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Mumit Sarkar A, Al Mukit A, Bari T, Islam R, Islam S, Sarker K, Chowdhury M, Harun Or Rashid M, Alim A. Association of low serum 25-Hydroxy vitamin D [25(OH) d] with hepatic encephalopathy in patients with decompensated liver cirrhosis. Arab J Gastroenterol 2024; 25:182-187. [PMID: 38458876 DOI: 10.1016/j.ajg.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 01/05/2024] [Accepted: 01/26/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND AND STUDY AIMS The mechanism of hepatic encephalopathy is complex and has not been conclusively established. Recent studies support lower serum 25-Hydroxy Vitamin D [25(OH) D] levels in patients with hepatic encephalopathy. This study aimed to evaluate the association between serum 25(OH) D and hepatic encephalopathy in patients with decompensated cirrhosis of liver. PATIENTS AND METHODS A total of 70 cirrhosis patients (35 cases of hepatic encephalopathy and 35 patients without encephalopathy as control, mean age 53.07 ± 12.99 years, 67 % male) were recruited for this study. Assessment of the severity of cirrhosis was done by using a model for end-stage liver disease(MELD) and Child Turcotte Pugh (CTP) scores, and assessment of the severity of hepatic encephalopathy was done according to West Haven criteria. Serum 25 (OH) D level was measured by Chemiluminescent Microparticle Immuno Assay(CMIA). RESULTS The mean serum 25(OH) D level among hepatic encephalopathy patients was significantly lower in comparison to the control group without encephalopathy (18.76 ± 8.84 nmol/L vs 31.19 ± 13.9 nmol/L, P<0.0001). 91.4 % of hepatic encephalopathy patients had moderate to severe 25(OH)D deficiency as compared to 51.4 % in the control group. There was a significant correlation observed between the severity of the 25 (OH) D deficiency and the severity of liver disease (r = - 0.35, P = 0.002). No statistically significant difference in serum 25(OH) D levels was found among patients with different hepatic encephalopathy grades (P = 0.416). CONCLUSION A significant association was found between a low serum 25(OH) D leveland hepatic encephalopathy. It requires further large-scale multicenter studies to establish it as a risk factor and predictor of hepatic encephalopathy.
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Affiliation(s)
| | | | - Tanzilul Bari
- Department of Gastroenterology, Rajshahi Medical College, Bangladesh
| | - Rofiqul Islam
- Department of Hepatology, Rajshahi Medical College, Bangladesh
| | - Shafiqul Islam
- Department of Gastroenterology, Rajshahi Medical College, Bangladesh
| | | | | | | | - Abdul Alim
- Department of Gastroenterology, Rajshahi Medical College, Bangladesh
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Lee EW, Liang JJ, McNamara GP. Interventional Radiology Management of Hepatic Encephalopathy. Clin Liver Dis 2024; 28:317-329. [PMID: 38548442 DOI: 10.1016/j.cld.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Hepatic encephalopathy (HE) is a clinically severe and devastating complication of decompensated liver disease affecting mortality, quality of life for patients and families, hospital admission rates, and overall health-care costs globally. Depending on the cause of HE, several medical treatment options have been developed and become available. In some refractory HE, such as spontaneous portosystemic shunt-related HE (SPSS-HE) or posttransjugular intrahepatic portosystemic shunt HE (post-TIPS HE), advanced interventional radiology (IR) procedures have been used, and shown to be effective in these conditions. This review presents 2 effective IR procedures for managing SPSS-HE and post-TIPS HE.
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Affiliation(s)
- Edward Wolfgang Lee
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Division of Liver and Pancreas Transplant Surgery, Department of Surgery, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - Justine J Liang
- Department of Anesthesiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Griffin P McNamara
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Zorzi S, Ayako Minemura Ordinola A, Cunha De Souza Lima E, Martins Teixeira G, Salvagno M, Sterchele ED, Taccone FS. A glimpse into multimodal neuromonitoring in acute liver failure: a case report. Ann Med Surg (Lond) 2024; 86:539-544. [PMID: 38222739 PMCID: PMC10783349 DOI: 10.1097/ms9.0000000000001519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/07/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction Acute liver failure (ALF) is a rapidly progressing, life-threatening syndrome characterized by liver-related coagulopathy and hepatic encephalopathy (HE). Given that higher HE grades correlate with poorer outcomes, clinical management of ALF necessitates close neurological monitoring. The primary objective of this case report is to highlight the diagnostic value of utilizing multimodal neuromonitoring (MNM) in a patient suffering from ALF. Case report A 56-year-old male patient with a history of chronic alcoholism, without prior chronic liver disease, and recent acetaminophen use was admitted to the hospital due to fatigue and presenting with a mild flapping tremor. The primary hypothesis was an acute hepatic injury caused by acetaminophen intoxication. In the following hours, the patient's condition deteriorated, accompanied by neurological decline and rising ammonia levels. The patient's neurological status was closely monitored using MNM. Bilaterally altered pupillary light reflex assessed by decreasing in the Neurological Pupil Index values, using automated pupillometry, initially suggested severe brain oedema. However, ultrasound measurements of the optic nerve sheath diameter showed normal values in both eyes, P2/P1 noninvasive intracranial pressure waveform assessment was within normal ranges and the cerebral computed tomography-scan revealed no signs of cerebral swelling. Increased middle cerebral artery velocities measured by Transcranial Doppler and the initiation of electroencephalography monitoring yielded the presence of status epilepticus. Discussion The utilization of MNM facilitated a more comprehensive understanding of the mechanisms underlying the patient's clinical deterioration in the setting of HE. Nonetheless, future studies are needed to show feasibility and to yield valuable insights that can enhance the outcomes for patients with HE using such an approach. Given the absence of specific guidelines in this particular context, it is advisable for physicians to give further consideration to the incorporation of MNM in the management of unconscious patients with ALF.
