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Di Cola S, Khan S, Lapenna L, Merli M. Emerging drugs for the treatment of sarcopenia in cirrhosis of the liver. Expert Opin Emerg Drugs 2024:1-11. [PMID: 38549232 DOI: 10.1080/14728214.2024.2332428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/14/2024] [Indexed: 04/19/2024]
Abstract
Introduction: Malnutrition and sarcopenia are common and impact the prognosis in patients with liver cirrhosis. The etiology is multifactorial and includes periods of reduced caloric intake, increased catabolism and direct molecular mechanisms that inhibit muscle synthesis. Although these conditions are widely acknowledged, and there is a growing interest in their diagnosis, robust evidence regarding the treatment and reversibility of these conditions is still lacking.Areas covered: We have explored the current evidence on the pharmacological treatment of sarcopenia in patients with cirrhosis. Additionally, we have searched for drugs already in use and ongoing trials for other chronic diseases.Expert opinion: The current guidelines recommend the use of a protein-adequate diet and moderate physical activity for treating sarcopenia in patients with cirrhosis. Currently, robust evidence is derived only from the supplementation of Branched-Chain Amino Acids, capable of increasing muscle mass and function. There are many drugs targeting various pathways that contribute to sarcopenia. However, evidence is sporadic and insufficient to suggest their use in clinical practice.Novel drugs specifically designed to enhance muscle mass and function should be developed. Finally, gender significantly influences the type of muscle alteration and therapeutic mechanisms; therefore, future studies should be designed taking gender differences into consideration.
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Affiliation(s)
- Simone Di Cola
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Saniya Khan
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Lucia Lapenna
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
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2
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Seo KI. [Sarcopenia in Chronic Liver Disease]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2023; 82:233-238. [PMID: 37997219 DOI: 10.4166/kjg.2023.127] [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: 10/18/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 11/25/2023]
Abstract
Sarcopenia is a crucial factor in assessing the nutritional status of chronic liver disease patients and predicting their prognosis and survival. The serum ammonia level is closely associated with sarcopenia regarding ammonia, a key regulator in the liver-muscle axis. In addition, various changes in energy metabolism and hormones are also involved in sarcopenia. The psoas muscle area can represent the overall skeletal muscle mass in liver disease patients. Therefore, measuring the psoas muscle area with computed tomography or magnetic resonance imaging is considered an objective and reliable method for assessing muscle mass. Providing sufficient calorie and protein intake is crucial for preventing and treating sarcopenia. In addition, engaging in appropriate exercise and addressing concurrent hormonal and metabolic changes can be helpful.
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Affiliation(s)
- Kwang Il Seo
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
- Chang Kee-Ryo Memorial Liver Institute, Kosin University College of Medicine, Busan, Korea
- Nutritional Support Team, Kosin University Gospel Hospital, Busan, Korea
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3
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Culver A, Hamang M, Wang Y, Jiang H, Yanum J, White E, Gawrieh S, Vuppalanchi RK, Chalasani NP, Dai G, Yaden BC. GDF8 Contributes to Liver Fibrogenesis and Concomitant Skeletal Muscle Wasting. Biomedicines 2023; 11:1909. [PMID: 37509548 PMCID: PMC10377408 DOI: 10.3390/biomedicines11071909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/23/2023] [Accepted: 06/23/2023] [Indexed: 07/30/2023] Open
Abstract
Patients with end-stage liver disease exhibit progressive skeletal muscle atrophy, highlighting a negative crosstalk between the injured liver and muscle. Our study was to determine whether TGFβ ligands function as the mediators. Acute or chronic liver injury was induced by a single or repeated administration of carbon tetrachloride. Skeletal muscle injury and repair was induced by intramuscular injection of cardiotoxin. Activin type IIB receptor (ActRIIB) ligands and growth differentiation factor 8 (Gdf8) were neutralized with ActRIIB-Fc fusion protein and a Gdf8-specific antibody, respectively. We found that acute hepatic injury induced rapid and adverse responses in muscle, which was blunted by neutralizing ActRIIB ligands. Chronic liver injury caused muscle atrophy and repair defects, which were prevented or reversed by inactivating ActRIIB ligands. Furthermore, we found that pericentral hepatocytes produce excessive Gdf8 in injured mouse liver and cirrhotic human liver. Specific inactivation of Gdf8 prevented liver injury-induced muscle atrophy, similar to neutralization of ActRIIB ligands. Inhibition of Gdf8 also reversed muscle atrophy in a treatment paradigm following chronic liver injury. Direct injection of exogenous Gdf8 protein into muscle along with acute focal muscle injury recapitulated similar dysregulated muscle regeneration as that observed with liver injury. The results indicate that injured liver negatively communicate with the muscle largely via Gdf8. Unexpectedly, inactivation of Gdf8 simultaneously ameliorated liver fibrosis in mice following chronic liver injury. In vitro, Gdf8 induced human hepatic stellate (LX-2) cells to form a septa-like structure and stimulated expression of profibrotic factors. Our findings identified Gdf8 as a novel hepatomyokine contributing to injured liver-muscle negative crosstalk along with liver injury progression.
