliferation as well as transcription of the oxidative stress surrogate marker heme oxygenase 1 by forskolin (10 µmol/L, 72 h) or NH4 Cl (5 mmol/L, 72 h) in cultured rat astrocytes. Increased Mrp4 mRNA and protein levels were also found in postmortem brain samples from patients with liver cirrhosis with HE but not in those without HE. The data show that Mrp4 is upregulated in HE, which may be relevant for the handling of neurosteroids and cyclic nucleotides in response to ammonia. GLIA 2015;63:2092-2105.
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Affiliation(s)
- Markus S Jördens
- Clinic for Gastroenterology, Hepatology, and Infectious Diseases, Heinrich-Heine University, Düsseldorf, Germany
| | - Verena Keitel
- Clinic for Gastroenterology, Hepatology, and Infectious Diseases, Heinrich-Heine University, Düsseldorf, Germany
| | - Ayse Karababa
- Clinic for Gastroenterology, Hepatology, and Infectious Diseases, Heinrich-Heine University, Düsseldorf, Germany
| | - Irina Zemtsova
- Clinic for Gastroenterology, Hepatology, and Infectious Diseases, Heinrich-Heine University, Düsseldorf, Germany
| | - Holger Bronger
- Clinic for Gastroenterology, Hepatology, and Infectious Diseases, Heinrich-Heine University, Düsseldorf, Germany
| | - Dieter Häussinger
- Clinic for Gastroenterology, Hepatology, and Infectious Diseases, Heinrich-Heine University, Düsseldorf, Germany
| | - Boris Görg
- Clinic for Gastroenterology, Hepatology, and Infectious Diseases, Heinrich-Heine University, Düsseldorf, Germany
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Balaguer S, Diaz L, Gomes A, Herrera G, O'Connor JE, Urios A, Felipo V, Montoliu C. Real-time cytometric assay of nitric oxide and superoxide interaction in peripheral blood monocytes: A no-wash, no-lyse kinetic method. CYTOMETRY PART B-CLINICAL CYTOMETRY 2015; 92:211-217. [PMID: 25758468 DOI: 10.1002/cyto.b.21237] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 01/06/2015] [Accepted: 02/19/2015] [Indexed: 11/05/2022]
Abstract
BACKGROUND Nitric oxide (NO) and its related reactive nitrogen species (RNS) and reactive oxygen species (ROS) are crucial in monocyte responses against pathogens and also in inflammatory conditions. Central to both processes is the generation of the strong oxidant peroxynitrite (ONOO) by a fast reaction between NO and superoxide anion. ONOO is a biochemical junction for ROS- and RNS cytotoxicity and causes protein nitrosylation. Circulating by-products of protein nitrosylation are early biomarkers of inflammation-based conditions, including minimal hepatic encephalopathy in cirrhotic patients (Montoliu et al., Am J Gastroenterol 2011; 106:1629-1637). In this context, we have designed a novel no-wash, no-lyse real-time flow cytometry assay to detect and follow-up the NO- and superoxide-driven generation of ONOO in peripheral blood monocytes. METHODS Whole blood samples were stained with CD45 and CD14 antibodies plus one of a series of fluorescent probes sensitive to RNS, ROS, or glutathione, namely 4-amino-5-methylamino-2',7'-difluorofluorescein diacetate, dihydrorhodamine 123, MitoSOX Red, dihydroethidium, and 5-chloromethylfluorescein diacetate. Samples were exposed sequentially to a NO donor and three different superoxide donors, and analyzed in real time by kinetic flow cytometry. Relevant kinetic descriptors, such as the rate of fluorescence change, were calculated from the kinetic plot. RESULTS The generation of ONOO, which consumes both NO and superoxide, led to a decrease in the intensity of the cellular fluorescence of the probes sensitive to these molecules. CONCLUSION This is a fast and simple assay that may be used to monitor the intracellular generation of ONOO in physiological, pathological, and pharmacological contexts. © 2015 International Clinical Cytometry Society.