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Affiliation(s)
- Stefano Zorzi
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
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Kosenko EA, Alilova GA, Tikhonova LA. Impaired Enzymatic Antioxidant Defense in Erythrocytes of Rats with Ammonia-Induced Encephalopathy: Role of NMDA Receptors. BIOCHEMISTRY. BIOKHIMIIA 2023; 88:1404-1415. [PMID: 37770406 DOI: 10.1134/s0006297923090195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 09/30/2023]
Abstract
Hepatic encephalopathy (HE), a neuropsychiatric disorder developing in patients with severe hepatic dysfunction, has been known for more than a century. However, pathogenetic mechanisms of cerebral dysfunction associated with liver disease are still poorly understood. There is a consensus that the primary cause of HE is accumulation of ammonia in the brain as a result of impaired liver detoxification capacity or the portosystemic shunt. Current evidence suggests that ammonia toxicity is mediated by hyperactivation of glutamate receptors, mainly N-methyl-D-aspartate receptors (NMDARs), and affects brain aerobic metabolism, which provides energy for multiple specific functions and neuronal viability. Recent reports on the presence of functional NMDARs in erythrocytes and the data on the deviations of blood parameters from their normal ranges indicate impaired hemodynamics and reduced oxygen-carrying capacity of erythrocytes in most patients with HE, thus suggesting a relationship between erythrocyte damage and cerebral dysfunction. In order to understand how hyperammonemia (HA)-induced disturbances in the energy metabolism in the brain (which needs a constant supply of large amounts of oxygen in the blood) lead to encephalopathy, it is necessary to reveal ammonia-induced impairments in the energy metabolism and antioxidant defense system of erythrocytes and to explore a potential role of ammonia in reduced brain oxygenation. To identify the said missing link, the activities of antioxidant enzymes and concentrations of reduced glutathione (GSH), oxidized glutathione (GSSG), and H2O2 were measured in the erythrocytes of rats with HA that were injected with the noncompetitive NMDAR antagonist MK-801. We found that in rats with HA, ammonia was accumulated in erythrocytes (cells lacking ammonia removal enzymes), which made them more susceptible to the prooxidant environment created during oxidative stress. This effect was completely or partially inhibited by MK-801. The data obtained might help to identify the risk factors in cognitive disorders and facilitate prediction of unfavorable outcomes of hypoperfusion in patients with a blood elevated ammonia concentration.
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Affiliation(s)
- Elena A Kosenko
- Institute of Theoretical and Experimental Biophysics of the Russian Academy of Sciences, Pushchino, Moscow Region, 142290, Russia.
| | - Gubidat A Alilova
- Institute of Theoretical and Experimental Biophysics of the Russian Academy of Sciences, Pushchino, Moscow Region, 142290, Russia
| | - Lyudmila A Tikhonova
- Institute of Theoretical and Experimental Biophysics of the Russian Academy of Sciences, Pushchino, Moscow Region, 142290, Russia
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Is NMDA-Receptor-Mediated Oxidative Stress in Mitochondria of Peripheral Tissues the Essential Factor in the Pathogenesis of Hepatic Encephalopathy? J Clin Med 2022; 11:jcm11030827. [PMID: 35160278 PMCID: PMC8836479 DOI: 10.3390/jcm11030827] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Hepatic encephalopathy (HE) is a neuropsychiatric syndrome of increased ammonia-mediated brain dysfunction caused by impaired hepatic detoxification or when the blood bypasses the liver. Ammonia-activated signal transduction pathways of hyperactivated NMDA receptors (NMDAR) are shown to trigger a cascade of pathological reactions in the brain, leading to oxidative stress. NMDARs outside the brain are widely distributed in peripheral tissues, including the liver, heart, pancreas, and erythrocytes. To determine the contribution of these receptors to ammonia-induced oxidative stress in peripheral tissues, it is relevant to investigate if there are any ammonia-related changes in antioxidant enzymes and free radical formation and whether blockade of NMDARs prevents these changes. Methods: Hyperammonemia was induced in rats by ammonium acetate injection. Oxidative stress was measured as changes in antioxidant enzyme activities and O2•− and H2O2 production by mitochondria isolated from the tissues and cells mentioned above. The effects of the NMDAR antagonist MK-801 on oxidative stress markers and on tissue ammonia levels were evaluated. Results: Increased ammonia levels in erythrocytes and mitochondria isolated from the liver, pancreas, and heart of hyperammonemic rats are shown to cause tissue-specific oxidative stress, which is prevented completely (or partially in erythrocyte) by MK-801. Conclusions: These results support the view that the pathogenesis of HE is multifactorial and that ammonia-induced multiorgan oxidative stress-mediated by activation of NMDAR is an integral part of the disease and, therefore, the toxic effects of ammonia in НЕ may be more global than initially expected.
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Spillane AM, Haraschak JL, McMichael MA. Resolution of Severe Neurologic Signs Following Intravenous Lipid Emulsion Therapy in a Young Dog With a Portosystemic Shunt: Case Report. Front Vet Sci 2021; 8:798198. [PMID: 34957288 PMCID: PMC8694260 DOI: 10.3389/fvets.2021.798198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
A 5-month-old male intact Great Pyrenees was presented for an acute onset of severe neurologic signs (stupor, absent menace, intermittent head turn to the left). The patient's history included possible naproxen ingestion with a maximum ingested dose of 59 mg/kg, exceeding the reported dose of >50 mg/kg known to cause neurologic signs. Blood sampling for baseline bloodwork was performed, and intravenous lipid emulsion (ILE) was subsequently administered, for treatment of the suspected toxicosis. Due to severe and life-threatening neurologic signs, other methods of decontamination were contraindicated and unlikely to be effective; extracorporeal therapy was also unavailable. Complete resolution of neurologic signs occurred 30 min after completion of ILE therapy. At this time, the owners found the missing naproxen tablets after returning home and the bloodwork results returned revealing findings consistent with hepatic encephalopathy. The fasted blood ammonia concentration immediately prior to ILE administration was 702.1 μg/dL (reference interval, RI: 24–36 μg/dL) and decreased to 194.1 μg/dL 24 h later. In the first 24 h, the patient also received three doses of lactulose, N-acetylcysteine, and intravenous fluids. The patient was subsequently diagnosed with a single, large intrahepatic portosystemic shunt via computed tomography and underwent an endovascular coil embolization procedure. Given the rapid and dramatic improvement in severe neurologic signs after ILE therapy alone, it is strongly suspected that this treatment resulted in improvement of hepatic encephalopathy.
