Metabolic Abnormalities and Grade of Encephalopathy in Acute Hepatic Failure

Abstract: Acute hepatic failure is associated with many biochemical abnormalities in plasma and brain. Changes that correlate well with the degree of behavioral impairment may be important factors in the development of encephalopathy. We measured the concentrations of intermediary metabolites, ammonia, and amino acids in brain and plasma and the rate of whole-brain glucose utilization in rats with an acutely devascularized liver. In all rats an estimate of the grade of encephalopathy (reflected by behavioral impairment) was made. Rats underwent portacaval shunting and hepatic artery ligation (or sham operation) and were kept normoglycemic and normothermic thereafter. We sampled blood and whole brain (by near-instantaneous freeze-blowing) 2, 4, or 6 h later. There were no alterations in levels of high-energy phosphate metabolites in the brain or in metabolites associated with the glycolytic pathway and Krebs cycle, except lactate and pyruvate. Brain glucose use was decreased similarly at all times after surgery. Levels of ammonia and many amino acids were increased in brain and plasma; brain aspartate, glutamate, and arginine levels were decreased. The increases in content of plasma ammonia and brain glutamine, proline, alanine, and aromatic amino acids and the decreases in brain aspartate and glutamate were most strongly correlated with behavioral impairment.     

Effect of Reducing Brain Glutamine Synthesis on Metabolic Symptoms of Hepatic Encephalopathy

Abstract: Liver failure, or shunting of intestinal blood around the liver, results in hyperammonemia and cerebral dysfunction. Recently it was shown that ammonia caused some of the metabolic signs of hepatic encephalopathy only after it was metabolized by glutamine synthetase in the brain. In the present study, small doses of methionine sulfoximine, an inhibitor of cerebral glutamine synthetase, were given to rats either at the time of portacaval shunting or 3–4 weeks later. The effects on several characteristic cerebral metabolic abnormalities produced by portacaval shunting were measured 1–3 days after injection of the inhibitor. All untreated portacaval-shunted rats had elevated plasma and brain ammonia concentrations, increased brain glutamine and tryptophan content, decreased brain glucose consumption, and increased permeability of the blood–brain barrier to tryptophan. All treated rats had high ammonia concentrations, but the brain glutamine content was normal, indicating inhibition of glutamine synthesis. One day after shunting and methionine sulfoximine administration, glucose consumption, tryptophan transport, and tryptophan brain content remained near control values. In the 3–4-week-shunted rats, which were studied 1–3 days after methionine sulfoximine administration, the effect was less pronounced. Brain glucose consumption and tryptophan content were partially normalized, but tryptophan transport was unaffected. The results agree with our earlier conclusion that glutamine synthesis is an essential step in the development of cerebral metabolic abnormalities in hyperammonemic states.     

Autophagy in Neurodegenerative Diseases: From Mechanism to Therapeutic Approach

Autophagy is a lysosome-dependent intracellular degradation process that allows recycling of cytoplasmic constituents into bioenergetic and biosynthetic materials for maintenance of homeostasis. Since the function of autophagy is particularly important in various stress conditions, perturbation of autophagy can lead to cellular dysfunction and diseases. Accumulation of abnormal protein aggregates, a common cause of neurodegenerative diseases, can be reduced through autophagic degradation. Recent studies have revealed defects in autophagy in most cases of neurodegenerative disorders. Moreover, deregulated excessive autophagy can also cause neurodegeneration. Thus, healthy activation of autophagy is essential for therapeutic approaches in neurodegenerative diseases and many autophagy-regulating compounds are under development for therapeutic purposes. This review describes the overall role of autophagy in neurodegeneration, focusing on various therapeutic strategies for modulating specific stages of autophagy and on the current status of drug development.     