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Affiliation(s)
- Susana Balaguer
- Laboratory of Cytomics, Mix Research Unit, Universidad De Valencia and Centro De Investigacion Principe Felipe, Valencia, Spain
| | - Laura Diaz
- Laboratory of Cytomics, Mix Research Unit, Universidad De Valencia and Centro De Investigacion Principe Felipe, Valencia, Spain
| | - Angela Gomes
- Laboratory of Cytomics, Mix Research Unit, Universidad De Valencia and Centro De Investigacion Principe Felipe, Valencia, Spain
| | - Guadalupe Herrera
- Fundacion Investigacion Hospital Clınico Universitario De Valencia, INCLIVA, Valencia, Spain
| | - José-Enrique O'Connor
- Laboratory of Cytomics, Mix Research Unit, Universidad De Valencia and Centro De Investigacion Principe Felipe, Valencia, Spain
| | - Amparo Urios
- Fundacion Investigacion Hospital Clınico Universitario De Valencia, INCLIVA, Valencia, Spain
| | - Vicente Felipo
- Laboratory of Neurobiology, Centro De Investigación Principe Felipe, Valencia, Spain
| | - Carmina Montoliu
- Fundacion Investigacion Hospital Clınico Universitario De Valencia, INCLIVA, Valencia, Spain
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Gimenez-Garzó C, Urios A, Agustí A, González-López O, Escudero-García D, Escudero-Sanchis A, Serra MA, Giner-Durán R, Montoliu C, Felipo V. Is cognitive impairment in cirrhotic patients due to increased peroxynitrite and oxidative stress? Antioxid Redox Signal 2015; 22:871-7. [PMID: 25557123 DOI: 10.1089/ars.2014.6240] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Cirrhotic patients may suffer minimal hepatic encephalopathy (MHE), with mild cognitive impairment. 3-Nitro-tyrosine levels are a good biomarker for diagnosis of the cognitive impairment and MHE in cirrhotic patients. This suggests that oxidative stress could be involved in the induction of cognitive and motor alterations in MHE. We have observed that patients with MHE show increased oxidative stress in blood compared with cirrhotic patients without MHE, with increased lipid peroxidation, DNA oxidation, protein carbonylation, 3-nitrotyrosine, oxidized glutathione (GSSG)/reduced glutathione (GSH) ratio, and GSH levels. The activities of antioxidant enzymes are enhanced in erythrocytes and mononuclear cells from patients with and without MHE compared with control subjects. Only glutathione peroxidase activity was increased in MHE patients compared with patients without MHE. Oxidative stress markers in blood, especially GSSG/GSH ratio, GSH, malondialdehyde, and 3-nitrotyrosine, correlate with deficits in attention and motor coordination. The increase in antioxidant activities in patients would be an adaptive mechanism to cope with enhanced oxidative stress, although it is not effective enough to normalize it. Our observations lead to the hypothesis that oxidative stress and increased peroxynitrite formation would mediate the synergistic effects of hyperammonemia and inflammation on cognitive and motor impairment in MHE.
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Affiliation(s)
- Carla Gimenez-Garzó
- 1 Laboratorio de Neurobiología , Centro Investigación Príncipe Felipe de Valencia, Valencia, Spain
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Milewski K, Hilgier W, Albrecht J, Zielińska M. The dimethylarginine (ADMA)/nitric oxide pathway in the brain and periphery of rats with thioacetamide-induced acute liver failure: Modulation by histidine. Neurochem Int 2014; 88:26-31. [PMID: 25523831 DOI: 10.1016/j.neuint.2014.12.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 11/25/2014] [Accepted: 12/04/2014] [Indexed: 12/12/2022]
Abstract
Hepatic encephalopathy (HE) is related to variations in the nitric oxide (NO) synthesis and oxidative/nitrosative stress (ONS), and asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of nitric oxide synthases (NOSs). In the present study we compared the effects of acute liver failure (ALF) in the rat TAA model on ADMA concentration in plasma and cerebral cortex, and on the activity and expression of the ADMA degrading enzyme, dimethylarginine dimethylaminohydrolase (DDAH), in brain and liver. ALF increased blood and brain ADMA, and the increase was correlated with decreased DDAH activity in both brain and liver. An i.p. administration of histidine (His), an amino acid reported to alleviate oxidative stress associated with HE (100 mg/kg b.w.), reversed the increase of brain ADMA, which was accompanied by the recovery of brain DDAH activity (determined ex vivo), and with an increase of the total NOS activity. His also activated DDAH ex vivo in brain homogenates derived from control and TAA rats. ALF in this model was also accompanied by increases of blood cyclooxygenase activity and blood and brain TNF-α content, markers of the inflammatory response in the periphery, but these changes were not affected by His, except for the reduction of TNF-α mRNA transcript in the brain. His increased the total antioxidant capacity of the brain cortex, but not of the blood, further documenting its direct neuroprotective power.