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Affiliation(s)
- Amanda M Spillane
- Department of Veterinary Clinical Medicine, University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | - Jenica L Haraschak
- Department of Veterinary Clinical Medicine, University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | - Maureen A McMichael
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL, United States
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Ligtenstein S, Song J, Jin J, Sun H, Paixao L, Zafar S, Westover MB. Do Triphasic Waves and Nonconvulsive Status Epilepticus Arise From Similar Mechanisms? A Computational Model. J Clin Neurophysiol 2021; 38:366-375. [PMID: 34155185 PMCID: PMC8429048 DOI: 10.1097/wnp.0000000000000719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
PURPOSE Triphasic waves arising in patients with toxic metabolic encephalopathy (TME) are often considered different from generalized periodic discharges (GPDs) in patients with generalized nonconvulsive status epilepticus (GNCSE). The primary objective of this study was to investigate whether a common mechanism can explain key aspects of both triphasic waves in TME and GPDs in GNCSE. METHOD A neural mass model was used for the simulation of EEG patterns in patients with acute hepatic encephalopathy, a common etiology of TME. Increased neuronal excitability and impaired synaptic transmission because of elevated ammonia levels in acute hepatic encephalopathy patients were used to explain how triphasic waves and GNCSE arise. The effect of gamma-aminobutyric acid-ergic drugs on epileptiform activity, simulated with a prolonged duration of the inhibitory postsynaptic potential, was also studied. RESULTS The simulations show that a model that includes increased neuronal excitability and impaired synaptic transmission can account for both the emergence of GPDs and GNCSE and their suppression by gamma-aminobutyric acid-ergic drugs. CONCLUSIONS The results of this study add to evidence from other studies calling into question the dichotomy between triphasic waves in TME and GPDs in GNCSE and support the hypothesis that all GPDs, including those arising in TME patients, occur via a common mechanism.
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Affiliation(s)
- Sophie Ligtenstein
- Department of Technical Medicine, Department of Applied Mathematics, University of Twente
| | | | - Jin Jin
- Department of Neurology, Massachusetts General Hospital, Boston MA
| | - Haoqi Sun
- Department of Neurology, Massachusetts General Hospital, Boston MA
| | - Luis Paixao
- Department of Neurology, Massachusetts General Hospital, Boston MA
| | - Sahar Zafar
- Department of Neurology, Massachusetts General Hospital, Boston MA
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Favier RP, de Graaf E, Corbee RJ, Kummeling A. Outcome of non-surgical dietary treatment with or without lactulose in dogs with congenital portosystemic shunts. Vet Q 2021; 40:108-114. [PMID: 32194008 PMCID: PMC7170303 DOI: 10.1080/01652176.2020.1745928] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Congenital portosystemic shunts (CPSS) are vascular anomalies, allowing portal blood to bypass the hepatic parenchyma, thereby accumulating toxic substances such as ammonia in the systemic circulation resulting in hepatic encephalopathy. Aim To evaluate the outcome of non-surgically treated dogs with a CPSS. Methods Case records of 78 dogs with a single congenital CPSS confirmed by ultrasound and/or computed tomography between September 2003 and February 2015 were reviewed. Median age at diagnosis of CPSS in dogs was 10.8 months (range 2–133 months). Non-surgical treatment was started as an adjusted diet (a diet restricted in protein) with or without lactulose. Owners were contacted by telephone to determine survival time and presumed cause of death, if applicable. In addition, a questionnaire was used to retrospectively assess quality of life (QoL) and CPSS scores in 37 dogs before and during non-surgical treatment. Differences between Kaplan–Meier curves were tested by a Log rank test. Results Overall estimated median survival time (EMST) was 38.5 months (range 1 day − 91 months; 78 dogs). No significant differences between EMSTs were found between dogs with extra- (n = 48) or intrahepatic (n = 29) shunts, nor between treatment with only an adjusted diet, or an adjusted diet combined with lactulose. During non-surgical treatment, significant improvement in perceived QoL and CPSS scores were found (P < 0.01). Conclusion Our study demonstrated that an overall median EMST of 3.2 years was reached and that owners retrospectively perceived that non-surgical treatment resulted in an improved QoL and clinical performance, irrespective of intrahepatic or extrahepatic CPSS location.
