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Thomas C, Alici Y, Breitbart W, Bruera E, Blackler L, Sulmasy DP. Drugs, delirium, and ethics at the end of life. J Am Geriatr Soc 2024; 72:1964-1972. [PMID: 38240387 PMCID: PMC11226357 DOI: 10.1111/jgs.18766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/27/2024]
Abstract
For older persons with delirium at the end of life, treatment involves complex trade-offs and highly value-sensitive decisions. The principles of beneficence, nonmaleficence, respect for autonomy, and justice establish important parameters but lack the structure necessary to guide clinicians in the optimal management of these patients. We propose a set of ethical rules to guide therapeutics-the canons of therapy-as a toolset to help clinicians deliberate about the competing concerns involved in the management of older patients with delirium at the end of life. These canons are standards of judgment that reflect how many experienced clinicians already intuitively practice, but which are helpful to articulate and apply as basic building blocks for a relatively neglected but emerging ethics of therapy. The canons of therapy most pertinent to the care of patients with delirium at the end of life are as follows: (1) restoration, which counsels that the goal of all treatment is to restore the patient, as much as possible, to homeostatic equilibrium; (2) means-end proportionality, which holds that every treatment should be well-fitted to the intended goal or end; (3) discretion, which counsels that an awareness of the limits of medical knowledge and practice should guide all treatment decisions; and (4) parsimony, which maintains that only as much therapeutic force as is necessary should be used to achieve the therapeutic goal. Carefully weighed and applied, these canons of therapy may provide the ethical structure needed to help clinicians optimally navigate complex cases.
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Affiliation(s)
- Columba Thomas
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
| | - Yesne Alici
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Liz Blackler
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel P. Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
- Departments of Medicine and Philosophy and the Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC, USA
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2
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Hoilat GJ, Suhail FK, Adhami T, John S. Evidence-based approach to management of hepatic encephalopathy in adults. World J Hepatol 2022; 14:670-681. [PMID: 35646276 PMCID: PMC9099111 DOI: 10.4254/wjh.v14.i4.670] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 08/07/2021] [Accepted: 03/27/2022] [Indexed: 02/06/2023] Open
Abstract
Hepatic encephalopathy (HE) is a reversible syndrome of impaired brain function and represents one of the many complications of portal hypertension and decompensated liver disease. Although ammonia is clearly implicated in the pathogenesis of HE, the pathogenesis of HE is multifactorial with numerous mechanisms that results in functional impairment of neuronal cells. The initial management of HE focuses on supportive care and stabilization which includes providing appropriate nutritional support. Thereafter, focus should be on identifying and treating the precipitating factors. There are many therapeutic agents available for the management of HE, most of which are directed towards lowering the gut nitrogen load and thus the serum ammonia level. This review aims to provide an update on the conventional and emerging treatment options for HE.
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Affiliation(s)
- Gilles Jadd Hoilat
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Fathima Keshia Suhail
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Talal Adhami
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Savio John
- Department of Gastroenterology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
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3
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Diffuse Cerebral Edema and Impending Herniation Complicating Hepatic Encephalopathy in Hereditary Hemorrhagic Telangiectasia. Case Rep Med 2022; 2022:2612544. [PMID: 35222647 PMCID: PMC8881178 DOI: 10.1155/2022/2612544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/28/2021] [Indexed: 11/19/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant vascular disease characterized by the formation of cutaneous and visceral telangiectasias and arteriovenous malformations (AVM). Multiple organs may be affected, including the nasal mucosa, skin, lungs, gastrointestinal tract, and brain. The following case highlights a unique manifestation of HHT in a patient with a gastrointestinal hemorrhage and epistaxis, resulting in hyperammonemia and diffuse cerebral edema and herniation. Clinicians should be aware of this potential complication in such patients and initiate ammonia-reducing agents early to avoid this devastating consequence.
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4
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Han X, Luo Z, Wang W, Zheng P, Li T, Mei Z, Wang J. Efficacy and Safety of Rifaximin Versus Placebo or Other Active Drugs in Critical ill Patients With Hepatic Encephalopathy. Front Pharmacol 2021; 12:696065. [PMID: 34690751 PMCID: PMC8533823 DOI: 10.3389/fphar.2021.696065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 09/21/2021] [Indexed: 12/11/2022] Open
Abstract
Objective: Rifaximin has been approved for use as a first-line therapy for secondary prophylaxis of hepatic encephalopathy (HE). This article is to update existing evidence on efficacy and safety of rifaximin treatment and prevention for HE. Methods: We systematically searched multiple databases until January 31 2021. The studies compared rifaximin vs. placebo or other active drugs (i.e., nonabsorbable disaccharides, other antibiotics, L-ornithine-L-aspartate (LOLA), and probiotics) for patients with overt HE (OHE), minimal HE (MHE), and recurrent HE. Results: Twenty-eight randomized controlled trials with a total of 2979 patients were included. Compared with the controls, rifaximin significantly reduced HE grade (OHE: RR = 1.11, 95% CI = 1.02-1.21), improved the cognitive impairments (MHE: RR = 1.82, 95% CI = 1.12-2.93) and prevented the risk of HE recurrent episodes (RR = 1.33, 95% CI = 1.18-1.49). No statistical difference was observed in mortality between rifaximin and their controls (RR = 0.82, 95% CI = 0.54-1.24). The incidence of total adverse events in rifaximin-treated groups was significantly lower than that in the controls during the treatment period (RR = 0.73, 95% CI = 0.54-0.98). In addition, rifaximin treatment was better than other active drugs in improving psychometric indicators (mental state, flapping tremor and portosystemic encephalopathy (PSE) index) and reducing the risk of rehospitalization in HE patients. Conclusion: Rifaximin therapy is effective and well-tolerated in different types of HE, which might be recommended as an alternative to conventional oral drugs in clinical settings.
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Affiliation(s)
- Xianghui Han
- Department of Liver Disease, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Institute of Chinese Traditional Surgery, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhanyang Luo
- Institute of Chinese Traditional Surgery, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Wenyi Wang
- Department of Liver Disease, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Peiyong Zheng
- Institute of Digestive Diseases, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Tian Li
- School of Basic Medicine, Fourth Military Medical University, Xi’an, China
| | - Zubing Mei
- Department of Anorectal Surgery, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
| | - Jianyi Wang
- Department of Liver Disease, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
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5
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Mulroy E, Baschieri F, Magrinelli F, Latorre A, Cortelli P, Bhatia KP. Movement Disorders and Liver Disease. Mov Disord Clin Pract 2021; 8:828-842. [PMID: 34401403 PMCID: PMC8354085 DOI: 10.1002/mdc3.13238] [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: 11/17/2020] [Revised: 04/24/2021] [Accepted: 04/27/2021] [Indexed: 12/15/2022] Open
Abstract
The association of movement disorders with structural or functional hepatic disease occurs in three principal scenarios: (1) combined involvement of both organ systems from a single disease entity, (2) nervous system dysfunction resulting from exposure to toxic compounds in the setting of defective hepatic clearance, or (3) hepatic and/or neurological injury secondary to exposure to exogenous drugs or toxins. An important early step in the workup of any patient with combined movement disorders and liver disease is the exclusion of Wilson's disease. Diagnostic delay remains common for this treatable disorder, and this has major implications for patient outcomes. Thereafter, a structured approach integrating variables such as age of onset, tempo of progression, nature and severity of liver involvement, movement disorder phenomenology, exposure to drugs/toxins and laboratory/neuroimaging findings is key to ensuring timely diagnosis and disease‐specific therapy. Herein, we provide an overview of disorders which may manifest with a combination of movement disorders and liver disease, structured under the three headings as detailed above. In each section, the most common disorders are discussed, along with important clinical pearls, suggested diagnostic workup, differential diagnoses and where appropriate, treatment considerations.
