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Sepehrinezhad A, Stolze Larsen F, Ashayeri Ahmadabad R, Shahbazi A, Sahab Negah S. The Glymphatic System May Play a Vital Role in the Pathogenesis of Hepatic Encephalopathy: A Narrative Review. Cells 2023; 12:cells12070979. [PMID: 37048052 PMCID: PMC10093707 DOI: 10.3390/cells12070979] [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: 10/19/2022] [Revised: 02/20/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
Hepatic encephalopathy (HE) is a neurological complication of liver disease resulting in cognitive, psychiatric, and motor symptoms. Although hyperammonemia is a key factor in the pathogenesis of HE, several other factors have recently been discovered. Among these, the impairment of a highly organized perivascular network known as the glymphatic pathway seems to be involved in the progression of some neurological complications due to the accumulation of misfolded proteins and waste substances in the brain interstitial fluids (ISF). The glymphatic system plays an important role in the clearance of brain metabolic derivatives and prevents aggregation of neurotoxic agents in the brain ISF. Impairment of it will result in aggravated accumulation of neurotoxic agents in the brain ISF. This could also be the case in patients with liver failure complicated by HE. Indeed, accumulation of some metabolic by-products and agents such as ammonia, glutamine, glutamate, and aromatic amino acids has been reported in the human brain ISF using microdialysis technique is attributed to worsening of HE and correlates with brain edema. Furthermore, it has been reported that the glymphatic system is impaired in the olfactory bulb, prefrontal cortex, and hippocampus in an experimental model of HE. In this review, we discuss different factors that may affect the function of the glymphatic pathways and how these changes may be involved in HE.
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Affiliation(s)
- Ali Sepehrinezhad
- Department of Neuroscience, Faculty of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran 1449614535, Iran
- Neuroscience Research Center, Mashhad University of Medical Sciences, Mashhad 9919191778, Iran
| | - Fin Stolze Larsen
- Department of Gastroenterology and Hepatology, Rigshospitalet, Copenhagen University Hospital, 999017 Copenhagen, Denmark
| | | | - Ali Shahbazi
- Department of Neuroscience, Faculty of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran 1449614535, Iran
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran 1449614535, Iran
| | - Sajad Sahab Negah
- Neuroscience Research Center, Mashhad University of Medical Sciences, Mashhad 9919191778, Iran
- Shefa Neuroscience Research Center, Khatam Alanbia Hospital, Tehran 1449614535, Iran
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Armstrong MJ, Gohar F, Dhaliwal A, Nightingale P, Baker G, Greaves D, Mangat K, Zia Z, Karkhanis S, Olliff S, Mehrzad H, Steeds RP, Tripathi D. Diastolic dysfunction on echocardiography does not predict survival after transjugular intrahepatic portosystemic stent-shunt in patients with cirrhosis. Aliment Pharmacol Ther 2019; 49:797-806. [PMID: 30773660 DOI: 10.1111/apt.15164] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/06/2018] [Accepted: 01/06/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cardiac dysfunction is frequently observed in patients with cirrhosis. There remains a paucity of data from routine clinical practice regarding the role of echocardiography in the pre-assessment of transjugular intrahepatic portosystemic stent-shunt. AIM Our study aimed to investigate if echocardiography parameters predict outcomes after transjugular intrahepatic portosystemic stent-shunt insertion in cirrhosis. METHODS Patients who underwent echocardiography and transjugular intrahepatic portosystemic stent-shunt insertion at the liver unit (Birmingham, UK) between 1999 and 2016 were included. All echocardiography measures (including left ventricle ejection fraction; early maximal ventricular filling/late filling velocity ratio, diastolic dysfunction as per British Society of Echocardiography guidelines) were independently reviewed by a cardiologist. Predictors of 30-day and overall transplant free-survival were assessed. RESULTS One Hundred and Seventeen patients with cirrhosis (median age 56 years; 54% alcohol; Child-Pugh B/C 71/14.5%; Model For End-Stage Liver Disease 12) underwent transjugular intrahepatic portosystemic stent-shunt for ascites (n = 78) and variceal haemorrhage (n = 39). Thirty-day and overall transplant-free survival was 90% (n = 105) and 31% (n = 36), respectively, over a median 663 (IQR 385-2368) days follow-up. Model for End-Stage Liver Disease (P < 0.001) and Child-Pugh Score (P = 0.002) significantly predicted 30-day and overall transplant-free survival. Model for End-Stage Liver Disease ≥15 implied three-fold risk of death. Six per cent (n = 7) of patients pre-transjugular intrahepatic portosystemic stent-shunt had a history of ischaemic heart disease and 34% (n = 40) had 1 or more cardiovascular disease risk factors. Fifty per cent (n = 59) had an abnormal echocardiogram and 33% (n = 39) had grade 1-3 diastolic dysfunction. On univariate analysis none of the echocardiography measures pre-intervention were related to 30-day or overall transplant-free survival post-transjugular intrahepatic portosystemic stent-shunt. CONCLUSIONS Ventricular, in particular diastolic dysfunction in patients with cirrhosis does not predict survival after transjugular intrahepatic portosystemic stent-shunt insertion. Model for End-Stage Liver Disease and Child-Pugh scores remain the best predictors of survival. Further prospective study is required to clarify the role of routine echocardiography prior to transjugular intrahepatic portosystemic stent-shunt insertion.
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Affiliation(s)
- Matthew J Armstrong
- Liver Unit, Queen Elizabeth University Hospital, Birmingham, UK.,NIHR Biomedical Research Centre, University of Birmingham, Edgbaston, Birmingham, UK
| | - Farhan Gohar
- Liver Unit, Queen Elizabeth University Hospital, Birmingham, UK
| | - Amritpal Dhaliwal
- Liver Unit, Queen Elizabeth University Hospital, Birmingham, UK.,NIHR Biomedical Research Centre, University of Birmingham, Edgbaston, Birmingham, UK
| | - Peter Nightingale
- Medical Statistics, Institute of Translational Medicine, Queen Elizabeth University Hospital, Birmingham, UK
| | - Graham Baker
- Liver Unit, Queen Elizabeth University Hospital, Birmingham, UK
| | - Daniel Greaves
- Liver Unit, Queen Elizabeth University Hospital, Birmingham, UK
| | - Kam Mangat
- Department of Diagnostic Imaging, National University Hospital (NUH), Singapore, Singapore
| | - Zergum Zia
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Birmingham, UK
| | - Salil Karkhanis
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Birmingham, UK
| | - Simon Olliff
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Birmingham, UK
| | - Homoyon Mehrzad
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Birmingham, UK
| | - Rick P Steeds
- Department of Cardiology, Queen Elizabeth University Hospital, Birmingham, UK
| | - Dhiraj Tripathi
- Liver Unit, Queen Elizabeth University Hospital, Birmingham, UK.,NIHR Biomedical Research Centre, University of Birmingham, Edgbaston, Birmingham, UK
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McAvoy NC. Editorial: increased cardiac output in cirrhosis - non-invasive assessment of regional blood flow by magnetic resonance angiography. Author's reply. Aliment Pharmacol Ther 2016; 43:1342-3. [PMID: 27166984 DOI: 10.1111/apt.13643] [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] [Indexed: 12/16/2022]
Affiliation(s)
- N C McAvoy
- Department of Hepatology, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK.
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