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Affiliation(s)
- Robert P Favier
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, the Netherlands
| | - Eline de Graaf
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, the Netherlands
| | - Ronald J Corbee
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, the Netherlands
| | - Anne Kummeling
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, the Netherlands
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Lee EW, Lee AE, Saab S, Kee ST. Retrograde Transvenous Obliteration (RTO): A New Treatment Option for Hepatic Encephalopathy. Dig Dis Sci 2020; 65:2483-2491. [PMID: 32002756 DOI: 10.1007/s10620-020-06050-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 01/06/2020] [Indexed: 12/31/2022]
Abstract
Hepatic Encephalopathy (HE) is a complication of liver disease, consisting of brain dysfunction often due to portosystemic shunting of blood flow in the liver. HE can range from minimal HE, presenting with normal neurological function, to overt HE, with neurological and neuropsychiatric abnormalities. Various clinical grading systems are used to differentiate HE to provide the appropriate treatments. Traditional treatment of HE aims to identify and resolve precipitating factors through targeting hyperammonemia and administering antibiotics or probiotics. While retrograde transvenous obliteration (RTO), including balloon-occluded retrograde transvenous obliteration, coil-assisted retrograde transvenous obliteration or plug-assisted retrograde tranvenous obliteration, is an established procedure to manage gastric varices, little is known about its potential to treat HE. RTO is a procedure to occlude a spontaneous portosystemic shunt, minimizing shunting of portal blood to systemic circulation. Though there is not a large study with HE patients who have undergone RTO; the results appear promising in reducing HE. Side effects, however, should be considered in the treatment of HE such as the transient worsening of portal hypertension and the formation of additional shunts. While additional studies are needed to assess the long-term success, RTO appears to be an effective alternative method to alleviate clinical symptoms of HE when pharmacological therapies and other conservative medical managements have failed.
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Affiliation(s)
- Edward Wolfgang Lee
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, Ronald Reagan Medical Center at UCLA, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA, 90095-743730, USA. .,Division of Liver and Pancreas Transplantation, Department of Surgery, UCLA Medical Center, Ronald Reagan Medical Center at UCLA, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA, 90095-743730, USA.
| | - Audrey E Lee
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, Ronald Reagan Medical Center at UCLA, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA, 90095-743730, USA
| | - Sammy Saab
- Division of Liver and Pancreas Transplantation, Department of Surgery, UCLA Medical Center, Ronald Reagan Medical Center at UCLA, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA, 90095-743730, USA.,Division of Hepatology, Department of Medicine, Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA
| | - Stephen T Kee
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, Ronald Reagan Medical Center at UCLA, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA, 90095-743730, USA
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Nifuroxazide attenuates experimentally-induced hepatic encephalopathy and the associated hyperammonemia and cJNK/caspase-8/TRAIL activation in rats. Life Sci 2020; 252:117610. [DOI: 10.1016/j.lfs.2020.117610] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/27/2020] [Accepted: 03/28/2020] [Indexed: 12/19/2022]
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van Straten G, van Dalen D, Mesu SJ, Rothuizen J, Teske E, Spee B, Favier RP, van Geijlswijk IM. Efficacy of orally administered sodium benzoate and sodium phenylbutyrate in dogs with congenital portosystemic shunts. J Vet Intern Med 2019; 33:1331-1335. [PMID: 30916412 PMCID: PMC6524074 DOI: 10.1111/jvim.15477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 02/25/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hyperammonemia can result in hepatic encephalopathy, which in severe cases eventually can lead to coma and death. In dogs, congenital portosystemic shunts (CPSS) are the most common cause for hyperammonemia. Conservative treatment consists of a protein modified diet, nonabsorbable disaccharides, antibiotics, or some combinations of these. Sodium benzoate (SB) and sodium phenylbutyrate (SPB) both are used in the acute and long-term treatment of humans with hyperammonemia caused by urea cycle enzyme deficiencies. Both treatments are believed to lower blood ammonia concentrations by promoting excretion of excess nitrogen via alternative pathways. OBJECTIVES To evaluate the efficacy and safety of PO treatment with SB and SPB on hyperammonemia and clinical signs in CPSS dogs. METHODS Randomized, double-blind, placebo-controlled crossover trial. Concentrations of blood ammonia and bile acids were measured in CPSS dogs before and after a 5-day treatment with SB, SPB, and placebo. A wash-out period of 3 days was used between treatments. A standard questionnaire was developed and distributed to owners to evaluate clinical signs before and after each treatment. RESULTS Blood ammonia concentrations were not influenced by any of the treatments and were comparable to those observed during placebo treatment. In addition, SB and SPB treatment did not result in improvement of clinical signs. Adverse effects during treatment included anorexia, vomiting, and lethargy. CONCLUSIONS AND CLINICAL IMPORTANCE Based on our results, we conclude that SB or SPB are not useful in the conservative treatment of hyperammonemia in dogs with CPSS.