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Affiliation(s)
- Eoin Mulroy
- Department of Clinical and Movement Neurosciences UCL Queen Square Institute of Neurology London United Kingdom
| | - Francesca Baschieri
- IRCCS Istituto delle Scienze Neurologiche di Bologna Bologna Italy.,Dipartimento di Scienze Biomediche e Neuromotorie Università di Bologna Bologna Italy
| | - Francesca Magrinelli
- Department of Clinical and Movement Neurosciences UCL Queen Square Institute of Neurology London United Kingdom.,Department of Neurosciences Biomedicine and Movement Sciences, University of Verona Verona Italy
| | - Anna Latorre
- Department of Clinical and Movement Neurosciences UCL Queen Square Institute of Neurology London United Kingdom
| | - Pietro Cortelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna Bologna Italy.,Dipartimento di Scienze Biomediche e Neuromotorie Università di Bologna Bologna Italy
| | - Kailash P Bhatia
- Department of Clinical and Movement Neurosciences UCL Queen Square Institute of Neurology London United Kingdom
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López-Franco Ó, Morin JP, Cortés-Sol A, Molina-Jiménez T, Del Moral DI, Flores-Muñoz M, Roldán-Roldán G, Juárez-Portilla C, Zepeda RC. Cognitive Impairment After Resolution of Hepatic Encephalopathy: A Systematic Review and Meta-Analysis. Front Neurosci 2021; 15:579263. [PMID: 33790729 PMCID: PMC8006450 DOI: 10.3389/fnins.2021.579263] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 01/14/2021] [Indexed: 12/26/2022] Open
Abstract
Hepatic encephalopathy (HE) is one of the most disabling metabolic diseases. It consists of a complication of liver disease through the action of neurotoxins, such as excessive production of ammonia from liver, resulting in impaired brain function. Its prevalence and incidence are not well known, although it has been established that up to 40% of cirrhotic patients may develop HE. Patients with HE episodes display a wide range of neurological disturbances, from subclinical alterations to coma. Recent evidence suggests that the resolution of hepatic encephalopathy does not fully restore cognitive functioning in cirrhotic patients. Therefore, the aim of this review was to evaluate the evidence supporting the presence of lingering cognitive deficits in patients with a history of HE compared to patients without HE history and how liver transplant affects such outcome in these patients. We performed two distinct meta-analysis of continuous outcomes. In both cases the results were pooled using random-effects models. Our results indicate that cirrhotic patients with a history of HE show clear cognitive deficits compared to control cirrhotic patients (Std. Mean Difference (in SDs) = −0.72 [CI 95%: −0.94, −0.50]) and that these differences are not fully restored after liver transplant (Std. Mean Difference (in SDs) = −0.48 [CI 95%: −0.77, −0.19]).
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Affiliation(s)
- Óscar López-Franco
- Laboratorio de Medicina Traslacional, Instituto de Ciencias de la Salud, Universidad Veracruzana, Xalapa, Mexico
| | - Jean-Pascal Morin
- Laboratorio de Neurobiología de la Conducta, Departamento de Fisiología, Facultad de Medicina, Universidad Nacional Autónoma de Mexico, Ciudad de Mexico, Mexico
| | | | - Tania Molina-Jiménez
- Instituto Interdisciplinario de Investigaciones de la Universidad de Xalapa, Xalapa, Mexico
| | - Diana I Del Moral
- Programa de Doctorado en Ciencias Biomédicas, Universidad Veracruzana, Xalapa, Mexico
| | - Mónica Flores-Muñoz
- Laboratorio de Medicina Traslacional, Instituto de Ciencias de la Salud, Universidad Veracruzana, Xalapa, Mexico
| | - Gabriel Roldán-Roldán
- Laboratorio de Neurobiología de la Conducta, Departamento de Fisiología, Facultad de Medicina, Universidad Nacional Autónoma de Mexico, Ciudad de Mexico, Mexico
| | - Claudia Juárez-Portilla
- Laboratorio de Biomedicina Integral y Salud, Centro de Investigaciones Biomédicas, Universidad Veracruzana, Xalapa, Mexico
| | - Rossana C Zepeda
- Laboratorio de Biomedicina Integral y Salud, Centro de Investigaciones Biomédicas, Universidad Veracruzana, Xalapa, Mexico
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7
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Formulation and optimization of neomycin Sulfate–Thioctic acid loaded in a eucalyptus oil self-nanoemulsion to enhance the beneficial activity of the substances and limit the side effects associated with the treatment of hepatic coma. J Drug Deliv Sci Technol 2021. [DOI: 10.1016/j.jddst.2020.102108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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8
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Yanny B, Winters A, Boutros S, Saab S. Hepatic Encephalopathy Challenges, Burden, and Diagnostic and Therapeutic Approach. Clin Liver Dis 2019; 23:607-623. [PMID: 31563214 DOI: 10.1016/j.cld.2019.07.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Hepatic encephalopathy (HE) is an important cause of morbidity and mortality in patients with cirrhosis. The impact of HE on the health care system is similarly profound. The number of hospital admissions for HE has increased in the last 10-year period. HE is a huge burden to the patients, care givers, and the health care system. HE represents a "revolving door" with readmission, severely affects care givers, and has effects on cognition that can persists after liver transplant. This article reviews the current literature to discuss the challenges and diagnostic and therapeutic approaches to HE.
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Affiliation(s)
- Beshoy Yanny
- Department of Medicine, University of California at Los Angeles, 1223 16th street, suite 3100, Santa Monica, CA 90404, USA.
| | - Adam Winters
- Department of Medicine, University of California at Los Angeles, 1223 16th street, suite 3100, Santa Monica, CA 90404, USA
| | - Sandra Boutros
- Department of Surgery, University of California at Los Angeles, 200 medical plaza, 3rd floor, Los Angeles, CA 90095, USA
| | - Sammy Saab
- Department of Medicine, University of California at Los Angeles, 1223 16th street, suite 3100, Santa Monica, CA 90404, USA; Department of Surgery, University of California at Los Angeles, 200 medical plaza, 3rd floor, Los Angeles, CA 90095, USA; Department of Nursing, University of California at Los Angeles, 200 medical plaza, 3rd floor, Los Angeles, CA 90095, USA
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9
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Cudalbu C, Taylor-Robinson SD. Brain Edema in Chronic Hepatic Encephalopathy. J Clin Exp Hepatol 2019; 9:362-382. [PMID: 31360029 PMCID: PMC6637228 DOI: 10.1016/j.jceh.2019.02.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 01/15/2019] [Accepted: 02/06/2019] [Indexed: 02/07/2023] Open
Abstract
Brain edema is a common feature associated with hepatic encephalopathy (HE). In patients with acute HE, brain edema has been shown to play a crucial role in the associated neurological deterioration. In chronic HE, advanced magnetic resonance imaging (MRI) techniques have demonstrated that low-grade brain edema appears also to be an important pathological feature. This review explores the different methods used to measure brain edema ex vivo and in vivo in animal models and in humans with chronic HE. In addition, an in-depth description of the main studies performed to date is provided. The role of brain edema in the neurological alterations linked to HE and whether HE and brain edema are the manifestations of the same pathophysiological mechanism or two different cerebral manifestations of brain dysfunction in liver disease are still under debate. In vivo MRI/magnetic resonance spectroscopy studies have allowed insight into the development of brain edema in chronic HE. However, additional in vivo longitudinal and multiparametric/multimodal studies are required (in humans and animal models) to elucidate the relationship between liver function, brain metabolic changes, cellular changes, cell swelling, and neurological manifestations in chronic HE.
