Forearm muscle metabolism studied using (31)P-MRS during progressive exercise to fatigue after Acz administration

The use of neuroimaging in the diagnosis of mitochondrial disease

Mutations in nuclear and mitochondrial DNA impacting mitochondrial function result in disease manifestations ranging from early death to abnormalities in all major organ systems and to symptoms that can be largely confined to muscle fatigue. The definitive diagnosis of a mitochondrial disorder can be difficult to establish. When the constellation of symptoms is suggestive of mitochondrial disease, neuroimaging features may be diagnostic and suggestive, can help direct further workup, and can help to further characterize the underlying brain abnormalities. Magnetic resonance imaging changes may be nonspecific, such as atrophy (both general and involving specific structures, such as cerebellum), more suggestive of particular disorders such as focal and often bilateral lesions confined to deep brain nuclei, or clearly characteristic of a given disorder such as stroke-like lesions that do not respect vascular boundaries in mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episode (MELAS). White matter hyperintensities with or without associated gray matter involvement may also be observed. Across patients and discrete disease subtypes (e.g., MELAS, Leigh syndrome, etc.), patterns of these features are helpful for diagnosis. However, it is also true that marked variability in expression occurs in all mitochondrial disease subtypes, illustrative of the complexity of the disease process. The present review summarizes the role of neuroimaging in the diagnosis and characterization of patients with suspected mitochondrial disease.

Methazolamide does not impair respiratory work performance in anesthetized rabbits

In human medicine, the carbonic anhydrase (CA) inhibitor acetazolamide is used to treat irregular breathing disorders. Previously, we demonstrated in the rabbit that this substance stabilized closed-loop gain properties of the respiratory control system, but concomitantly weakened respiratory muscles. Among others, the highly diffusible CA-inhibitor methazolamide differs from acetazolamide in that it fails to activate Ca2+-dependent potassium channels in skeletal muscles. Therefore, we aimed to find out, whether or not methazolamide may exert attenuating adverse effects on respiratory muscle performance as acetazolamide. In anesthetized spontaneously breathing rabbits ( n = 7), we measured simultaneously the CO2 responses of tidal phrenic nerve activity, tidal transpulmonary pressure changes, and tidal volume before and after intravenous application of methazolamide at two mean (± SE) cumulative doses of 3.5 ± 0.1 and 20.8 ± 0.4 mg/kg. Similar to acetazolamide, low- and high-dose methazolamide enhanced baseline ventilation by 52 ± 10% and 166 ± 30%, respectively ( P < 0.01) and lowered the base excess in a dose-dependent manner by up to 8.3 ± 0.9 mmol/l ( P < 0.001). The transmission of a CO2-induced rise in phrenic nerve activity into volume and/or pressure and, hence, respiratory work performance was 0.27 ± 0.05 ml·kg−1·kPa·unit−1 under control conditions, but remained unchanged upon low- or high-dose methazolamide, at 0.30 ± 0.06 and 0.28 ± 0.07 ml·kg−1·kPa·unit−1, respectively. We conclude that methazolamide does not cause respiratory muscle weakening at elevated levels of ventilatory drive. This substance (so far not used for medication of respiratory diseases) may thus exert stabilizing influences on breathing control without adverse effects on respiratory muscle function.

Muscle metabolism and acid-base status during exercise in forearm work-related myalgia measured with31P-MRS