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Affiliation(s)
- Giora van Straten
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
| | - Diewke van Dalen
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
| | - Sietske J. Mesu
- Pharmacy Department, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
| | - Jan Rothuizen
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
| | - Erik Teske
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
| | - Bart Spee
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
| | - Robert P. Favier
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
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Martí‐Carvajal AJ, Gluud C, Arevalo‐Rodriguez I, Martí‐Amarista CE. Acetyl-L-carnitine for patients with hepatic encephalopathy. Cochrane Database Syst Rev 2019; 1:CD011451. [PMID: 30610762 PMCID: PMC6353234 DOI: 10.1002/14651858.cd011451.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hepatic encephalopathy is a common and devastating neuropsychiatric complication of acute liver failure or chronic liver disease. Ammonia content in the blood seems to play a role in the development of hepatic encephalopathy. Treatment for hepatic encephalopathy is complex. Acetyl-L-carnitine is a substance that may reduce ammonia toxicity. This review assessed the benefits and harms of acetyl-L-carnitine for patients with hepatic encephalopathy. OBJECTIVES To assess the benefits and harms of acetyl-L-carnitine for patients with hepatic encephalopathy. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, LILACS, and Science Citation Index Expanded for randomised clinical trials. We sought additional randomised clinical trials from the World Health Organization Clinical Trials Search Portal and ClinicalTrials.gov. We performed all electronic searches until 10 September 2018. We looked through the reference lists of retrieved publications and review articles, and we searched the FDA and EMA websites. SELECTION CRITERIA We searched for randomised clinical trials in any setting, recruiting people with hepatic encephalopathy. Trials were eligible for inclusion if they compared acetyl-L-carnitine plus standard care (e.g. antibiotics, lactulose) versus placebo or no acetyl-L-carnitine plus standard care. We are well aware that by selecting randomised clinical trials, we placed greater focus on potential benefits than on potential harms. DATA COLLECTION AND ANALYSIS We selected randomised clinical trials, assessed risk of bias in eight domains, and extracted data in a duplicate and independent fashion. We estimated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes. We measured statistical heterogeneity using I² and D² statistics. We subjected our analyses to fixed-effect and random-effects model meta-analyses. We assessed bias risk domains to control systematic errors. We assessed overall quality of the data for each individual outcome by using the GRADE approach. MAIN RESULTS We identified five randomised clinical trials involving 398 participants. All trials included only participants with cirrhosis as the underlying cause of hepatic encephalopathy. Trials included participants with covert or overt hepatic encephalopathy. All trials were conducted in Italy by a single team and assessed acetyl-L-carnitine compared with placebo. Oral intervention was the most frequent route of administration. All trials were at high risk of bias and were underpowered. None of the trials were sponsored by the pharmaceutical industry.None of the identified trials reported information on all-cause mortality, serious adverse events, or days of hospitalisation. Only one trial assessed quality of life using the Short Form (SF)-36 scale (67 participants; very low-quality evidence). The effects of acetyl-L-carnitine compared with placebo on general health at 90 days are uncertain (MD -6.20 points, 95% confidence interval (CI) -9.51 to -2.89). Results for additional domains of the SF-36 are also uncertain. One trial assessed fatigue using the Wessely and Powell test (121 participants; very low-quality evidence). The effects are uncertain in people with moderate-grade hepatic encephalopathy (mental fatigue: MD 0.40 points, 95% CI -0.21 to 1.01; physical fatigue: MD -0.20 points, 95% CI -0.92 to 0.52) and mild-grade hepatic encephalopathy (mental fatigue: -0.80 points, 95% CI -1.48 to -0.12; physical fatigue: 0.20 points, 95% CI -0.72 to 1.12). Meta-analysis showed a reduction in blood ammonium levels favouring acetyl-L-carnitine versus placebo (MD -13.06 mg/dL, 95% CI -17.24 to -8.99; 387 participants; 5 trials; very low-quality evidence). It is unclear whether acetyl-L-carnitine versus placebo increases the risk of non-serious adverse events (8/126 (6.34%) vs 3/120 (2.50%); RR 2.51, 95% CI 0.68 to 9.22; 2 trials; very low-quality evidence). Overall, adverse events data were poorly reported and harms may have been underestimated. AUTHORS' CONCLUSIONS This Cochrane systematic review analysed a heterogeneous group of five trials at high risk of bias and with high risk of random errors conducted by only one research team. We assessed acetyl-L-carnitine versus placebo in participants with cirrhosis with covert or overt hepatic encephalopathy. Hence, we have no data on the drug for hepatic encephalopathy in acute liver failure. We found no information about all-cause mortality, serious adverse events, or days of hospitalisation. We found no clear differences in effect between acetyl-L-carnitine and placebo regarding quality of life, fatigue, and non-serious adverse events. Acetyl-L-carnitine reduces blood ammonium levels compared with placebo. We rated all evidence as of very low quality due to pitfalls in design and execution, inconsistency, small sample sizes, and very few events. The harms profile for acetyl-L-carnitine is presently unclear. Accordingly, we need further randomised clinical trials to assess acetyl-L-carnitine versus placebo conducted according to the SPIRIT statements and reported according to the CONSORT statements.
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Affiliation(s)
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Ingrid Arevalo‐Rodriguez
- Hospital Universitario Ramon y Cajal (IRYCIS)Clinical Biostatistics UnitMadridSpain
- CIBER Epidemiology and Public Health (CIBERESP)MadridSpain
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Milyukov VE, Sharifova KM. [Multiple organ manifestations of liver failure in acute small bowel obstruction]. Khirurgiia (Mosk) 2019:73-79. [PMID: 31532170 DOI: 10.17116/hirurgia201909173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Modern surgical and intensive care achievements did not result decrease of mortality in patients with acute small bowel obstruction (ASBO). Direct cause of mortality in ASBO patients is peritonitis followed by multiple organ failure syndrome including acute failure of liver, kidneys, lungs and other organs. Publications devoted to the problem of acute liver failure and its complicationsare reviewed in the article. Mechanisms of pathogenesis and clinical manifestations of multiple organ failure syndrome in patients with acute small bowel obstruction are analyzed.
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Affiliation(s)
- V E Milyukov
- Sechenov First Moscow State Medical University of the Ministry of Health of the Russia, Moscow, Russia
| | - Kh M Sharifova
- Sechenov First Moscow State Medical University of the Ministry of Health of the Russia, Moscow, Russia
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Saline is as effective as nitrogen scavengers for treatment of hyperammonemia. Sci Rep 2017; 7:13112. [PMID: 29030642 PMCID: PMC5640627 DOI: 10.1038/s41598-017-12686-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 09/14/2017] [Indexed: 12/22/2022] Open
Abstract
Urea cycle enzyme deficiency (UCED) patients with hyperammonemia are treated with sodium benzoate (SB) and sodium phenylacetate (SPA) to induce alternative pathways of nitrogen excretion. The suggested guidelines supporting their use in the management of hyperammonemia are primarily based on non-analytic studies such as case reports and case series. Canine congenital portosystemic shunting (CPSS) is a naturally occurring model for hyperammonemia. Here, we performed cross-over, randomized, placebo-controlled studies in healthy dogs to assess safety and pharmacokinetics of SB and SPA (phase I). As follow-up safety and efficacy of SB was evaluated in CPSS-dogs with hyperammonemia (phase II). Pharmacokinetics of SB and SPA were comparable to those reported in humans. Treatment with SB and SPA was safe and both nitrogen scavengers were converted into their respective metabolites hippuric acid and phenylacetylglutamine or phenylacetylglycine, with a preference for phenylacetylglycine. In CPSS-dogs, treatment with SB resulted in the same effect on plasma ammonia as the control treatment (i.e. saline infusion) suggesting that the decrease is a result of volume expansion and/or forced diuresis rather than increased production of nitrogenous waste. Consequentially, treatment of hyperammonemia justifies additional/placebo-controlled trials in human medicine.