氨基酸代谢与肝性脑病

肝性脑病 (HepaticEncephalopathy)又称肝昏迷 ,即由于严重肝病引起的中枢神经系统功能紊乱 ,患者出现一系列神经精神病状 ,直至进入昏迷。在此仅从氨基酸代谢异常的角度叙述与肝性脑病的关系。     

Brain Histamine in Rats with Hepatic Encephalopathy

Chronic liver failure induced by portocaval anastomosis (PCA) in Wistar rats resulted in a dramatic increase in histamine concentration in hypothalamus and a smaller, but clearly pronounced, elevation in the rest of brain. Between 10 and 120 days following surgery, shunted rats exhibited a histamine level 2.4- to 13-fold higher in hypothalamus and 1.5- to 2.5-fold higher in the rest of brain as compared to their control, sham-operated pairs. There were no significant changes in histamine concentration in the other examined tissues. The increase in brain histamine could not be attributed to the inhibition of its degradation, because activity of histamine N-methyltransferase remained unchanged for at least 40 days. Although the activity of histidine decarboxylase also remained unchanged when measured at a saturating concentration of L-histidine, the increase in histamine content in brain seems to be due to its enhanced synthesis brought about by increased availability of L-histidine in the tissue, as indicated by two to four times higher concentrations of this amino acid in PCA rats.     

Dopamine and Serotonin Metabolism in Hepatic Encephalopathy

Patients with stupor or coma from fulminant hepatic failure were found to have high cerebrospinal fluid concentrations of homovanillic acid (HVA) and 5-hydroxyindole acetic acid (5-HIAA), metabolites of dopamine and serotonin respectively. Excessive amounts of their precursors—phenylalanine and tyrosine and free tryptophan—were found in the patients'' plasma. Methionine, which participates in dopamine degradation, was also much increased. Similar disturbances were found in patients suffering an acute exacerbation of chronic encephalopathy. These abnormalities would be consistent with other evidence of an increased turnover of serotonin and possibly dopamine in the brain during hepatic encephalopathy.     

四氯化碳诱导大鼠肝性脑病模型的制备

目的建立肝性脑病（HE）动物模型。方法应用四氯化碳联合酒精自饮法制作慢性肝功能衰竭引起HE发生的模型,进行迷宫试验、脑电图、血液生化、形态学、行为活动观察等检测。结果 1.肉眼下可见模型组肝脏普遍肿大,表面较粗糙,有较粗的颗粒,暗红色;正常组肝脏未见异常。模型组肝内有大量纤维增生,肝细胞溶解,弥漫性大片坏死,残留肝细胞成片气球样变。2.与对照组大鼠比较,造模组第九周水迷宫测试逃避潜伏期明显延长,以潜伏期延长超过正常x＋2.5 s为标准,本实验有14/20（55%）只大鼠水迷宫潜伏期明显延长;3.HE模型组血氨浓度明显高于正常对照组,组间比较差异有显著性（P〈0.01）;4.正常组脑电图以α波为主,无明显异常;模型组出现肝性脑病变化。结论 1.建立了肝硬化合并肝性脑病较为理想的动物模型;2.水迷宫测试联合检测更易检出HE。     

循证护理在肝硬化肝性脑病护理中的应用研究

目的:探究循证护理在肝硬化肝性脑病护理中的临床应用价值.方法:回顾性分析2009年1月～2010年12月在我院就诊的50例肝硬化肝性脑病(HE)患者的临床资料,随机分为研究组和对照组,观察分析采用循证护理和常规护理的方法在HE护理中的效果.结果:研究组和对照组的有效率分别为84％、60％,将两组患者的有效率进行卡方检验,差异有统计学意义(X2=10.23,P＜0.05).结论:循证护理在肝硬化肝性脑病护理中有重要的临床应用价值,值得在临床上推广应用.     