In this study, we examined muscle metabolic and acid-base status during incremental wrist extension exercise in the forearm of individuals with work-related myalgia (WRM). Eighteen women employed in full-time occupations involving repetitive forearm labor were recruited in this cross-sectional study. Nine of these women were diagnosed with WRM, while the other nine had no previous WRM history and were used as age-matched controls (Con). Phosphorus-31 magnetic resonance spectroscopy (31P-MRS) was used to noninvasively monitor the intracellular concentrations of phosphocreatine ([PCr]) and inorganic phosphate ([Pi]) as well as intracellular pH (pHi) status during exercise in WRM and Con. We observed a 38% decreased work capacity in WRM compared with Con [0.18 W (SD 0.03) vs. 0.28 W (SD 0.10); P = 0.007]. Piecewise linear regression of the incremental exercise data revealed that the onset of a faster decrease in pHi(i.e., the pH threshold, pHT) and the onset of a faster increase in log([Pi]/[PCr]) (i.e., the phosphorylation threshold, PT) occurred at a 14% relatively lower power output in WRM [pHT: 45.2% (SD 5.3) vs. 59.0% (SD 4.6), P < 0.001; PT: 44.8% (SD 4.3) vs. 57.8% (SD 3.1), P < 0.001; % of peak power output, Con vs. WRM, respectively]. Monoexponential modeling of the kinetics of [PCr] and pHirecovery following exercise demonstrated a slower ( P = 0.005) time constant (τ) for [PCr] in WRM [113 s (SD 25)] vs. Con [77 s (SD 23)] and a slower ( P = 0.007) τ for pHiin WRM [370 s (SD 178)] vs. Con [179 s (SD 52)]. In conclusion, our results suggest that WRM is associated with an increased reliance on nonoxidative metabolism. Possible mechanisms include a reduction in local muscle blood flow and perfusion, an increased ATP cost of force production, or both.

Acetazolamide prevents vacuolar myopathy in skeletal muscle of K(+) -depleted rats

BACKGROUND AND PURPOSE

Acetazolamide and dichlorphenamide are carbonic anhydrase (CA) inhibitors effective in the clinical condition of hypokalemic periodic paralysis (hypoPP). Whether these drugs prevent vacuolar myopathy, which is a pathogenic factor in hypoPP, is unknown. The effects of these drugs on the efflux of lactate from skeletal muscle were also investigated.

EXPERIMENTAL APPROACH

For 10 days, K(+)-depleted rats, a model of hypoPP, were administered 5.6 mg kg(-1) day(-1) of acetazolamide, dichlorphenamide or bendroflumethiazide (the last is not an inhibitor of CA). Histological analysis of vacuolar myopathy and in vitro lactate efflux measurements were performed in skeletal muscles from treated and untreated K(+)-depleted rats, and also from normokalemic rats.

KEY RESULTS

About three times as many vacuoles were found in the type II fibres of tibialis anterioris muscle sections from K(+)-depleted rats as were found in the same muscle from normokalemic rats. In ex vivo experiments, a higher efflux of lactate on in vitro incubation was found in muscles of K(+)-depleted rats compared with that found in muscles from normokalemic rats. After treatment of K(+)-depleted rats with acetazolamide, the numbers of vacuoles in tibialis anterioris muscle decreased to near normal values. Incubation with acetazolamide in vitro inhibited efflux of lactate from muscles of K(+)-depleted rats. In contrast, bendroflumethiazide and dichlorphenamide failed to prevent vacuolar myopathy after treatment in vivo and failed to inhibit lactate efflux in vitro.

CONCLUSIONS AND IMPLICATIONS

Acetazolamide prevents vacuolar myopathy in K(+)-depleted rats. This effect was associated with inhibition of lactate transport, rather than inhibition of CA.

Importance of pH regulation and lactate/H+transport capacity for work production during supramaximal exercise in humans