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Paschoal Junior FM, Nogueira RDC, Oliveira MDL, Paschoal EHA, Teixeira MJ, D’Albuquerque LAC, Bor-Seng-Shu E. Cerebral hemodynamic and metabolic changes in fulminant hepatic failure. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:470-476. [DOI: 10.1590/0004-282x20170076] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 03/30/2017] [Indexed: 12/30/2022]
Abstract
ABSTRACT Intracranial hypertension and brain swelling are a major cause of morbidity and mortality of patients suffering from fulminant hepatic failure (FHF). The pathogenesis of these complications has been investigated in man, in experimental models and in isolated cell systems. Currently, the mechanism underlying cerebral edema and intracranial hypertension in the presence of FHF is multi-factorial in etiology and only partially understood. The aim of this paper is to review the pathophysiology of cerebral hemodynamic and metabolism changes in FHF in order to improve understanding of intracranial dynamics complication in FHF.
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Improvement of sleep architecture parameters in cirrhotic patients with recurrent hepatic encephalopathy with the use of rifaximin. Eur J Gastroenterol Hepatol 2017; 29:302-308. [PMID: 27977438 DOI: 10.1097/meg.0000000000000786] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIM Sleep disorders are frequently reported in patients with cirrhosis and hepatic encephalopathy (HE). This study assessed the effect of rifaximin on sleep architecture parameters in patients with recurrent HE. PATIENTS AND METHODS This sequential, prospective, and exploratory study involved all patients with cirrhosis and recurrent HE admitted between June 2014 and September 2015. HE was assessed according to the West-Haven Classification. Patients underwent 24-h polysomnography (PSG) and 7-day actigraphy. Rapid eye movement (REM) sleep was considered to be an indicator of good sleep quality. Patients completed questionnaires assessing the quality of sleep and sleepiness. After a 28-day course of rifaximin, the same assessment was repeated. RESULTS Fifteen patients were included (nine men, mean age: 57±11 years). Child-Pugh scores ranged from B7 to C15. Before rifaximin, the mean HE score was 2.7±0.7. Data from PSG analysis indicated long total sleep time (TST): 571±288 min, and limited REM sleep: 2.5% TST (0-19). Seven-day actigraphy showed an impaired number of steps: 1690/24 h (176-6945). Questionnaires indicated that patients experienced impaired sleep quality and excessive daytime sleepiness. After rifaximin, HE scores decreased to 1.7±0.6 (P<0.001). REM sleep increased to 8.5% TST (0-25) (P=0.003). No changes were observed for TST, number of steps, and on questionnaires. CONCLUSION Patients with recurrent HE suffer from poor sleep quality and excessive daytime sleepiness. On 24-h PSG, rifaximin improves objective sleep architecture parameters with no changes in the subjective quality of sleep and sleepiness.
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Benson JC, Payabvash S, Thalken GL, Alonso J, Rykken J, Ott F, McKinney AM. Delineation of microhemorrhage in acute hepatic encephalopathy using susceptibility-weighted imaging. Eur J Radiol 2016; 85:629-34. [PMID: 26860677 DOI: 10.1016/j.ejrad.2015.12.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 12/03/2015] [Accepted: 12/27/2015] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Microhemorrhages (MH's) in patients with acute hepatic encephalopathy (AHE) have scarcely been described. This study set out to assess if MH's occur in characteristic locations and frequency in patients with AHE superimposed on chronic liver failure, and to determine if such findings correlate with the clinical and MRI severity. MATERIALS AND METHODS Over a 4.5-year period, AHE patients with SWI MRI were included. The maximum plasma ammonia level (PAL), number and location of "frank" hemorrhages (>5mm size) or MH's (<5mm) on SWI, and severity of DWI and FLAIR were recorded. Susceptibility foci in the basal ganglia were disregarded, as those changes might represent common mineralization. The presence of MH's was correlated with the MRI and clinical severity. RESULTS Punctate MH foci were found in 18/38 (47.4%) patients. The most common locations were periventricular white matter (6/38 patients, 15.8%) and cerebral cortex (5/38, 13.2%). Of 47 MH's, only a tiny minority (8.5%) occurred in regions of abnormality on FLAIR or DWI. Both the MRI severity on FLAIR (r=0.420, p=0.013) and DWI (r=0.320, p=0.045) mildly correlated with clinical outcome, but the correlation was not significant after Bonferroni correction. No significant correlation was found between the number of MH's and the clinical score, clinical outcome, FLAIR severity, or DWI severity (range r=-0.083-0.152, p=0.363-0.618). The number of MH's was not significantly different among various vasculopathies. Foci on SWI improved in two patients following liver transplantation. CONCLUSION SWI-positive foci outside of the basal ganglia (presumed MH's) are present in nearly half of AHE patients, but do not portend outcome. Regions with the most observed MH's were the periventricular white matter, cortical gray matter, and subcortical white matter.