Proton-Decoupled 31P Magnetic Resonance Spectroscopy Reveals Osmotic and Metabolic Disturbances in Human Hepatic Encephalopathy

Abstract: Quantitative proton and quantitative proton-decoupled ³¹P magnetic resonance spectroscopy (MRS) of the brain was performed in 16 patients with liver disease (10 with and six without chronic hepatic encephalopathy) and four patients with hyponatremia, as well as 20 age-matched normal subjects. Patients with hepatic encephalopathy were distinguished from controls by significant reduction in levels of cerebral nucleoside triphosphate (2.45 ± 0.20 vs. 2.91 ± 0.21 mmol/kg of brain; p < 0.0003), inorganic phosphate ( p < 0.03), and phosphocreatine ( p < 0.04). In addition of increased levels of cerebral glutamate plus glutamine and decreased concentrations of myo -inositol, patients with hepatic encephalopathy showed a reduction of total visible choline and of glycerophosphoryl-choline (0.67 ± 0.13 vs. 0.92 ± 0.20 mmol/kg of brain in controls; p < 0.005) in ¹H MRS, and of glycerophosphoryl-ethanolamine (0.40 ± 0.12 vs. 0.68 ± 0.12 mmol/kg of brain in controls; p < 0.0003) in proton-decoupled ³¹P MRS. Of the reduction of "total choline," 61% was accounted for by glycerophosphorylcholine, a cerebral osmolyte. Similar metabolic abnormalities were seen in hyponatremic patients. The results are consistent with disturbances of cerebral osmoregulation and energy metabolism in patients with chronic hepatic encephalopathy.     

Metformin Inhibits Glutaminase Activity and Protects against Hepatic Encephalopathy

Aim

To investigate the influence of metformin use on liver dysfunction and hepatic encephalopathy in a retrospective cohort of diabetic cirrhotic patients. To analyze the impact of metformin on glutaminase activity and ammonia production in vitro.

Methods

Eighty-two cirrhotic patients with type 2 diabetes were included. Forty-one patients were classified as insulin sensitizers experienced (metformin) and 41 as controls (cirrhotic patients with type 2 diabetes mellitus without metformin treatment). Baseline analysis included: insulin, glucose, glucagon, leptin, adiponectin, TNFr2, AST, ALT. HOMA-IR was calculated. Baseline HE risk was calculated according to minimal hepatic encephalopathy, oral glutamine challenge and mutations in glutaminase gene. We performed an experimental study in vitro including an enzymatic activity assay where glutaminase inhibition was measured according to different metformin concentrations. In Caco2 cells, glutaminase activity inhibition was evaluated by ammonia production at 24, 48 and 72 hours after metformina treatment.

Results

Hepatic encephalopathy was diagnosed during follow-up in 23.2% (19/82): 4.9% (2/41) in patients receiving metformin and 41.5% (17/41) in patients without metformin treatment (logRank 9.81; p = 0.002). In multivariate analysis, metformin use [H.R.11.4 (95% CI: 1.2–108.8); p = 0.034], age at diagnosis [H.R.1.12 (95% CI: 1.04–1.2); p = 0.002], female sex [H.R.10.4 (95% CI: 1.5–71.6); p = 0.017] and HE risk [H.R.21.3 (95% CI: 2.8–163.4); p = 0.003] were found independently associated with hepatic encephalopathy. In the enzymatic assay, glutaminase activity inhibition reached 68% with metformin 100 mM. In Caco2 cells, metformin (20 mM) decreased glutaminase activity up to 24% at 72 hours post-treatment (p<0.05).

Conclusions

Metformin was found independently related to overt hepatic encephalopathy in patients with type 2 diabetes mellitus and high risk of hepatic encephalopathy. Metformin inhibits glutaminase activity in vitro. Therefore, metformin use seems to be protective against hepatic encephalopathy in diabetic cirrhotic patients.     