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Key Words
- 1H MRS, proton magnetic resonance spectroscopy
- ADC, apparent diffusion coefficient
- ALF, acute liver failure
- AQP, aquaporins
- BBB, blood-brain barrier
- BDL, bile duct ligation
- CNS, central nervous system
- CSF, cerebrospinal fluid
- Cr, creatine
- DTI, diffusion tensor imaging
- DWI, diffusion-weighted imaging
- FLAIR, fluid-attenuated inversion recovery
- GM, gray matter
- Gln, glutamine
- Glx, sum of glutamine and glutamate
- HE, hepatic encephalopathy
- Ins, inositol
- LPS, lipopolysaccharide
- Lac, lactate
- MD, mean diffusivity
- MRI, magnetic resonance imaging
- MRS, magnetic resonance spectroscopy
- MT, magnetization transfer
- MTR, MT ratio
- NMR, nuclear magnetic resonance
- PCA, portocaval anastomosis
- TE, echo time
- WM, white matter
- brain edema
- chronic hepatic encephalopathy
- in vivo magnetic resonance imaging
- in vivo magnetic resonance spectroscopy
- liver cirrhosis
- mIns, myo-inositol
- tCho, total choline
- tCr, total creatine
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Affiliation(s)
- Cristina Cudalbu
- Centre d'Imagerie Biomedicale (CIBM), Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Simon D. Taylor-Robinson
- Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer, St Mary's Hospital Campus, Imperial College London, London, United Kingdom
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10
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Xie XL, Zhou WT, Zhang KK, Chen LJ, Wang Q. METH-Induced Neurotoxicity Is Alleviated by Lactulose Pretreatment Through Suppressing Oxidative Stress and Neuroinflammation in Rat Striatum. Front Neurosci 2018; 12:802. [PMID: 30450033 PMCID: PMC6224488 DOI: 10.3389/fnins.2018.00802] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 10/15/2018] [Indexed: 11/13/2022] Open
Abstract
Abuse of methamphetamine (METH) results in neurological and psychiatric abnormalities. Lactulose is a poorly absorbed derivative of lactose and can effectively alleviate METH-induced neurotoxicity in rats. The present study was designed to investigate the effects of lactulose on METH-induced neurotoxicity. Rats received METH (15 mg/kg, 8 intraperitoneal injections, 12-h interval) or saline and received lactulose (5.3 g/kg, oral gavage, 12-h interval) or vehicle 2 days prior to the METH administration. Reactive oxygen species (ROS) and malondialdehyde (MDA) were measured. Protein levels of toll-like receptor 4 (TLR4), myeloid differentiation factor 88 (MyD88), tumor necrosis factor receptor associated factor 6 (TRAF6), nuclear factor κB (NFκB), interleukin (IL)-1β, IL-6, TNF-α, cleaved caspase 3, and poly(ADP-ribose) polymerase-1 (PARP-1) were determined by western blotting. mRNA expressions of nuclear factor erythroid 2-relatted factor-2 (Nrf2), p62, and heme oxygenase-1 (HO-1) were assessed by RT-qPCR. The lactulose pretreatment decreased METH-induced cytoplasmic damage in rat livers according to histopathological observation. Compared to the control group, overproduction of ROS and MDA were observed in rat striatums in the METH alone-treated group, while the lactulose pretreatment significantly attenuated the METH-induced up-regulation of oxidative stress. The lactulose pretreatment significantly repressed over-expressions of proteins of TLR4, MyD88, TRAF6, NFκB, IL-1β, IL-6, TNF-α, cleaved caspase 3, PARP-1. The lactulose pretreatment increased mRNA expressions of Nrf2, p62, and HO-1. These findings suggest that lactulose pretreatment can alleviate METH-induced neurotoxicity through suppressing neuroinflammation and oxidative stress, which might be attributed to the activation of the Nrf2/HO-1 axis.
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Affiliation(s)
- Xiao-Li Xie
- Department of Toxicology, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
| | - Wen-Tao Zhou
- Department of Toxicology, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
| | - Kai-Kai Zhang
- Department of Forensic Pathology, School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Li-Jian Chen
- Department of Forensic Pathology, School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Qi Wang
- Department of Forensic Pathology, School of Forensic Medicine, Southern Medical University, Guangzhou, China
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11
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Singh P, Chung HJ, Lee IA, D'Souza R, Kim HJ, Hong ST. Elucidation of the anti-hyperammonemic mechanism of Lactobacillus amylovorus JBD401 by comparative genomic analysis. BMC Genomics 2018; 19:292. [PMID: 29695242 PMCID: PMC5918772 DOI: 10.1186/s12864-018-4672-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 04/13/2018] [Indexed: 12/15/2022] Open
Abstract
Background Recent experimental evidence showed that lactobacilli could be used as potential therapeutic agents for hyperammonemia. However, lack of understanding on how lactobacilli reduce blood ammonia levels limits application of lactobacilli to treat hyperammonemia. Results We report the finished and annotated genome sequence of L. amylovorus JBD401 (GenBank accession no. CP012389). L. amylovorus JBD401 reducing blood ammonia levels dramatically was identified by high-throughput screening of several thousand probiotic strains both within and across Lactobacillus species in vitro. Administration of L. amylovorus JBD401 to hyperammonemia-induced mice reduced the blood ammonia levels of the mice to the normal range. Genome sequencing showed that L. amylovorus JBD401 had a circular chromosome of 1,946,267 bp with an average GC content of 38.13%. Comparative analysis of the L. amylovorus JBD401 genome with L. acidophilus and L. amylovorus strains showed that L. amylovorus JBD401 possessed genes for ammonia assimilation into various amino acids and polyamines Interestingly, the genome of L. amylovorus JBD401 contained unusually large number of various pseudogenes suggesting an active stage of evolution. Conclusions L. amylovorus JBD401 has genes for assimilation of free ammonia into various amino acids and polyamines which results in removal of free ammonia in intestinal lumen to reduce the blood ammonia levels in the host. This work explains the mechanism of how probiotics reduce blood ammonia levels. Electronic supplementary material The online version of this article (10.1186/s12864-018-4672-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Parul Singh
- Department of Biomedical Sciences and Institute for Medical Science, Chonbuk National University Medical School, Jeonju, Chonbuk, 54907, South Korea
| | - Hea-Jong Chung
- Department of Biomedical Sciences and Institute for Medical Science, Chonbuk National University Medical School, Jeonju, Chonbuk, 54907, South Korea
| | - In-Ah Lee
- Present address: Department of Chemistry, Gunsan National University, Gunsan, Chonbuk, 51450, South Korea
| | - Roshan D'Souza
- Department of Biomedical Sciences and Institute for Medical Science, Chonbuk National University Medical School, Jeonju, Chonbuk, 54907, South Korea
| | - Hyeon-Jin Kim
- JINIS BDRD institute, JINIS Biopharmaceuticals Co., 913 Gwahak-Ro, Bongdong, Wanju, Chonbuk, 55321, South Korea
| | - Seong-Tshool Hong
- Department of Biomedical Sciences and Institute for Medical Science, Chonbuk National University Medical School, Jeonju, Chonbuk, 54907, South Korea.
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12
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Romeiro FG, Ietsugu MDV, Franzoni LDC, Augusti L, Alvarez M, Santos LAA, Lima TB, Koga KH, Moriguchi SM, Caramori CA, Silva GF, Betting LEGG. Which of the branched-chain amino acids increases cerebral blood flow in hepatic encephalopathy? A double-blind randomized trial. Neuroimage Clin 2018; 19:302-310. [PMID: 30013913 PMCID: PMC6044187 DOI: 10.1016/j.nicl.2018.03.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 03/07/2018] [Accepted: 03/21/2018] [Indexed: 02/06/2023]
Abstract
Branched-chain amino acids increase the brain perfusion of patients with hepatic encephalopathy (HE), but the amino acid and the mechanisms involved are still unknown. This study compared brain perfusion and clinical improvement during leucine or isoleucine supplementation. After randomization, 27 subjects with cirrhosis and HE received leucine or isoleucine supplements for one year. Brain single Photon Emission Computed Tomography (SPECT) and dynamic brain scintigraphy (DBS) were performed pretreatment and at 1, 8 and 12 months of supplementation. Brain perfusion was increased only in the isoleucine group at 8 months of treatment by both SPECT and DBS (p < 0.001 and p = 0.05, respectively) and by SPECT at the 12th month (p < 0.05). This was associated with hepatic encephalopathy improvement at 8 and 12 months (p = 0.008 and 0.004, respectively), which was not observed in the leucine group (p = 0.313 and 0.055, respectively). Isoleucine supplementation achieved a better impact on brain perfusion restoration in HE.