We examine the influence of the cytosolic and membrane-bound contents of carbonic anhydrase (CA; CAII, CAIII, CAIV, and CAXIV) and the muscle content of proteins involved in lactate and proton transport [monocarboxylate transporter (MCT) 1, MCT4, and Na+/H+exchanger 1 (NHE1)] on work capacity during supramaximal exercise. Eight healthy, sedentary subjects performed exercises at 120% of the work rate corresponding to maximal oxygen uptake (Ẇmax) until exhaustion in placebo (Con) and metabolic alkalosis (Alk) conditions. The total (Wtot) and supramaximal work performed (Wsup) was measured. Muscle biopsies were obtained before and immediately after standardized exercises (se) at 120% Ẇmaxin both conditions to determine the content of the targeted proteins, the decrease in muscle pH (ΔpHm), and the muscle lactate accumulation ([Lac]m) per joule of Wsup(ΔpHm/Wsup-seand Δ[Lac]m/Wsup-se, respectively) and the dynamic buffer capacity. In Con, Wsupwas negatively correlated with ΔpHm/Wsup-se, positively correlated with Δ[Lac]m/Wsup-seand MCT1, and tended to be positively correlated with MCT4 and NHE1. CAII + CAIII were correlated positively with ΔpHm/Wsup-seand negatively with Δ[Lac]m/Wsup-se, while CAIV was positively related to Wtot. The changes in Wsupwith Alk were correlated positively with those in dynamic buffer capacity and negatively with Wsupin Con. Performance improvement with Alk was greater in subjects having a low content of proteins involved in pH regulation and lactate/proton transport. These results show the importance of pH regulating mechanisms and lactate/proton transport on work capacity and the role of the CA to delay decrease in pHmand accumulation in [Lac]mduring supramaximal exercise in humans.

Effect of acetazolamide on pulmonary and muscle gas exchange during normoxic and hypoxic exercise

Acetazolamide (ACZ) is used to prevent acute mountain sickness at altitude. Because it could affect O2 transport in several different and potentially conflicting ways, we examined its effects on pulmonary and muscle gas exchange and acid-base status during cycle exercise at approximately 30, 50 and 90% VO2max in normoxia (F(IO2) = 0.2093) and acute hypoxia (F(IO2) = 0.125). In a double-blind, order-balanced, crossover design, six healthy, trained men (normoxic VO2max= 59 ml kg(-1) min(-1)) exercised at both F(IO2) values after ACZ (3 doses of 250 mg, 8 h apart) and placebo. One week later this protocol was repeated using the other drug (placebo or ACZ). We measured cardiac output (QT), leg blood flow (LBF), and muscle and pulmonary gas exchange, the latter using the multiple inert gas elimination technique. ACZ did not significantly affect VO2, QT, LBF or muscle gas exchange. As expected, ACZ led to lower arterial and venous blood [HCO3-], pH and lactate levels (P < 0.05), and increased ventilation (P < 0.05). In both normoxia and hypoxia, ACZ resulted in higher arterial P(O2) and saturation and a lower alveolar-arterial P(O2) difference (AaD(O2)) due to both less VA/Q mismatch and less diffusion limitation (P < 0.05). In summary, ACZ improved arterial oxygenation during exercise, due to both greater ventilation and more efficient pulmonary gas exchange. However, muscle gas exchange was unaffected.

Expression of membrane-bound carbonic anhydrases IV, IX, and XIV in the mouse heart

Expression of membrane-bound carbonic anhydrases (CAs) of CA IV, CA IX, CA XII, and CA XIV has been investigated in the mouse heart. Western blots using microsomal membranes of wild-type hearts demonstrate a 39-, 43-, and 54-kDa band representing CA IV, CA IX, and CA XIV, respectively, but CA XII could not be detected. Expression of CA IX in the CA IV/CA XIV knockout animals was further confirmed using matrix-assisted laser desorption ionization time-of-flight mass spectrometry. Cardiac cells were immunostained using anti-CA/FITC and anti-alpha-actinin/TRITC, as well as anti-CA/FITC and anti-SERCA2/TRITC. Subcellular CA localization was investigated by confocal laser scanning microscopy. CA localization in the sarcolemmal (SL) membrane was examined by double immunostaining using anti-CA/FITC and anti-MCT-1/TRITC. CAs showed a distinct distribution pattern in the sarcoplasmic reticulum (SR) membrane. CA XIV is predominantly localized in the longitudinal SR, whereas CA IX is mainly expressed in the terminal SR/t-tubular region. CA IV is present in both SR regions, whereas CA XII is not found in the SR. In the SL membrane, only CA IV and CA XIV are present. We conclude that CA IV and CA XIV are associated with the SR as well as with the SL membrane, CA IX is located in the terminal SR/t-tubular region, and CA XII is not present in the mouse heart. Therefore, the unique subcellular localization of CA IX and CA XIV in cardiac myocytes suggests different functions of both enzymes in excitation-contraction coupling.