Glutamine in the Pathogenesis of Hepatic Encephalopathy: The Trojan Horse Hypothesis Revisited

Hepatic encephalopathy (HE) is major neuropsychiatric disorder occurring in patients with severe liver disease and ammonia is generally considered to represent the major toxin responsible for this condition. Ammonia in brain is chiefly metabolized (“detoxified”) to glutamine in astrocytes due to predominant localization of glutamine synthetase in these cells. While glutamine has long been considered innocuous, a deleterious role more recently has been attributed to this amino acid. This article reviews the mechanisms by which glutamine contributes to the pathogenesis of HE, how glutamine is transported into mitochondria and subsequently hydrolyzed leading to high levels of ammonia, the latter triggering oxidative and nitrative stress, the mitochondrial permeability transition and mitochondrial injury, a sequence of events we have collectively termed as the Trojan horse hypothesis of hepatic encephalopathy.     

乳果糖和枯草杆菌屎球菌二联活菌治疗轻微性肝性脑病疗效观察

目的:探讨乳果糖和枯草杆菌屎球菌二联活菌治疗肝硬化所致轻微性肝性脑病(MHE)的疗效。方法:将患有MHE的患者84例随机分为四组,对照组(A组,仅接受肝硬化综合治疗),乳果糖组(B组,在A组基础上加用乳果糖口服液),枯草杆菌屎球菌二联活菌组(C组,在A组基础上加用枯草杆菌屎球菌二联活菌胶囊),联合组(D组,在A组基础上联合应用乳果糖和枯草杆菌屎球菌二联活菌胶囊),每组均治疗4周。分别于治疗后第一周,第二周,第四周观察患者的数字连接实验(NCT)、数字符号实验(DST)结果,血氨变化及不良反应的发生情况。结果:B、C、D组NCT时间,DST分数及血氨均较A组改善明显,其中以D组最显著(P0.05),且随着治疗时间延长,B、C、D组以上各指标逐渐改善,其中D组以治疗后2周效果最明显(P0.05)。四组均无明显不良反应,其中D组不良反应率最低。结论:单用乳果糖与单用枯草杆菌二联活菌均可改善MHE患者的病情,但联合用药效果明显优于单药治疗,且随用药时间延长,疗效明显,安全性高,值得在临床推广。     

Endogenous Benzodiazepine Receptor Ligands in Human and Animal Hepatic Encephalopathy

The role of endogenous benzodiazepine receptor ligands in the pathogenesis of hepatic encephalopathy was studied in humans and in rat models of hepatic encephalopathy. Endogenous benzodiazepine ligands were extracted from rat brain and human CSF by acid treatment and purification by HPLC. Detection and partial characterization of these endogenous benzodiazepine ligands were carried out using both radioreceptor binding assays and radioimmunoassays with anti-benzodiazepine antibodies. Four different benzodiazepine receptor ligands were identified in human and rat tissue, two of which may be diazepam and desmethyldiazepam, based on elution profiles and anti-benzo-diazepine antibody reactivity. Human CSF and serum from patients with hepatic encephalopathy contained approximately 10 times more endogenous benzodiazepine receptor ligand than CSF from controls or nonencephalopathic patients with liver disease. The levels of brain benzodiazepine receptor ligand compounds were also increased approximately 10-fold in rats suffering from fulminant hepatic failure, but not in rats with portacaval shunts, a model of chronic hepatic disease. The increased concentrations of these substances could be behaviorally significant and may contribute to the pathogenesis of hepatic encephalopathy.     

Evidence for an Astrocytic Glutamate Transporter Deficit in Hepatic Encephalopathy

There is increasing evidence to suggest that hepatic encephalopathy in acute liver failure is the result of altered glutamatergic function. In particular, the high affinity uptake of glutamate is decreased in brain slices and synaptosomes from rats with acute liver failure as well as by exposure of cultured astrocytes to concentrations of ammonia equivalent to those reported in brain in acute liver failure. Both protein and gene expression of the recently cloned and sequenced astrocytic glutamate transporter GLT-1 are significantly reduced in the brains of rats with acute liver failure. Decreased expression of GLT-1 in brain in acute liver failure results in increased extracellular brain glutamate concentrations which correlates with arterial ammonia concentrations and with the appearance of severe encephalopathy and brain edema in these animals. Ammonia-induced reductions in expression of GLT-1 resulting in increased extracellular glutamate concentrations could explain some of the symptoms (hyperexcitability, cerebral edema) characteristic of hepatic encephalopathy in acute liver failure.     