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Affiliation(s)
- Krzysztof Milewski
- Department of Neurotoxicology, Mossakowski Medical Research Centre, Polish Academy of Sciences, Pawińskiego 5 Str, 02-106 Warsaw, Poland
| | - Wojciech Hilgier
- Department of Neurotoxicology, Mossakowski Medical Research Centre, Polish Academy of Sciences, Pawińskiego 5 Str, 02-106 Warsaw, Poland
| | - Jan Albrecht
- Department of Neurotoxicology, Mossakowski Medical Research Centre, Polish Academy of Sciences, Pawińskiego 5 Str, 02-106 Warsaw, Poland
| | - Magdalena Zielińska
- Department of Neurotoxicology, Mossakowski Medical Research Centre, Polish Academy of Sciences, Pawińskiego 5 Str, 02-106 Warsaw, Poland.
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Bosoi CR, Tremblay M, Rose CF. Induction of systemic oxidative stress leads to brain oedema in portacaval shunted rats. Liver Int 2014; 34:1322-9. [PMID: 25354203 DOI: 10.1111/liv.12414] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 11/16/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS The pathogenesis of hepatic encephalopathy (HE) is multifactorial and often associated with the development of brain oedema. In addition to ammonia playing a central role, systemic oxidative stress is believed to aggravate the neuropsychological effects of ammonia in patients with chronic liver disease (CLD). The aim of this study was to (i) induce systemic oxidative stress in hyperammonaemic portacaval anastomosed (PCA) rats by inhibiting the antioxidant glutathione using Dimethyl maleate (DEM) and (ii) investigate whether a synergistic relationship between ammonia and oxidative stress contributes to the pathogenesis of brain oedema in CLD. METHODS Four-week PCA and sham-operated rats received DEM (0.4-4 mg/kg/day) for the last 10 days before sacrifice when oxidative stress markers [reactive oxygen species (ROS) and malondialdehyde (MDA)] were assessed in blood and frontal cortex. Brain water content was measured using a specific gravimetric technique. RESULTS Dimethyl maleate induced an increase in ROS and MDA in the blood, but not in the brain, of the PCA rats, compared with non-treated PCA rats. This was accompanied with an increase in brain water content (PCA+DEM: 78.45 ± 0.13% vs. PCA: 77.38 ± 0.11%, P < 0.001). Higher doses of DEM induced systemic oxidative stress in sham-operated controls, but brain oedema did not develop. CONCLUSIONS Dimethyl maleate provoked systemic, not central, oxidative stress in PCA rats, resulting in the development of brain oedema. Independently, hyperammonaemia and systemic oxidative stress do not precipitate brain oedema; therefore, our findings sustain that a synergistic effect between hyperammonaemia and systemic oxidative stress is responsible for the development of brain oedema in HE.
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Affiliation(s)
- Cristina R Bosoi
- Neuroscience Research Unit, Hôpital Saint-Luc (CRCHUM), Université de Montréal, Québec, Canada
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Pu Y, Yang JH, Jing-Yang, Xu Y, Tang YM. Progress in diagnosis of minimal hepatic encephalopathy. Shijie Huaren Xiaohua Zazhi 2014; 22:3759-3765. [DOI: 10.11569/wcjd.v22.i25.3759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Minimal hepatic encephalopathy (MHE) is defined as HE without symptoms on clinical/neurological examination, but with deficits in some cognitive areas that can only be measured by neuropsychometric testing. MHE is associated with reduced quality of working, driving, memory, and cognitive function, and is a risk factor for the development of overt HE. Compared with non-MHE patients, MHE patients have a high mortality rate, so positive screening and intervention in patients with MHE are needed to improve the quality of life in patients with cirrhosis and reduce traffic accidents and the social burden of medical care. The current approach to the diagnosis of MHE includes mental scales (paper pencil test, computer test, or the combination of the two), electrophysiological examination, and imaging examination. Diagnosis of MHE is still a challenge now, and it is needed to establish a better clinical diagnosis standard to improve the diagnostic level.
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Abstract
The interleukin-6 (IL-6) is a pleiotropic cytokine that plays a key role in interaction between immune and nervous system. Although IL-6 has neurotrophic properties and beneficial effects in the CNS, its overexpression is generally detrimental, adding to the pathophysiology associated with CNS disorders. The source of the increase in peripheral IL-6 remains to be established and varies among different pathologies, but has been found to be associated with cognitive dysfunction in several pathologies. This comprehensive review provides an update summary of the studies performed in humans concerning the role of central and peripheral IL-6 in cognitive dysfunction in dementias and in other systemic diseases accompained by cognitive dysfuction such as cardiovascular, liver disease, Behçet's disease and systemic lupus erythematosus. Further research is needed to correlate specific deficits in IL-6 and its receptors in pathologies characterized by cognitive dysfunction and to understand how systemic IL-6 affects high cerebral function in order to open new directions in pharmacological treatments that modulate IL-6 signalling.