A quantitative study of bioenergetics in skeletal muscle lacking carbonic anhydrase III using 31P magnetic resonance spectroscopy

Oxidative slow skeletal muscle contains carbonic anhydrase III in high concentration, but its primary function remains unknown. To determine whether its lack handicaps energy metabolism and/or acid elimination, we measured the intracellular pH and energy phosphates by (31)P magnetic resonance spectroscopy in hind limb muscles of wild-type and CA III knockout mice during and after ischemia and intense exercise (electrical stimulation). Thirty minutes of ischemia caused phosphocreatine (PCr) to fall and P(i) to rise while pH and ATP remained constant in both strains of mice. PCr and P(i) kinetics during ischemia and recovery were not significantly different between the two genotypes. From this we conclude that under neutral pH conditions resting muscle anaerobic metabolism, the rate of the creatine kinase reaction, intracellular buffering of protons, and phosphorylation of creatine by mitochondrial oxygen metabolism are not influenced by the lack of CA III. Two minutes of intense stimulation of the mouse gastrocnemius caused PCr, ATP, and pH to fall and ADP and P(i) to rise, and these changes, with the exception of ATP, were all significantly larger in the CA III knockouts. The rate of return of pH and ADP to control values was the same in wild-type and mutant mice, but in the mutants PCr and P(i) recovery were delayed in the first minute after stimulation. Because the tension decrease during fatigue is known to be the same in the two genotypes, we conclude that a lack of CA III impairs mitochondrial ATP synthesis.

Reliability of 31P-magnetic resonance spectroscopy during an exhaustive incremental exercise test in children

This study examined the reliability of (31)P-magnetic resonance spectroscopy (MRS) to measure parameters of muscle metabolic function in children. On separate days, 14 children (7 boys and 7 girls) completed three knee-extensor incremental tests to exhaustion inside a whole-body scanner (1.5 T, Phillips). The dynamic changes in the ratio of inorganic phosphate to phosphocreatine (Pi/PCr) and intracellular muscle pH were resolved every 30 s. Using plots of Pi/PCr and pH against power output (W), intracellular thresholds (ITs) for each variable were determined using both subjective and objective procedures. The IT(Pi/PCr) and IT(pH) were observed subjectively in 93 and 81% of their respective plots, whereas the objective method identified the IT(Pi/PCr) in 88% of the plots. The IT(pH) was undetectable using the objective method. End exercise (END) END(Pi/PCr), END(pH), IT(Pi/PCr) and IT(pH) were examined using typical error statistics expressed as a % coefficient of variation (CV) across all three exercise tests. The CVs for the power output at the subjectively determined IT(Pi/PCr) and IT(pH) were 10.6 and 10.3%, respectively. Objective identification of the IT(Pi/PCr) had a CV of 16.3%. CVs for END(pH) and END(Pi/PCr) were 0.9 and 50.0%, respectively. MRS provides a valuable window into metabolic changes during exercise in children. During knee-extensor exercise to exhaustion, END(pH) and the subjectively determined IT(Pi/PCr) and IT(pH) demonstrate good reliability and thus stable measures for the future study of developmental metabolism. However, the objectively determined IT(Pi/PCr) and END(Pi/PCr) displayed poor reliability.

Effect of acetazolamide on leg endurance exercise at sea level and simulated altitude