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Affiliation(s)
- John C Benson
- Hennepin County and University of Minnesota Medical Centers, Department of Radiology, Minneapolis, MN, USA.
| | - Seyedmehdi Payabvash
- Hennepin County and University of Minnesota Medical Centers, Department of Radiology, Minneapolis, MN, USA
| | - Gregory L Thalken
- Hennepin County and University of Minnesota Medical Centers, Department of Radiology, Minneapolis, MN, USA
| | - Juli Alonso
- Unitat de Ressonància Magnètica, Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jeffrey Rykken
- Hennepin County and University of Minnesota Medical Centers, Department of Radiology, Minneapolis, MN, USA
| | - Frederick Ott
- Hennepin County and University of Minnesota Medical Centers, Department of Radiology, Minneapolis, MN, USA
| | - Alexander M McKinney
- Hennepin County and University of Minnesota Medical Centers, Department of Radiology, Minneapolis, MN, USA
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Camerino SRAES, Lima RCP, França TCL, Herculano EDA, Rodrigues DSA, Gouveia MGDS, Cameron LC, Prado ES. Keto analogue and amino acid supplementation and its effects on ammonemia and performance under thermoneutral conditions. Food Funct 2016; 7:872-80. [DOI: 10.1039/c5fo01054c] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Keto analogue and amino acid supplementation decreases ammonemia during exercise without affecting performance.
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Affiliation(s)
| | | | | | | | | | | | - L. C. Cameron
- Laboratory of Protein Biochemistry
- Federal University of State of Rio de Janeiro
- Rio de Janeiro
- Rio de Janeiro
- Brazil
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19
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El-seid SS, Attia FA, El-Raouf MA, Abd Al-Azeem GS, Mohammed NAELG, Anwar H. The role of Helicobacter pylori in minimal hepatic encephalopathy. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2015. [DOI: 10.4103/1110-7782.155849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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20
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Kim KM, Kim GS, Ko JS, Gwak MS, Lee SK, Son MG. Factors associated with consciousness recovery time after liver transplantation in recipients with hepatic encephalopathy. Transplant Proc 2015; 46:712-5. [PMID: 24767331 DOI: 10.1016/j.transproceed.2013.12.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 11/30/2013] [Accepted: 12/11/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hepatic encephalopathy (HE) occurs as a result of liver failure and is often considered to be a clinical indication for liver transplantation (LT). An assessment of post-transplantation consciousness level in recipients with HE is crucial, because recovery of consciousness implies reestablishment of transplant liver function and lack of perioperative brain damage. The purpose of this study is to evaluate factors associated with consciousness recovery time after LT in recipients with HE. METHODS Out of 633 adult recipients who underwent LT, recipients who exhibited HE at the time of LT were analyzed retrospectively. The time between graft reperfusion and postoperative consciousness recovery was determined, and recipients were divided into 2 groups: group E with recovery of consciousness early (≤48 hours), and group L with recovery of consciousness late (>48 hours). Analyzed variables included recipient sex, age, graft type, Model for End-Stage Liver Disease score, HE history/duration/type/grade, and preoperative laboratory values, including blood ammonia concentration. RESULTS HE was present at the time of LT in 69 (10.9%) of 633 recipients. Among the 69 recipients, 11 recipients who died or underwent reoperation before consciousness recovery were excluded, and 58 recipients (group E: n = 32; group L: n = 26) were enrolled into analysis. Multivariate analysis showed that HE duration >5 days (odds ratio [OR], 15.58; 95% confidence interval [CI], 1.35-179.56; P = .028) and HE type C (OR, 30.90; 95% CI, 1.67-573.48; P = .021) were the independent factors associated with late recovery from HE after LT. CONCLUSIONS We suggest that recipients with long-duration or type C HE should be carefully managed during the post-transplantation period to prevent deterioration of HE.
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Affiliation(s)
- K M Kim
- Department of Anesthesiology and Pain Medicine, Dongtan Sacred Heart Hospital, Hallym University School of Medicine, Hwasung, Korea
| | - G S Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - J S Ko
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - M S Gwak
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - S-K Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - M G Son
- Department of Anesthesiology and Pain Medicine, Dongtan Sacred Heart Hospital, Hallym University School of Medicine, Hwasung, Korea
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Hepatic encephalopathy in patients with acute decompensation of cirrhosis and acute-on-chronic liver failure. J Hepatol 2015; 62:437-47. [PMID: 25218789 DOI: 10.1016/j.jhep.2014.09.005] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 08/29/2014] [Accepted: 09/02/2014] [Indexed: 12/12/2022]
Abstract
Hepatic encephalopathy in a hospitalized cirrhotic patient is associated with a high mortality rate and its presence adds further to the mortality of patients with acute-on-chronic liver failure (ACLF). The exact pathophysiological mechanisms of HE in this group of patients are unclear but hyperammonemia, systemic inflammation (including sepsis, bacterial translocation, and insulin resistance) and oxidative stress, modulated by glutaminase gene alteration, remain as key factors. Moreover, alcohol misuse, hyponatremia, renal insufficiency, and microbiota are actively explored. HE diagnosis requires exclusion of other causes of neurological, metabolic and psychiatric dysfunction. Hospitalization in the ICU should be considered in every patient with overt HE, but particularly if this is associated with ACLF. Precipitating factors should be identified and treated as required. Evidence-based specific management options are limited to bowel cleansing and non-absorbable antibiotics. Ammonia lowering drugs, such as glycerol phenylbutyrate and ornithine phenylacetate show promise but are still in clinical trials. Albumin dialysis may be useful in refractory cases. Antibiotics, prebiotics, and treatment of diabetes reduce systemic inflammation. Where possible and not contraindicated, large portal-systemic shunts may be embolized but liver transplantation is the most definitive step in the management of HE in this setting. HE in patients with ACLF appears to be clinically and pathophysiologically distinct from that of acute decompensation and requires further studies and characterization.