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Key Words
- AC, arm circumference
- APMT, adductor pollicis muscle thickness
- BCAA, branched-chain amino acids
- BCKA, branched-chain ketoacids
- BMI, body mass index
- Branched-chain amino acids
- CAMA, corrected mid-arm muscle area
- CBF, cerebral blood flow
- Cerebral blood flow
- EEG, electroencephalogram
- FDR, false discovery rate
- GDH, glutamate dehydrogenase
- GLN, glutamine
- GLU, glutamate
- HE, hepatic encephalopathy
- HGS, handgrip strength
- HPLC, high-performance liquid chromatography
- HRQoL, health-related quality of life
- Hepatic encephalopathy
- Liver cirrhosis
- MAMC, mid-arm muscle circumference
- MELD, Model of End-Stage Liver Disease
- NH3, ammonia
- PDH, pyruvate dehydrogenase complex
- ROIs, regions of interest
- ROS, reactive oxygen species
- SF-36, 36-item Short-Form General Health Survey
- SPECT, Single Photon Emission Computed Tomography
- SPM12, Statistical Parametrical Mapping 12
- TCA, tricarboxylic acid
- TSF, triceps skinfold
- α-KG, α-ketoglutarate
- αKGDH, α-ketoglutarate dehydrogenase complex
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Affiliation(s)
- Fernando Gomes Romeiro
- Department of Internal Medicine, Botucatu Medical School, UNESP - Univ Estadual Paulista. Av. Prof. Mário Rubens Guimarães Montenegro, s/n Distrito de Rubião Jr, Botucatu, São Paulo 18618-687, Brazil.
| | - Marjorie do Val Ietsugu
- Department of Internal Medicine, Botucatu Medical School, UNESP - Univ Estadual Paulista. Av. Prof. Mário Rubens Guimarães Montenegro, s/n Distrito de Rubião Jr, Botucatu, São Paulo 18618-687, Brazil
| | - Letícia de Campos Franzoni
- Department of Internal Medicine, Botucatu Medical School, UNESP - Univ Estadual Paulista. Av. Prof. Mário Rubens Guimarães Montenegro, s/n Distrito de Rubião Jr, Botucatu, São Paulo 18618-687, Brazil
| | - Laís Augusti
- Department of Internal Medicine, Botucatu Medical School, UNESP - Univ Estadual Paulista. Av. Prof. Mário Rubens Guimarães Montenegro, s/n Distrito de Rubião Jr, Botucatu, São Paulo 18618-687, Brazil
| | - Matheus Alvarez
- Department of Physics and Biophysics, Botucatu Biosciences Institute, UNESP - Univ Estadual Paulista, Rua Prof. Dr. Antonio Celso Wagner Zanin, s/n, Botucatu, São Paulo 18618-689, Brazil.
| | - Lívia Alves Amaral Santos
- Department of Internal Medicine, Botucatu Medical School, UNESP - Univ Estadual Paulista. Av. Prof. Mário Rubens Guimarães Montenegro, s/n Distrito de Rubião Jr, Botucatu, São Paulo 18618-687, Brazil
| | - Talles Bazeia Lima
- Department of Internal Medicine, Botucatu Medical School, UNESP - Univ Estadual Paulista. Av. Prof. Mário Rubens Guimarães Montenegro, s/n Distrito de Rubião Jr, Botucatu, São Paulo 18618-687, Brazil
| | - Kátia Hiromoto Koga
- Department of Tropical Diseases and Imaging Diagnosis, Botucatu Medical School, UNESP - Univ Estadual Paulista, Av. Prof. Mário Rubens Guimarães Montenegro, s/n. Distrito de Rubião Jr, Botucatu, São Paulo 18618-687, Brazil.
| | - Sônia Marta Moriguchi
- Department of Tropical Diseases and Imaging Diagnosis, Botucatu Medical School, UNESP - Univ Estadual Paulista, Av. Prof. Mário Rubens Guimarães Montenegro, s/n. Distrito de Rubião Jr, Botucatu, São Paulo 18618-687, Brazil
| | - Carlos Antonio Caramori
- Department of Internal Medicine, Botucatu Medical School, UNESP - Univ Estadual Paulista. Av. Prof. Mário Rubens Guimarães Montenegro, s/n Distrito de Rubião Jr, Botucatu, São Paulo 18618-687, Brazil
| | - Giovanni Faria Silva
- Department of Internal Medicine, Botucatu Medical School, UNESP - Univ Estadual Paulista. Av. Prof. Mário Rubens Guimarães Montenegro, s/n Distrito de Rubião Jr, Botucatu, São Paulo 18618-687, Brazil.
| | - Luiz Eduardo Gomes Garcia Betting
- Department of Neurology, Psychology and Psychiatry, Botucatu Medical School, UNESP - Univ Estadual Paulista, Av. Prof. Mário Rubens Guimarães Montenegro, s/n Distrito de Rubião Jr, Botucatu, São Paulo 18618-687, Brazil.
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The Pharmabiotic Approach to Treat Hyperammonemia. Nutrients 2018; 10:nu10020140. [PMID: 29382084 PMCID: PMC5852716 DOI: 10.3390/nu10020140] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/22/2018] [Accepted: 01/26/2018] [Indexed: 12/12/2022] Open
Abstract
Ammonia is constantly produced as a metabolic waste from amino acid catabolism in mammals. Ammonia, the toxic waste metabolite, is resolved in the liver where the urea cycle converts free ammonia to urea. Liver malfunctions cause hyperammonemia that leads to central nervous system (CNS) dysfunctions, such as brain edema, convulsions, and coma. The current treatments for hyperammonemia, such as antibiotics or lactulose, are designed to decrease the intestinal production of ammonia and/or its absorption into the body and are not effective, besides being often accompanied by side effects. In recent years, increasing evidence has shown that modifications of the gut microbiota could be used to treat hyperammonemia. Considering the role of the gut microbiota and the physiological characteristics of the intestine, the removal of ammonia from the intestine by modulating the gut microbiota would be an ideal approach to treat hyperammonemia. In this review, we discuss the significance of hyperammonemia and its related diseases and the efficacy of the current management methods for hyperammonemia to understand the mechanism of ammonia transport in the human body. The possibility to use the gut microbiota as pharmabiotics to treat hyperammonemia and its related diseases is also explored.
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Angelbello AJ, Chen JL, Childs-Disney JL, Zhang P, Wang ZF, Disney MD. Using Genome Sequence to Enable the Design of Medicines and Chemical Probes. Chem Rev 2018; 118:1599-1663. [PMID: 29322778 DOI: 10.1021/acs.chemrev.7b00504] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Rapid progress in genome sequencing technology has put us firmly into a postgenomic era. A key challenge in biomedical research is harnessing genome sequence to fulfill the promise of personalized medicine. This Review describes how genome sequencing has enabled the identification of disease-causing biomolecules and how these data have been converted into chemical probes of function, preclinical lead modalities, and ultimately U.S. Food and Drug Administration (FDA)-approved drugs. In particular, we focus on the use of oligonucleotide-based modalities to target disease-causing RNAs; small molecules that target DNA, RNA, or protein; the rational repurposing of known therapeutic modalities; and the advantages of pharmacogenetics. Lastly, we discuss the remaining challenges and opportunities in the direct utilization of genome sequence to enable design of medicines.
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Affiliation(s)
- Alicia J Angelbello
- Departments of Chemistry and Neuroscience, The Scripps Research Institute , 130 Scripps Way, Jupiter, Florida 33458, United States
| | - Jonathan L Chen
- Departments of Chemistry and Neuroscience, The Scripps Research Institute , 130 Scripps Way, Jupiter, Florida 33458, United States
| | - Jessica L Childs-Disney
- Departments of Chemistry and Neuroscience, The Scripps Research Institute , 130 Scripps Way, Jupiter, Florida 33458, United States
| | - Peiyuan Zhang
- Departments of Chemistry and Neuroscience, The Scripps Research Institute , 130 Scripps Way, Jupiter, Florida 33458, United States
| | - Zi-Fu Wang
- Departments of Chemistry and Neuroscience, The Scripps Research Institute , 130 Scripps Way, Jupiter, Florida 33458, United States
| | - Matthew D Disney
- Departments of Chemistry and Neuroscience, The Scripps Research Institute , 130 Scripps Way, Jupiter, Florida 33458, United States
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Anyanwu C, Ezeudu C, Le H, Egwim O. Clinical Relevance and Cost-Savings of Levocarnitine Versus Ammonul in the Management Of Hyperammonemia in a Cancer Patient: The Impact of a Clinical Pharmacist. P & T : A PEER-REVIEWED JOURNAL FOR FORMULARY MANAGEMENT 2018; 43:52-56. [PMID: 29290677 PMCID: PMC5737254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Hyperammonemia, a relatively uncommon condition characterized by elevated ammonia levels in the blood, presents with varied physiological etiologies that may send patients to the intensive care unit (ICU) with encephalopathy. An immediate decrease in ammonia levels is necessary to avert neurological damage. However, due to the multifaceted nature of hyperammonemia, a definite determination of etiology is not always possible. OBJECTIVE This case report examines the clinical and economic impact of a pharmacist in managing acute hyperammonemia of unknown etiology in a 62-year-old Hispanic man who had recently been diagnosed with metastatic medullary thyroid cancer and associated hypercalcemia. The patient was treated with levocarnitine after the failure of several other treatments. RESULTS Levocarnitine therapy controlled the patient's ammonia levels, which had progressively reached extremely high levels. His mental status, which had deteriorated severely, returned to baseline. CONCLUSION This case illustrates the importance of having a clinical pharmacist in the ICU. The pharmacist's expertise and knowledge helped avert adverse clinical consequences and promoted considerable cost-savings. This case also shows that levocarnitine may be an effective treatment for certain cases of hyperammonia-induced encephalopathy with unknown etiology.