Acetazolamide can be taken at sea level to prevent acute mountain sickness during subsequent altitude exposure. Acetazolamide causes metabolic acidosis at sea level and altitude, and increases SaO2 (arterial oxygen saturation) at altitude. The aim of the present study was to determine whether acetazolamide impairs muscle endurance at sea level but not simulated altitude (4300 m for <3 h). Six subjects (20+/-1 years of age; mean+/-S.E.M.) performed exhaustive constant work rate one-leg knee-extension exercise (25+/-2 W) once a week for 4 weeks, twice at sea level and twice at altitude. Each week, subjects took either acetazolamide (250 mg) or placebo orally in a double-blind fashion (three times a day) for 2 days. On day 2, all exercise bouts began approx. 2.5 h after the last dose of acetazolamide or placebo. Acetazolamide caused similar acidosis (pH) in all subjects at sea level (7.43+/-0.01 with placebo compared with 7.34+/-0.01 with acetazolamide; P<0.05) and altitude (7.48+/-0.03 with placebo compared with 7.37+/-0.01 with acetazolamide; P<0.05). However, endurance performance was impaired with acetazolamide only at sea level (48+/-4 min with placebo compared with 36+/-5 min with acetazolamide; P<0.05), but not altitude (17+/-2 min with placebo compared with 20+/-3 min with acetazolamide; P = not significant). In conclusion, lack of impairment of endurance performance by acetazolamide compared with placebo at altitude was probably due to off-setting secondary effects resulting from acidosis, e.g. ventilatory induced increase in SaO2 for acetazolamide compared with placebo (89+/-1 compared with 86+/-1% respectively; P<0.05), which resulted in an increased oxygen pressure gradient from capillary to exercising muscle.

Phosphorylation and protonation of neighboring MiRP2 sites: function and pathophysiology of MiRP2-Kv3.4 potassium channels in periodic paralysis

MinK-related peptide 2 (MiRP2) and Kv3.4 subunits assemble in skeletal muscle to create subthreshold, voltage-gated potassium channels. MiRP2 acts on Kv3.4 to shift the voltage dependence of activation, speed recovery from inactivation, suppress cumulative inactivation and increase unitary conductance. We previously found an R83H missense mutation in MiRP2 that segregated with periodic paralysis in two families and diminished the effects of MiRP2 on Kv3.4. Here we show that MiRP2 has a single, functional PKC phosphorylation site at serine 82 and that normal MiRP2-Kv3.4 function requires phosphorylation of the site. The R83H variant does not prevent PKC phosphorylation of neighboring S82; rather, the change shifts the voltage dependence of activation and endows MiRP2-Kv3.4 channels with sensitivity to changes in intracellular pH across the physiological range. Thus, current passed by single R83H channels decreases as internal pH is lowered (pK(a) approximately 7.3, consistent with histidine protonation) whereas wild-type channels are largely insensitive. These findings identify a key regulatory domain in MiRP2 and suggest a mechanistic link between acidosis and episodes of periodic paralysis.

NaHCO3-induced alkalosis reduces the phosphocreatine slow component during heavy-intensity forearm exercise

During heavy-intensity exercise, the mechanisms responsible for the continued slow decline in phosphocreatine concentration ([PCr]) (PCr slow component) have not been established. In this study, we tested the hypothesis that a reduced intracellular acidosis would result in a greater oxidative flux and, consequently, a reduced magnitude of the PCr slow component. Subjects (n = 10) performed isotonic wrist flexion in a control trial and in an induced alkalosis (Alk) trial (0.3g/kg oral dose of NaHCO3, 90 min before testing). Wrist flexion, at a contraction rate of 0.5 Hz, was performed for 9 min at moderate- (75% of onset of acidosis; intracellular pH threshold) and heavy-intensity (125% intracellular pH threshold) exercise. 31P-magnetic resonance spectroscopy was used to measure intracellular [H+], [PCr], [Pi], and [ATP]. The initial recovery data were used to estimate the rate of ATP synthesis and oxidative flux at the end of heavy-intensity exercise. In repeated trials, venous blood sampling was used to measure plasma [H+], [HCO3-], and [Lac-]. Throughout rest and exercise, plasma [H+] was lower (P < 0.05) and [HCO3-] was elevated (P < 0.05) in Alk compared with control. During the final 3 min of heavy-intensity exercise, Alk caused a lower (P < 0.05) intracellular [H+] [246 (SD 117) vs. 291 nmol/l (SD 129)], a greater (P < 0.05) [PCr] [12.7 (SD 7.0) vs. 9.9 mmol/l (SD 6.0)], and a reduced accumulation of [ADP] [0.065 (SD 0.031) vs. 0.098 mmol/l (SD 0.059)]. Oxidative flux was similar (P > 0.05) in the conditions at the end of heavy-intensity exercise. In conclusion, our results are consistent with a reduced intracellular acidosis, causing a decrease in the magnitude of the PCr slow component. The decreased PCr slow component in Alk did not appear to be due to an elevated oxidative flux.