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Martí-Carvajal AJ, Gluud C, Arevalo-Rodriguez I. Acetyl-L-carnitine for patients with hepatic encephalopathy. Hippokratia 2014. [DOI: 10.1002/14651858.cd011451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; The Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Ingrid Arevalo-Rodriguez
- Fundación Universitaria de Ciencias de la Salud; Division of Research; Carrera 19 Nº 8a - 32 Bogotá D.C. Bogota DC Colombia 11001
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Bosoi CR, Rose CF. Elevated cerebral lactate: Implications in the pathogenesis of hepatic encephalopathy. Metab Brain Dis 2014; 29:919-25. [PMID: 24916505 DOI: 10.1007/s11011-014-9573-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 05/28/2014] [Indexed: 01/31/2023]
Abstract
Hepatic encephalopathy (HE), a complex neuropsychiatric syndrome, is a frequent complication of liver failure/disease. Increased concentrations of lactate are commonly observed in HE patients, in the systemic circulation, but also in the brain. Traditionally, increased cerebral lactate is considered a marker of energy failure/impairment however alterations in lactate homeostasis may also lead to a rise in brain lactate and result in neuronal dysfunction. The latter may involve the development of brain edema. This review will target the significance of increased cerebral lactate in the pathogenesis of HE.
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Affiliation(s)
- Cristina R Bosoi
- Hepato-Neuro Laboratory, Centre Hospitalier de l'Université de Montréal (CRCHUM), 900, rue Saint-Denis - Tour Viger R08.422, Québec, H2X 0A9, Canada,
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Bosoi CR, Tremblay M, Rose CF. Induction of systemic oxidative stress leads to brain oedema in portacaval shunted rats. Liver Int 2014; 34:1322-9. [PMID: 25354203 DOI: 10.1111/liv.12414] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 11/16/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS The pathogenesis of hepatic encephalopathy (HE) is multifactorial and often associated with the development of brain oedema. In addition to ammonia playing a central role, systemic oxidative stress is believed to aggravate the neuropsychological effects of ammonia in patients with chronic liver disease (CLD). The aim of this study was to (i) induce systemic oxidative stress in hyperammonaemic portacaval anastomosed (PCA) rats by inhibiting the antioxidant glutathione using Dimethyl maleate (DEM) and (ii) investigate whether a synergistic relationship between ammonia and oxidative stress contributes to the pathogenesis of brain oedema in CLD. METHODS Four-week PCA and sham-operated rats received DEM (0.4-4 mg/kg/day) for the last 10 days before sacrifice when oxidative stress markers [reactive oxygen species (ROS) and malondialdehyde (MDA)] were assessed in blood and frontal cortex. Brain water content was measured using a specific gravimetric technique. RESULTS Dimethyl maleate induced an increase in ROS and MDA in the blood, but not in the brain, of the PCA rats, compared with non-treated PCA rats. This was accompanied with an increase in brain water content (PCA+DEM: 78.45 ± 0.13% vs. PCA: 77.38 ± 0.11%, P < 0.001). Higher doses of DEM induced systemic oxidative stress in sham-operated controls, but brain oedema did not develop. CONCLUSIONS Dimethyl maleate provoked systemic, not central, oxidative stress in PCA rats, resulting in the development of brain oedema. Independently, hyperammonaemia and systemic oxidative stress do not precipitate brain oedema; therefore, our findings sustain that a synergistic effect between hyperammonaemia and systemic oxidative stress is responsible for the development of brain oedema in HE.
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Affiliation(s)
- Cristina R Bosoi
- Neuroscience Research Unit, Hôpital Saint-Luc (CRCHUM), Université de Montréal, Québec, Canada
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25
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Affiliation(s)
- Patricia M Jones
- Department of Pathology, University of Texas Southwestern Medical Center and
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Watt P, lordache S, Russell P. Ornithine Transcarbamylase Deficiency: Diagnostic and Management Challenges in the ICU. J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A young male patient presented with altered sensorium and rapid clinical deterioration following a short period of nonspecific illness and was subsequently diagnosed with ornithine transcarbamylase deficiency (OTCD). We discuss the pathophysiology of OTCD, the difficulties surrounding diagnosis and treatment, and highlight some of the controversies and general management issues of the disease.
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Affiliation(s)
- Philip Watt
- Consultant Anaesthetist with interest in ICM, Lead Clinician for ICU, Kettering General Hospital NHS Foundation Trust
| | - Sabina lordache
- Specialist Trainee Year 3 Anaesthesia, Central Middlesex Hospital, The North West London Hospitals NHS Trust
| | - Philip Russell
- Core Trainee Year 2 Anaesthetics, Pilgrim Hospital, Boston
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Cichoż-Lach H, Michalak A. Current pathogenetic aspects of hepatic encephalopathy and noncirrhotic hyperammonemic encephalopathy. World J Gastroenterol 2013; 19:26-34. [PMID: 23326159 PMCID: PMC3545226 DOI: 10.3748/wjg.v19.i1.26] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 07/25/2012] [Accepted: 07/28/2012] [Indexed: 02/06/2023] Open
Abstract
Hepatic encephalopathy is a medical phenomenon that is described as a neuropsychiatric manifestation of chronic or acute liver disease that is characterized by psychomotor, intellectual and cognitive abnormalities with emotional/affective and behavioral disturbances. This article focuses on the underlying mechanisms of the condition and the differences between hepatic encephalopathy and noncirrhotic hyperammonemic encephalopathy. Hepatic encephalopathy is a serious condition that can cause neurological death with brain edema and intracranial hypertension. It is assumed that approximately 60%-80% of patients with liver cirrhosis develop hepatic encephalopathy. This review explores the complex mechanisms that lead to hepatic encephalopathy. However, noncirrhotic hyperammonemic encephalopathy is not associated with hepatic diseases and has a completely different etiology. Noncirrhotic hyperammonemic encephalopathy is a severe occurrence that is connected with multiple pathogeneses.
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