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Jeong JH, Kim DK, Lee NS, Jeong YG, Kim HW, Kim JS, Han SY. Neuroprotective Effect of Nortriptyline in Overt Hepatic Encephalopathy Through Attenuation of Mitochondrial Dysfunction. ASN Neuro 2018; 10:1759091418810583. [PMID: 30428281 PMCID: PMC6238202 DOI: 10.1177/1759091418810583] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/21/2018] [Accepted: 10/01/2018] [Indexed: 12/12/2022] Open
Abstract
Hyperammonemia associated with overt hepatic encephalopathy (OHE) causes excitotoxic neuronal death through activation of the cytochrome C (CytC)-mediated mitochondria-dependent apoptotic pathway. We tested the therapeutic effect of nortriptyline (NT), a mitochondrial permeability transition pore (mPTP) blocker that can possibly inhibit mitochondrial CytC efflux to the cytosol on in vivo and in vitro OHE models. After ensuring the generation of OHE rats, established by bile duct ligation (BDL), they were intraperitoneally administered either 20 mg/kg NT (i.e., BDL+NT) or another vehicle (i.e., BDL+VEH) for 14 days. Compared with the control, BDL+VEH showed an increment of motor deficits, cell death, synaptic loss, apoptosis, and mitochondria with aberrant morphology in substantia nigra compacta dopaminergic (DA-ergic) neurons. However, the extent was significantly reversed in BDL+NT. Subsequently, we studied the neuroprotective mechanism of NT using PC-12 cells, a DA-ergic cell line, which exposed glutamate used as an excitotoxin. Compared with the control, the cells exposed to 15 mM glutamate (i.e., GLU) showed incremental cell death, apoptosis, and demise in mitochondrial respiration. Importantly, efflux of CytC from mitochondria to cytosol and the dissipation of mitochondrial membrane potential (△Ψm), an indicator of mPTP opening, were prominent in GLU. However, compared with the GLU, the cells cotreated with 10 μM NT (i.e., GLU+NT) showed a significant reduction in the aforementioned phenomenon. Together, we concluded that NT can be used for OHE therapeutics, mitigating the excitotoxic death of substantia nigra compacta DA-ergic neurons via mPTP-associated mitochondrial dysfunction inhibition.
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Affiliation(s)
- Ji Heun Jeong
- Department of Anatomy, College of Medicine, Konyang University, Daejeon, South Korea
| | - Do Kyung Kim
- Department of Anatomy, College of Medicine, Konyang University, Daejeon, South Korea
| | - Nam-Seob Lee
- Department of Anatomy, College of Medicine, Konyang University, Daejeon, South Korea
| | - Young-Gil Jeong
- Department of Anatomy, College of Medicine, Konyang University, Daejeon, South Korea
| | - Ho Won Kim
- Myunggok Medical Research Institute, College of Medicine, Konyang University, Daejeon, South Korea
| | - Jong-Seok Kim
- Myunggok Medical Research Institute, College of Medicine, Konyang University, Daejeon, South Korea
| | - Seung-Yun Han
- Department of Anatomy, College of Medicine, Konyang University, Daejeon, South Korea
- Myunggok Medical Research Institute, College of Medicine, Konyang University, Daejeon, South Korea
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Abstract
BACKGROUND Hepatic encephalopathy is a disorder of brain function as a result of liver failure or portosystemic shunt or both. Both hepatic encephalopathy (clinically overt) and minimal hepatic encephalopathy (not clinically overt) significantly impair patient's quality of life and daily functioning, and represent a significant burden on healthcare resources. Probiotics are live micro-organisms, which when administered in adequate amounts, may confer a health benefit on the host. OBJECTIVES To determine the beneficial and harmful effects of probiotics in any dosage, compared with placebo or no intervention, or with any other treatment for people with any grade of acute or chronic hepatic encephalopathy. This review did not consider the primary prophylaxis of hepatic encephalopathy. SEARCH METHODS We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, conference proceedings, reference lists of included trials, and the World Health Organization International Clinical Trials Registry Platform until June 2016. SELECTION CRITERIA We included randomised clinical trials that compared probiotics in any dosage with placebo or no intervention, or with any other treatment in people with hepatic encephalopathy. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. We conducted random-effects model meta-analysis due to obvious heterogeneity of participants and interventions. We defined a P value of 0.05 or less as significant. We expressed dichotomous outcomes as risk ratio (RR) and continuous outcomes as mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS We included 21 trials with 1420 participants, of these, 14 were new trials. Fourteen trials compared a probiotic with placebo or no treatment, and seven trials compared a probiotic with lactulose. The trials used a variety of probiotics; the most commonly used group of probiotic was VSL#3, a proprietary name for a group of eight probiotics. Duration of administration ranged from 10 days to 180 days. Eight trials declared their funding source, of which six were independently funded and two were industry funded. The remaining 13 trials did not disclose their funding source. We classified 19 of the 21 trials at high risk of bias.We found no effect on all-cause mortality when probiotics were compared with placebo or no treatment (7 trials; 404 participants; RR 0.58, 95% CI 0.23 to 1.44; low-quality evidence). No-recovery (as measured by incomplete resolution of symptoms) was lower for participants treated with probiotic (10 trials; 574 participants; RR 0.67, 95% CI 0.56 to 0.79; moderate-quality evidence). Adverse events were lower for participants treated with probiotic than with no intervention when considering the development of overt hepatic encephalopathy (10 trials; 585 participants; RR 0.29, 95% CI 0.16 to 0.51; low-quality evidence), but effects on hospitalisation and change of/or withdrawal from treatment were uncertain (hospitalisation: 3 trials, 163 participants; RR 0.67, 95% CI 0.11 to 4.00; very low-quality evidence; change of/or withdrawal from treatment: 9 trials, 551 participants; RR 0.70, 95% CI 0.46 to 1.07; very low-quality evidence). Probiotics may slightly improve quality of life compared with no intervention (3 trials; 115 participants; results not meta-analysed; low-quality evidence). Plasma ammonia concentration was lower for participants treated with probiotic (10 trials; 705 participants; MD -8.29 μmol/L, 95% CI -13.17 to -3.41; low-quality evidence). There were no reports of septicaemia attributable to probiotic in any trial.When probiotics were compared with lactulose, the effects on all-cause mortality were uncertain (2 trials; 200 participants; RR 5.00, 95% CI 0.25 to 102.00; very low-quality evidence); lack of recovery (7 trials; 430 participants; RR 1.01, 95% CI 0.85 to 1.21; very low-quality evidence); adverse events considering the development of overt hepatic encephalopathy (6 trials; 420 participants; RR 1.17, 95% CI 0.63 to 2.17; very low-quality evidence); hospitalisation (1 trial; 80 participants; RR 0.33, 95% CI 0.04 to 3.07; very low-quality evidence); intolerance leading to discontinuation (3 trials; 220 participants; RR 0.35, 95% CI 0.08 to 1.43; very low-quality evidence); change of/or withdrawal from treatment (7 trials; 490 participants; RR 1.27, 95% CI 0.88 to 1.82; very low-quality evidence); quality of life (results not meta-analysed; 1 trial; 69 participants); and plasma ammonia concentration overall (6 trials; 325 participants; MD -2.93 μmol/L, 95% CI -9.36 to 3.50; very low-quality evidence). There were no reports of septicaemia attributable to probiotic in any trial. AUTHORS' CONCLUSIONS The majority of included trials suffered from a high risk of systematic error ('bias') and a high risk of random error ('play of chance'). Accordingly, we consider the evidence to be of low quality. Compared with placebo or no intervention, probiotics probably improve recovery and may lead to improvements in the development of overt hepatic encephalopathy, quality of life, and plasma ammonia concentrations, but probiotics may lead to little or no difference in mortality. Whether probiotics are better than lactulose for hepatic encephalopathy is uncertain because the quality of the available evidence is very low. High-quality randomised clinical trials with standardised outcome collection and data reporting are needed to further clarify the true efficacy of probiotics.