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Affiliation(s)
- Isabel Trapero
- Department of Nursing, University of Valencia, 46010, Valencia, Spain
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Chemistry and biology of biomolecule nitration. ACTA ACUST UNITED AC 2014; 19:1086-92. [PMID: 22999877 DOI: 10.1016/j.chembiol.2012.07.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2012] [Revised: 07/25/2012] [Accepted: 07/27/2012] [Indexed: 12/27/2022]
Abstract
Posttranslational modifications of proteins play key roles in the regulation of biological processes and lead to various physiological responses. In recent years, a number of analytical technologies have been developed to help understand the diversity and disease relevance of these modifications. The main areas of focus have included phosphorylation, cysteine redox chemistry, and transformations mediated directly by oxidative stress. However, the nitration of biomolecules is an exciting and relatively understudied area of research. Reactive nitrogen species generated in various disease states can create nitrated biomolecules, and we are only beginning to understand the potential implications of these species. This review explores some of the recent advances in current knowledge concerning the chemistry and biology of nitrated biomolecules.
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Felipo V, Urios A, Valero P, Sánchez M, Serra MA, Pareja I, Rodríguez F, Gimenez-Garzó C, Sanmartín J, Montoliu C. Serum nitrotyrosine and psychometric tests as indicators of impaired fitness to drive in cirrhotic patients with minimal hepatic encephalopathy. Liver Int 2013; 33:1478-89. [PMID: 23714168 DOI: 10.1111/liv.12206] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 05/05/2013] [Indexed: 01/18/2023]
Abstract
BACKGROUND & AIMS Cirrhotic patients with minimal hepatic encephalopathy (MHE) show impaired driving ability and increased vehicle accidents. The neurological deficits contributing to impair driving and the underlying mechanisms are poorly understood. Early detection of driving impairment would help to reduce traffic accidents in MHE patients. It would be therefore useful to have psychometric or biochemical parameters reflecting driving impairment. The aims of this work were as follows: (i) to shed light on the neurological deficits contributing to impair driving; (ii) to assess whether some psychometric test or biochemical parameter is a good indicator of driving impairment. METHODS We assessed in 22 controls, 36 cirrhotic patients without and 15 with MHE, driving performance using a driving simulator (SIMUVEG) and Driver Test. MHE was diagnosed using the psychometric hepatic encephalopathy score (PHES). Psychometric tests assessing different neurological functions (mental processing speed, attention, visuo-spatial and bimanual coordination) were performed. Blood ammonia and parameters related with nitric oxide-cGMP metabolism, IL-6, IL-18 and 3-nitrotyrosine were measured. RESULTS Patients with MHE showed impaired driving ability correlating with MHE grade, with impaired vehicle lateral control in spite of reduced driving speed. Patients with MHE show psychomotor slowing, longer reaction times, impaired bimanual and visuo-spatial coordination and concentrated attention and slowed speed of anticipation and increased blood ammonia, cGMP, IL-6, IL-18 and 3-nitrotyrosine. CONCLUSIONS Impaired mental processing speed, attention and alterations in visuo-spatial and motor coordination seem main contributors to impaired driving ability in patients with MHE. Increased serum 3-nitrotyrosine is associated with impaired driving ability.
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Affiliation(s)
- Vicente Felipo
- Laboratory of Neurobiology, Centro de Investigación Principe Felipe, Valencia, Spain
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Abstract
Liver failure affects brain function, leading to neurological and psychiatric alterations; such alterations are referred to as hepatic encephalopathy (HE). Early diagnosis of minimal HE reveals an unexpectedly high incidence of mild cognitive impairment and psychomotor slowing in patients with liver cirrhosis - conditions that have serious health, social and economic consequences. The mechanisms responsible for the neurological alterations in HE are beginning to emerge. New therapeutic strategies acting on specific targets in the brain (phosphodiesterase 5, type A GABA receptors, cyclooxygenase and mitogen-activated protein kinase p38) have been shown to restore cognitive and motor function in animal models of chronic HE, and NMDA receptor antagonists have been shown to increase survival in acute liver failure. This article reviews the latest studies aimed at understanding how liver failure affects brain function and potential ways to ameliorate these effects.