Integrative Metabolic Signatures for Hepatic Radiation Injury

Background

Radiation-induced liver disease (RILD) is a dose-limiting factor in curative radiation therapy (RT) for liver cancers, making early detection of radiation-associated liver injury absolutely essential for medical intervention. A metabolomic approach was used to determine metabolic signatures that could serve as biomarkers for early detection of RILD in mice.

Methods

Anesthetized C57BL/6 mice received 0, 10 or 50 Gy Whole Liver Irradiation (WLI) and were contrasted to mice, which received 10 Gy whole body irradiation (WBI). Liver and plasma samples were collected at 24 hours after irradiation. The samples were processed using Gas Chromatography/Mass Spectrometry and Liquid Chromatography/Mass Spectrometry.

Results

Twenty four hours after WLI, 407 metabolites were detected in liver samples while 347 metabolites were detected in plasma. Plasma metabolites associated with 50 Gy WLI included several amino acids, purine and pyrimidine metabolites, microbial metabolites, and most prominently bradykinin and 3-indoxyl-sulfate. Liver metabolites associated with 50 Gy WLI included pentose phosphate, purine, and pyrimidine metabolites in liver. Plasma biomarkers in common between WLI and WBI were enriched in microbial metabolites such as 3 indoxyl sulfate, indole-3-lactic acid, phenyllactic acid, pipecolic acid, hippuric acid, and markers of DNA damage such as 2-deoxyuridine. Metabolites associated with tryptophan and indoles may reflect radiation-induced gut microbiome effects. Predominant liver biomarkers in common between WBI and WLI were amino acids, sugars, TCA metabolites (fumarate), fatty acids (lineolate, n-hexadecanoic acid) and DNA damage markers (uridine).

Conclusions

We identified a set of metabolomic markers that may prove useful as plasma biomarkers of RILD and WBI. Pathway analysis also suggested that the unique metabolic changes observed after liver irradiation was an integrative response of the intestine, liver and kidney.     

肝性脑病患者脑脊液Tau 蛋白水平测定及其临床意义

目的:探讨肝性脑病患者脑脊液中总Tau蛋白(t-Tau)和磷酸化Tau蛋白(p-Tau)水平的变化及其与疾病严重程度的相关性。方法:采集26例肝性脑病患者及31例健康对照的脑脊液标本,采用酶联免疫吸附法(Elisa)检测脑脊液中的t-Tau和p-Tau水平,分析其与Child-Pugh评分和West Haven分级的相关性。结果:(1)肝性脑病患者脑脊液t-Tau和p-Tau水平显著高于健康对照组(P0.01)。(2)肝性脑病患者脑脊液t-Tau(γ=0.876,P0.01;γ=0.952,P0.01)、p-Tau(γ=0.808,P0.01;γ=0.808,P0.01)水平与Child-Pugh评分及West-Haven分级呈正相关。结论:由于脑脊液t-Tau和p-Tau水平为神经元损害的标志物,同时反应脑内应激状况,本研究证实肝性脑病患者脑内处于应激状态并有神经元损伤。     

支链氨基酸在肝性脑病中应用的研究进展

肝性脑病作为肝脏疾病终末期常见的并发症之一,严重降低病人的生活质量,影响疾病预后.不合理的营养摄人是肝性脑病的诱因之一.支链氨基酸的应用不仅可预防肝病病人发生肝性脑病,还可以降低肝性脑病病人的意识障碍.本文简述肝性脑病的发生机制,并从理论基础、临床研究叙述支链氨基酸的治疗作用机制,且对常见支链氨基酸药物及已报道的不良反...