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Affiliation(s)
- Rohan Dalal
- Sydney Medical School, Westmead Hospital, Sydney, Australia
| | - Richard G McGee
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, Australia, 2145
| | - Stephen M Riordan
- Gastrointestinal and Liver Unit, The Prince of Wales, Barker St, Randwick, Australia, NSW 2031
| | - Angela C Webster
- Sydney School of Public Health, The University of Sydney, Edward Ford Building A27, Sydney, NSW, Australia, 2006
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Kundu M, Mondal S, Roy A, Martinson JL, Pahan K. Sodium Benzoate, a Food Additive and a Metabolite of Cinnamon, Enriches Regulatory T Cells via STAT6-Mediated Upregulation of TGF-β. THE JOURNAL OF IMMUNOLOGY 2016; 197:3099-3110. [PMID: 27605008 DOI: 10.4049/jimmunol.1501628] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 08/12/2016] [Indexed: 12/14/2022]
Abstract
Upregulation and/or maintenance of regulatory T cells (Tregs) during autoimmune insults may have therapeutic efficacy in autoimmune diseases. Earlier we have reported that sodium benzoate (NaB), a metabolite of cinnamon and a Food and Drug Administration-approved drug against urea cycle disorders, upregulates Tregs and protects mice from experimental allergic encephalomyelitis, an animal model of multiple sclerosis. However, mechanisms by which NaB increases Tregs are poorly understood. Because TGF-β is an important inducer of Tregs, we examined the effect of NaB on the status of TGF-β. In this study, we demonstrated that NaB induced the expression of TGF-β mRNA and protein in normal as well as proteolipid protein-primed splenocytes. The presence of a consensus STAT6 binding site in the promoter of the TGF-β gene, activation of STAT6 in splenocytes by NaB, recruitment of STAT6 to the TGF-β promoter by NaB, and abrogation of NaB-induced expression of TGF-β in splenocytes by small interfering RNA knockdown of STAT6 suggest that NaB induces the expression of TGF-β via activation of STAT6. Furthermore, we demonstrated that blocking of TGF-β by neutralizing Abs abrogated NaB-mediated protection of Tregs and experimental allergic encephalomyelitis. These studies identify a new function of NaB in upregulating TGF-β via activation of STAT6, which may be beneficial in MS patients.
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Affiliation(s)
- Madhuchhanda Kundu
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL 60612
| | - Susanta Mondal
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL 60612
| | - Avik Roy
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL 60612
| | - Jeffrey L Martinson
- Department of Immunology, Rush University Medical Center, Chicago, IL 60612; and
| | - Kalipada Pahan
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL 60612; .,Division of Research and Development, Jesse Brown Veterans Affairs Medical Center, Chicago, IL 60612
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Northrop NA, Halpin LE, Yamamoto BK. Peripheral ammonia and blood brain barrier structure and function after methamphetamine. Neuropharmacology 2016; 107:18-26. [PMID: 26972828 DOI: 10.1016/j.neuropharm.2016.03.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 03/07/2016] [Accepted: 03/09/2016] [Indexed: 01/28/2023]
Abstract
An effect of the widely abuse psychostimulant, methamphetamine (Meth), is blood-brain-barrier (BBB) disruption; however, the mechanism by which Meth causes BBB disruption remains unclear. Recently it has been shown that Meth produces liver damage and consequent increases in plasma ammonia. Ammonia can mediate oxidative stress and inflammation, both of which are known to cause BBB disruption. Therefore, the current studies examined the role of peripheral ammonia in Meth-induced disruption of BBB structure and function. A neurotoxic Meth regimen (10 mg/kg, ip, q 2 h, ×4) administered to rats increased plasma ammonia and active MMP-9 in the cortex 2 h after the last Meth injection, compared to saline treated rats. At 24 h after Meth treatment, decreased immunoreactivity of BBB structural proteins, occludin and claudin-5, and increased extravasation of 10,000 Da FITC-dextran were observed, as compared to saline controls. Pretreatment with lactulose (5.3 g/kg, po, q 12 h), a drug that remains in the lumen of the intestine and promotes ammonia excretion, prevented the Meth-induced increases in plasma ammonia. These results were paralleled by the prevention of decreases in BBB structural proteins, increases in extravasation of 10,000 Da FITC-dextran and increases in active MMP-9. The results indicate that Meth-induced increases in ammonia produce BBB disruption and suggest that MMP-9 activation mediates the BBB disruption. These findings identify a novel mechanism of Meth-induced BBB disruption that is mediated by plasma ammonia and are the first to identify a peripheral contribution to Meth-induced BBB disruption.
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Affiliation(s)
- Nicole A Northrop
- Department of Neurosciences, University of Toledo College of Medicine, 3000 Arlington Ave., Toledo, OH 43614, USA
| | - Laura E Halpin
- Department of Neurosciences, University of Toledo College of Medicine, 3000 Arlington Ave., Toledo, OH 43614, USA
| | - Bryan K Yamamoto
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, 635 Barnhill Drive, Indianapolis, IN 46202, USA.
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Childs-Disney JL, Disney MD. Small Molecule Targeting of a MicroRNA Associated with Hepatocellular Carcinoma. ACS Chem Biol 2016; 11:375-80. [PMID: 26551630 DOI: 10.1021/acschembio.5b00615] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Development of precision therapeutics is of immense interest, particularly as applied to the treatment of cancer. By analyzing the preferred cellular RNA targets of small molecules, we discovered that 5"-azido neomycin B binds the Drosha processing site in the microRNA (miR)-525 precursor. MiR-525 confers invasive properties to hepatocellular carcinoma (HCC) cells. Although HCC is one of the most common cancers, treatment options are limited, making the disease often fatal. Herein, we find that addition of 5"-azido neomycin B and its FDA-approved precursor, neomycin B, to an HCC cell line selectively inhibits production of the mature miRNA, boosts a downstream protein, and inhibits invasion. Interestingly, neomycin B is a second-line agent for hepatic encephalopathy (HE) and bacterial infections due to cirrhosis. Our results provocatively suggest that neomycin B, or second-generation derivatives, may be dual functioning molecules to treat both HE and HCC. Collectively, these studies show that rational design approaches can be tailored to disease-associated RNAs to afford potential lead therapeutics.
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Affiliation(s)
- Jessica L. Childs-Disney
- Department of Chemistry, The Scripps Research Institute, Scripps Florida, 130 Scripps Way #3A1, Jupiter, Florida 33458, United States
| | - Matthew D. Disney
- Department of Chemistry, The Scripps Research Institute, Scripps Florida, 130 Scripps Way #3A1, Jupiter, Florida 33458, United States
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21
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Romeiro FG, Augusti L. Nutritional assessment in cirrhotic patients with hepatic encephalopathy. World J Hepatol 2015; 7:2940-2954. [PMID: 26730273 PMCID: PMC4691697 DOI: 10.4254/wjh.v7.i30.2940] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 09/23/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatic encephalopathy (HE) is one of the worst complications of liver disease and can be greatly influenced by nutritional status. Ammonia metabolism, inflammation and muscle wasting are relevant processes in HE pathophysiology. Malnutrition worsens the prognosis in HE, requiring early assessment of nutritional status of these patients. Body composition changes induced by liver disease and limitations superimposed by HE hamper the proper accomplishment of exams in this population, but evidence is growing that assessment of muscle mass and muscle function is mandatory due to the role of skeletal muscles in ammonia metabolism. In this review, we present the pathophysiological aspects involved in HE to support further discussion about advantages and drawbacks of some methods for evaluating the nutritional status of cirrhotic patients with HE, focusing on body composition.