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Bosoi CR, Rose CF. Oxidative stress: a systemic factor implicated in the pathogenesis of hepatic encephalopathy. Metab Brain Dis 2013; 28:175-8. [PMID: 23124921 DOI: 10.1007/s11011-012-9351-5] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 10/22/2012] [Indexed: 12/16/2022]
Abstract
Although ammonia is considered the main factor involved in the pathogenesis of hepatic encephalopathy (HE), it correlates well with the severity of HE in acute liver failure, but not in chronic liver disease. Oxidative stress is another factor believed to play a role in the pathogenesis of this syndrome; it represents an imbalance between the production and neutralization of reactive oxygen species, which leads to cellular dysfunction. In the setting of liver disease, oxidative stress represents a systemic phenomenon induced by several mechanisms: decreased antioxidant synthesis, increased systemic release of oxidant enzymes, generation of reactive oxygen species, and impaired neutrophil function. High ammonia concentrations induce cerebral oxidative stress, thus contributing to severe hepatic encephalopathy, as observed in acute liver failure. In chronic liver disease, significantly lower degrees of hyperammonemia (<500 μM) do not induce cerebral nor systemic oxidative stress. Data from both animal and human studies sustain that there is a synergistic effect between systemic oxidative stress, and ammonia that is implicated in the pathogenesis of hepatic encephalopathy.
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Affiliation(s)
- Cristina R Bosoi
- Neuroscience Research Unit, Hôpital Saint-Luc (CRCHUM), Université de Montréal, Montreal, Québec, Canada
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Häussinger D, Sies H. Hepatic encephalopathy: clinical aspects and pathogenetic concept. Arch Biochem Biophys 2013; 536:97-100. [PMID: 23643660 DOI: 10.1016/j.abb.2013.04.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Tranah TH, Vijay GKM, Ryan JM, Shawcross DL. Systemic inflammation and ammonia in hepatic encephalopathy. Metab Brain Dis 2013; 28:1-5. [PMID: 23224356 DOI: 10.1007/s11011-012-9370-2] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2012] [Accepted: 11/26/2012] [Indexed: 02/07/2023]
Abstract
Infection and inflammation have been associated with the development of delirium for many centuries and there is a rapidly growing evidence base supporting the role of inflammation in exacerbating the neurological manifestations of both acute and chronic liver failure. Inflammation in the context of hepatic encephalopathy (HE) can arise directly within the brain itself resulting in astrocytic, microglial and neuronal dysfunction, impacting on the development of 'brain failure'. Inflammation may also develop systemically and indirectly influence brain function. Systemic inflammation develops following liver injury, resulting in hyperammonemia and a 'cytotoxic soup' of pro-inflammatory mediators which are released into the circulation and modulate the impact of ammonia on the brain. The aim of this review is to summarise the current evidence base supporting the synergistic role of systemic inflammation and hyperammonemia in the pathogenesis of hepatic encephalopathy. Systemic inflammation and ammonia induce neutrophil degranulation and release reactive oxygen species into the peripheral circulation that may ultimately cross the blood brain barrier. Circulating endotoxin arising from the gut (bacterial translocation), superimposed sepsis, and hyperammonemia upregulate the expression of microbial pattern recognition receptors such as Toll-like receptors. The early recognition and management of systemic inflammation may not only facilitate improved outcomes in HE but supports the development of novel therapeutic strategies that reduce circulating endotoxemia and immune cell dysfunction.
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Affiliation(s)
- Thomas H Tranah
- Institute of Liver Studies, King's College London School of Medicine at King's College Hospital, King's College Hospital, Denmark Hill, London, UK
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Bosoi CR, Rose CF. Brain edema in acute liver failure and chronic liver disease: similarities and differences. Neurochem Int 2013; 62:446-57. [PMID: 23376027 DOI: 10.1016/j.neuint.2013.01.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 01/11/2013] [Accepted: 01/16/2013] [Indexed: 12/12/2022]
Abstract
Hepatic encephalopathy (HE) is a complex neuropsychiatric syndrome that typically develops as a result of acute liver failure or chronic liver disease. Brain edema is a common feature associated with HE. In acute liver failure, brain edema contributes to an increase in intracranial pressure, which can fatally lead to brain stem herniation. In chronic liver disease, intracranial hypertension is rarely observed, even though brain edema may be present. This discrepancy in the development of intracranial hypertension in acute liver failure versus chronic liver disease suggests that brain edema plays a different role in relation to the onset of HE. Furthermore, the pathophysiological mechanisms involved in the development of brain edema in acute liver failure and chronic liver disease are dissimilar. This review explores the types of brain edema, the cells, and pathogenic factors involved in its development, while emphasizing the differences in acute liver failure versus chronic liver disease. The implications of brain edema developing as a neuropathological consequence of HE, or as a cause of HE, are also discussed.
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Affiliation(s)
- Cristina R Bosoi
- Neuroscience Research Unit, Hôpital Saint-Luc (CRCHUM), Université de Montréal, Québec, Canada
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