The role of carbonic anhydrase in the recovery of skeletal muscle from anoxia

To investigate the role of carbonic anhydrase in the recovery of skeletal muscle from anoxia, pH and cell phosphates were measured by (31)P-nuclear magnetic resonance in superfused newborn rabbit myotubes and cultured mouse soleus cells (H-2K(b)-ts a58) after approximately 2-3.5 h without superfusion. In control studies, pH and phosphocreatine fell and P(i) rose during anoxia and recovered within <10 min after reperfusion began. A carbonic anhydrase inhibitor, acetazolamide, and dimethylamiloride, an inhibitor of the Na(+)/H(+) antiporter NHE1, delayed the recoveries of pH, phosphocreatine, and P(i) for >10 min, but the rate of recovery, once initiated, was unchanged. In the presence of the inhibitors, after reperfusion started, the pH did not rise immediately, despite a large inwardly directed HCO(3)(-) gradient, suggesting that HCO(3)(-) movement was unimportant in acid elimination. Lactate, measured by its methyl protons, rose during anoxia and did not fall after 1 h of reperfusion and could not have eliminated protons by cotransport. We conclude that NHE1 is the major exporter of protons by skeletal muscle in recovery from a period of anoxia and that it is essential for functioning carbonic anhydrase to be attached to NHE1 to activate it. The mechanism of late recovery of pH could be the mobilization of another proton transporter or removal of the inhibition of the Na(+)/H(+) antiporter. Inhibition of carbonic anhydrase in skeletal muscle retards acid removal and modifies muscle metabolism significantly after anoxia.

Electrophysiology and molecular pharmacology of muscle channelopathies

As voltage-gated ion channels are essential for membrane excitation, it is not surprising that mutations in the respective channel genes cause diseases characterised by altered cell excitability. Skeletal muscle was the first tIssue in which such diseases, namely the myotonias and periodic paralyses, were recognised as ion channelopathies. The detection of the functional defect that is brought about by the disease-causing mutation is essential for the understanding of the pathology. Much progress on the road to this aim was achieved by the combination of molecular biology and electrophysiological patch clamp techniques. The functional expression of the mutations in expression systems allows to study the functional alterations of mutant channels and to develop new strategies for the therapy of ion channelopathies, e.g. by designing drugs that specifically suppress the effects of malfunctioning channels.

Acetazolamide reduces exercise capacity and increases leg fatigue under hypoxic conditions

Acetazolamide (Acz) is used at altitude to prevent acute mountain sickness, but its effect on exercise capacity under hypoxic conditions is uncertain. Nine healthy men completed this double-blind, randomized, crossover study. All subjects underwent incremental exercise to exhaustion with an inspired O(2) fraction of 0.13, hypoxic ventilatory responses, and hypercapnic ventilatory responses after Acz (500 mg twice daily for 5 doses) and placebo. Maximum power of 203 +/- 38 (SD) W on Acz was less than the placebo value of 225 +/- 40 W (P < 0.01). At peak exercise, arterialized capillary pH was lower and Po(2) higher on Acz (P < 0.01). Ventilation was 118.6 +/- 20.0 l/min at the maximal power on Acz and 102.4 +/- 20.7 l/min at the same power on placebo (P < 0.02), and Borg score for leg fatigue was increased on Acz (P < 0.02), with no difference in Borg score for dyspnea. Hypercapnic ventilatory response on Acz was greater (P < 0.02), whereas hypoxic ventilatory response was unchanged. During hypoxic exercise, Acz reduced exercise capacity associated with increased perception of leg fatigue. Despite increased ventilation, dyspnea was not increased.