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Scheau C, Dinu R, Tarta-Arsene E, Scheau AE, Badarau IA, Lupescu IG. Current Stance of Magnetic Resonance Imaging in the Diagnosis and Monitoring of Hepatic Encephalopathy. MAEDICA 2015; 10:243-247. [PMID: 28261361 PMCID: PMC5327831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Hepatic encephalopathy is a complex of neuropsychiatric manifestations in patients with acute or chronic liver insufficiency and/or porto-systemic shunts. MATERIAL AND METHODS The diagnostic can be sustained by various elements, clinical and paraclinical. Selected patients with hepatic encephalopathy have been investigated by Magnetic Resonance, in parallel with specific biochemical analysis. OUTCOMES This paper emphasizes the importance of Magnetic Resonance Imaging in an accurate diagnosis and patient monitoring after treatment. CONCLUSIONS Magnetic Resonance Spectroscopy has a substantial role, showing even minute metabolite ratio changes, with a potential in investigating minimal hepatic encephalopathy.
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Affiliation(s)
- Cristian Scheau
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Roxana Dinu
- Department of Gastroenterology, Colentina Clinical Hospital, Bucharest, Romania
| | | | - Andreea Elena Scheau
- Department of Radiology and Medical Imaging, Fundeni Clinical Institute, Bucharest, Romania
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Dynnik VV, Kononov AV, Sergeev AI, Teplov IY, Tankanag AV, Zinchenko VP. To Break or to Brake Neuronal Network Accelerated by Ammonium Ions? PLoS One 2015. [PMID: 26217943 PMCID: PMC4517767 DOI: 10.1371/journal.pone.0134145] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Purpose The aim of present study was to investigate the effects of ammonium ions on in vitro neuronal network activity and to search alternative methods of acute ammonia neurotoxicity prevention. Methods Rat hippocampal neuronal and astrocytes co-cultures in vitro, fluorescent microscopy and perforated patch clamp were used to monitor the changes in intracellular Ca2+- and membrane potential produced by ammonium ions and various modulators in the cells implicated in neural networks. Results Low concentrations of NH4Cl (0.1–4 mM) produce short temporal effects on network activity. Application of 5–8 mM NH4Cl: invariably transforms diverse network firing regimen to identical burst patterns, characterized by substantial neuronal membrane depolarization at plateau phase of potential and high-amplitude Ca2+-oscillations; raises frequency and average for period of oscillations Ca2+-level in all cells implicated in network; results in the appearance of group of «run out» cells with high intracellular Ca2+ and steadily diminished amplitudes of oscillations; increases astrocyte Ca2+-signalling, characterized by the appearance of groups of cells with increased intracellular Ca2+-level and/or chaotic Ca2+-oscillations. Accelerated network activity may be suppressed by the blockade of NMDA or AMPA/kainate-receptors or by overactivation of AMPA/kainite-receptors. Ammonia still activate neuronal firing in the presence of GABA(A) receptors antagonist bicuculline, indicating that «disinhibition phenomenon» is not implicated in the mechanisms of networks acceleration. Network activity may also be slowed down by glycine, agonists of metabotropic inhibitory receptors, betaine, L-carnitine, L-arginine, etc. Conclusions Obtained results demonstrate that ammonium ions accelerate neuronal networks firing, implicating ionotropic glutamate receptors, having preserved the activities of group of inhibitory ionotropic and metabotropic receptors. This may mean, that ammonia neurotoxicity might be prevented by the activation of various inhibitory receptors (i.e. by the reinforcement of negative feedback control), instead of application of various enzyme inhibitors and receptor antagonists (breaking of neural, metabolic and signaling systems).
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Affiliation(s)
- Vladimir V. Dynnik
- Laboratory of intracellular signaling, Institute of Cell Biophysics, Russian Academy of Sciences, Pushchino, Russia
- Laboratory of bioenergetics, Institute of Theoretical and Experimental Biophysics, Russian Academy of Sciences, Pushchino, Russia
- * E-mail:
| | - Alexey V. Kononov
- Laboratory of intracellular signaling, Institute of Cell Biophysics, Russian Academy of Sciences, Pushchino, Russia
| | - Alexander I. Sergeev
- Laboratory of intracellular signaling, Institute of Cell Biophysics, Russian Academy of Sciences, Pushchino, Russia
| | - Iliya Y. Teplov
- Laboratory of intracellular signaling, Institute of Cell Biophysics, Russian Academy of Sciences, Pushchino, Russia
| | - Arina V. Tankanag
- Laboratory of intracellular signaling, Institute of Cell Biophysics, Russian Academy of Sciences, Pushchino, Russia
| | - Valery P. Zinchenko
- Laboratory of intracellular signaling, Institute of Cell Biophysics, Russian Academy of Sciences, Pushchino, Russia
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Ammonia mediates methamphetamine-induced increases in glutamate and excitotoxicity. Neuropsychopharmacology 2014; 39:1031-8. [PMID: 24165886 PMCID: PMC3924538 DOI: 10.1038/npp.2013.306] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 10/04/2013] [Accepted: 10/23/2013] [Indexed: 01/05/2023]
Abstract
Ammonia has been identified to have a significant role in the long-term damage to dopamine and serotonin terminals produced by methamphetamine (METH), but how ammonia contributes to this damage is unknown. Experiments were conducted to identify whether increases in brain ammonia affect METH-induced increases in glutamate and subsequent excitotoxicity. Increases in striatal glutamate were measured using in vivo microdialysis. To examine the role of ammonia in mediating changes in extracellular glutamate after METH exposure, lactulose was used to decrease plasma and brain ammonia. Lactulose is a non-absorbable disaccharide, which alters the intestinal lumen through multiple mechanisms that lead to the increased peripheral excretion of ammonia. METH caused a significant increase in extracellular glutamate that was prevented by lactulose. Lactulose had no effect on METH-induced hyperthermia. To determine if ammonia contributed to excitotoxicity, the effect of METH and lactulose treatment on calpain-mediated spectrin proteolysis was measured. METH significantly increased calpain-specific spectrin breakdown products, and this increase was prevented with lactulose treatment. To examine if ammonia-induced increases in extracellular glutamate were mediated by excitatory amino-acid transporters, the reverse dialysis of ammonia, the glutamate transporter inhibitor, DL-threo-β-benzyloxyaspartic acid (TBOA), or the combination of the two directly into the striatum of awake, freely moving rats was conducted. TBOA blocked the increases in extracellular glutamate produced by the reverse dialysis of ammonia. These findings demonstrate that ammonia mediates METH-induced increases in extracellular glutamate through an excitatory amino-acid transporter to cause excitotoxicity.
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Misel ML, Gish RG, Patton H, Mendler M. Sodium benzoate for treatment of hepatic encephalopathy. Gastroenterol Hepatol (N Y) 2013; 9:219-227. [PMID: 24711766 PMCID: PMC3977640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Hepatic encephalopathy (HE) is a serious but usually reversible neuropsychiatric complication of cirrhosis, inborn errors of metabolism involving disorders of the urea cycle, and noncirrhotic portosystemic shunting that most commonly arises from a transjugular intrahepatic portosystemic shunting procedure. Symptoms can include alterations in cognitive function, neuromuscular activity, and consciousness, as well as sleep disorders and mood changes. HE is associated with significant morbidity and mortality and, if not properly treated, will lead to increased hospital admissions and healthcare costs. Although the standard therapies of lactulose and rifaximin (Xifaxan, Salix) are effective for most patients, these drugs may be associated with significant adverse effects and expense and, in some patients, inadequate therapeutic response. A need for adjunctive therapies exists. Drugs that target serum and tissue ammonia metabolism and elimination may be important adjuncts to drugs that reduce ammonia production and absorption from the gastrointestinal tract for patients with severe or persistent overt symptoms of HE. Sodium benzoate is an inexpensive adjunctive agent that can be used in addition to lactulose and rifaximin and may provide an option for some select patients with refractory HE who have failed to respond to standard therapies or who cannot afford them. Although sodium benzoate does not share the same adverse effect profiles of standard therapies for HE, its efficacy has not been well established. Given the significant dose-dependent sodium content of this therapy, it may not be appropriate for patients with significant fluid retention or kidney dysfunction.
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Affiliation(s)
- Michael L Misel
- Dr. Misel is a Pharmacist Specialist for Liver/Kidney Transplant and Hepatology at the Center for Abdominal Transplantation/Department of Pharmacy Services at the University of California San Diego Health System in San Diego, California. Dr. Gish is the Director, Dr. Patton is an Assistant Clinical Professor of Medicine, and Dr. Mendler is a Clinical Professor of Medicine at the Center for Hepatobiliary Disease and Abdominal Transplantation in the Division of GI Hepatology at the University of California San Diego in San Diego, California
| | - Robert G Gish
- Dr. Misel is a Pharmacist Specialist for Liver/Kidney Transplant and Hepatology at the Center for Abdominal Transplantation/Department of Pharmacy Services at the University of California San Diego Health System in San Diego, California. Dr. Gish is the Director, Dr. Patton is an Assistant Clinical Professor of Medicine, and Dr. Mendler is a Clinical Professor of Medicine at the Center for Hepatobiliary Disease and Abdominal Transplantation in the Division of GI Hepatology at the University of California San Diego in San Diego, California
| | - Heather Patton
- Dr. Misel is a Pharmacist Specialist for Liver/Kidney Transplant and Hepatology at the Center for Abdominal Transplantation/Department of Pharmacy Services at the University of California San Diego Health System in San Diego, California. Dr. Gish is the Director, Dr. Patton is an Assistant Clinical Professor of Medicine, and Dr. Mendler is a Clinical Professor of Medicine at the Center for Hepatobiliary Disease and Abdominal Transplantation in the Division of GI Hepatology at the University of California San Diego in San Diego, California
| | - Michel Mendler
- Dr. Misel is a Pharmacist Specialist for Liver/Kidney Transplant and Hepatology at the Center for Abdominal Transplantation/Department of Pharmacy Services at the University of California San Diego Health System in San Diego, California. Dr. Gish is the Director, Dr. Patton is an Assistant Clinical Professor of Medicine, and Dr. Mendler is a Clinical Professor of Medicine at the Center for Hepatobiliary Disease and Abdominal Transplantation in the Division of GI Hepatology at the University of California San Diego in San Diego, California
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Erythromycin versus neomycin in the treatment of hepatic encephalopathy in cirrhosis: a randomized double-blind study. BMC Gastroenterol 2013; 13:13. [PMID: 23324408 PMCID: PMC3551652 DOI: 10.1186/1471-230x-13-13] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 01/12/2013] [Indexed: 01/19/2023] Open
Abstract
Background Hepatic encephalopathy (HE) is a severe complication in patients with hepatic cirrhosis, which causes numerous hospital admissions and deaths. Antibiotics are the best options in HE treatment, but head-to-head comparisons between these drugs are scarce. Erythromycin combines the antimicrobial effect and prokinetic properties in the same drug, but it has never been used in HE treatment. Our aim was to evaluate the efficacy of erythromycin as an HE treatment. Methods We achieved a randomized controlled trial of adult patients with HE and hepatic cirrhosis admitted in our hospital. After randomization, the subjects received either erythromycin 250 mg or neomycin 1 g orally QID until hospital discharge or prescription of another antibiotic. All subjects were blindly evaluated every day towards quantifying clinical, neuropsychometric, hepatic and renal exams. Statistical analysis was employed to compare the groups and correlate the variables with hospitalization duration. Results 30 patients were evaluated (15 treated with each drug). At hospital admission, the groups were homogeneous, but the erythromycin group subjects achieved a shorter hospitalization stay (p = 0.032) and a more expressive reduction in alanine aminotranspherase levels (p = 0.026). Hospitalization duration was positively correlated with C reactive protein levels measured previous to (p = 0.015) and after treatment (p = 0.01). Conclusions In the sample evaluated erythromycin was associated with significant reductions in hospital stay and in alanine aminotranspherase values. Hospitalization time was positive correlated with C reactive protein levels measured before and after the treatments.
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Abstract
Ammonia is metabolized by the liver and has established neurological effects. The current study examined the possibility that ammonia contributes to the neurotoxic effects of methamphetamine (METH). The results show that a binge dosing regimen of METH to the rat increased plasma and brain ammonia concentrations that were paralleled by evidence of hepatotoxicity. The role of peripheral ammonia in the neurotoxic effects of METH was further substantiated by the demonstration that the enhancement of peripheral ammonia excretion blocked the increases in brain and plasma ammonia and attenuated the long-term depletions of dopamine and serotonin typically produced by METH. Conversely, the localized perfusion of ammonia in combination with METH, but not METH alone or ammonia alone, into the striatum recapitulated the neuronal damage produced by the systemic administration of METH. Furthermore, this damage produced by the local administration of ammonia and METH was blocked by the GYKI 52466 [4-(8-methyl-9H-1,3-dioxolo[4,5-h][2,3]benzodiazepin-5-yl)-benzamine hydrochloride], an AMPA receptor antagonist. These findings highlight the importance of ammonia derived from the periphery as a small-molecule mediator of METH neurotoxicity and more broadly emphasize the importance of peripheral organ damage as a possible mechanism that mediates the neuropathology produced by drugs of abuse and other neuroactive molecules.
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Iadevaia MD, Prete AD, Cesaro C, Gaeta L, Zulli C, Loguercio C. Rifaximin in the treatment of hepatic encephalopathy. Hepat Med 2011; 3:109-17. [PMID: 24367227 PMCID: PMC3846583 DOI: 10.2147/hmer.s11988] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Hepatic encephalopathy is a challenging complication in patients with advanced liver disease. It can be defined as a neuropsychiatric syndrome caused by portosystemic venous shunting, ranging from minimal to overt hepatic encephalopathy or coma. Its pathophysiology is still unclear, although increased levels of ammonia play a key role. Diagnosis of hepatic encephalopathy is currently based on specific tests evaluating the neuropsychiatric state of patients and their quality of life; the severity of hepatic encephalopathy is measured by the West Haven criteria. Treatment of hepatic encephalopathy consists of pharmacological and corrective measures, as well as nutritional interventions. Rifaximin received approval for the treatment of hepatic encephalopathy in 2010 because of its few side effects and pharmacological benefits. The aim of this work is to review the use and efficacy of rifaximin both in acute and long-term management of hepatic encephalopathy. Treatment of overt hepatic encephalopathy involves management of the acute episode as well as maintenance of remission in those patients who have previously experienced an episode, in order to improve their quality of life. The positive effect of rifaximin in reducing health care costs is also discussed.
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Affiliation(s)
- Maddalena Diana Iadevaia
- Department of Internistica Clinica e Sperimentale, F Magrassi e A Lanzara, Hepatogastroenterology Unit, Second University of Naples, Naples, Italy
| | - Anna Del Prete
- Department of Internistica Clinica e Sperimentale, F Magrassi e A Lanzara, Hepatogastroenterology Unit, Second University of Naples, Naples, Italy
| | - Claudia Cesaro
- Department of Internistica Clinica e Sperimentale, F Magrassi e A Lanzara, Hepatogastroenterology Unit, Second University of Naples, Naples, Italy
| | - Laura Gaeta
- Department of Internistica Clinica e Sperimentale, F Magrassi e A Lanzara, Hepatogastroenterology Unit, Second University of Naples, Naples, Italy
| | - Claudio Zulli
- Department of Internistica Clinica e Sperimentale, F Magrassi e A Lanzara, Hepatogastroenterology Unit, Second University of Naples, Naples, Italy
| | - Carmelina Loguercio
- Department of Internistica Clinica e Sperimentale, F Magrassi e A Lanzara, Hepatogastroenterology Unit, Second University of Naples, Naples, Italy
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