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Affiliation(s)
- Alexander Culver
- Department of Biology, School of Science, Center for Developmental and Regenerative Biology, Indiana University-Purdue University Indianapolis, Indianapolis, IN 46202, USA
| | - Matthew Hamang
- Department of Biology, School of Science, Center for Developmental and Regenerative Biology, Indiana University-Purdue University Indianapolis, Indianapolis, IN 46202, USA
| | - Yan Wang
- Department of Biology, School of Science, Center for Developmental and Regenerative Biology, Indiana University-Purdue University Indianapolis, Indianapolis, IN 46202, USA
| | - Huaizhou Jiang
- Department of Biology, School of Science, Center for Developmental and Regenerative Biology, Indiana University-Purdue University Indianapolis, Indianapolis, IN 46202, USA
| | - Jennifer Yanum
- Department of Biology, School of Science, Center for Developmental and Regenerative Biology, Indiana University-Purdue University Indianapolis, Indianapolis, IN 46202, USA
| | - Emily White
- Department of Biological Sciences, College of Science, Purdue University, West Lafayette, IN 46202, USA
| | - Samer Gawrieh
- Division of Gastroenterology and Hepatology, School of Medicine, Indiana University, Indianapolis, IN 46202, USA
| | - Raj K Vuppalanchi
- Division of Gastroenterology and Hepatology, School of Medicine, Indiana University, Indianapolis, IN 46202, USA
| | - Naga P Chalasani
- Division of Gastroenterology and Hepatology, School of Medicine, Indiana University, Indianapolis, IN 46202, USA
| | - Guoli Dai
- Department of Biology, School of Science, Center for Developmental and Regenerative Biology, Indiana University-Purdue University Indianapolis, Indianapolis, IN 46202, USA
| | - Benjamin C Yaden
- Department of Biology, School of Science, Center for Developmental and Regenerative Biology, Indiana University-Purdue University Indianapolis, Indianapolis, IN 46202, USA
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Coelho MPP, de Castro PASV, de Vries TP, Colosimo EA, Bezerra JMT, Rocha GA, Silva LD. Sarcopenia in chronic viral hepatitis: From concept to clinical relevance. World J Hepatol 2023; 15:649-665. [PMID: 37305369 PMCID: PMC10251280 DOI: 10.4254/wjh.v15.i5.649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/17/2023] [Accepted: 04/06/2023] [Indexed: 05/24/2023] Open
Abstract
Although the frequency of metabolic risk factors for cirrhosis and hepatocellular carcinoma (HCC) is increasing, chronic hepatitis B (CHB) and chronic hepatitis C (CHC) remain the most relevant risk factors for advanced liver disease worldwide. In addition to liver damage, hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are associated with a myriad of extrahepatic manifestations including mixed cryoglobulinaemia, lymphoproliferative disorders, renal disease, insulin resistance, type 2 diabetes, sicca syndrome, rheumatoid arthritis-like polyarthritis, and autoantibody production. Recently, the list has grown to include sarcopenia. Loss of muscle mass or muscle function is a critical feature of malnutrition in cirrhotic patients and has been found in approximately 23.0%-60.0% of patients with advanced liver disease. Nonetheless, among published studies, there is significant heterogeneity in the aetiologies of hepatic diseases and measurement methods used to determine sarcopenia. In particular, the interaction between sarcopenia, CHB and CHC has not been completely clarified in a real-world setting. Sarcopenia can result from a complex and multifaceted virus-host-environment interplay in individuals chronically infected with HBV or HCV. Thus, in the present review, we provide an overview of the concept, prevalence, clinical relevance, and potential mechanisms of sarcopenia in patients with chronic viral hepatitis, with an emphasis on clinical outcomes, which have been associated with skeletal muscle loss in these patients. A comprehensive overview of sarcopenia in individuals chronically infected with HBV or HCV, independent of the stage of the liver disease, will reinforce the necessity of an integrated medical/nutritional/physical education approach in the daily clinical care of patients with CHB and CHC.
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Affiliation(s)
- Marta Paula Pereira Coelho
- Sciences Applied to Adult Health Care Post-Graduate Programme, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Pedro Alves Soares Vaz de Castro
- Medical Undergraduate Student, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Thaís Pontello de Vries
- Sciences Applied to Adult Health Care Post-Graduate Programme, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Enrico Antônio Colosimo
- Department of Statistics, Instituto de Ciências Exatas, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Juliana Maria Trindade Bezerra
- Department of Biological Sciences, Universidade Estadual do Maranhão, Açailândia 65715-000, Maranhão, Brazil
- Post-Graduate Programme of Animal Science, Universidade Estadual do Maranhão, São Luiz do Maranhão 65.055-310, Maranhão, Brazil
| | - Gifone Aguiar Rocha
- Laboratory of Research in Bacteriology, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Luciana Diniz Silva
- Department of Internal Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
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The cytokine adsorber Cytosorb® does not reduce ammonia concentrations in critically ill patients with liver failure. Intensive Care Med 2023; 49:360-362. [PMID: 36763124 PMCID: PMC9998587 DOI: 10.1007/s00134-023-06998-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 02/11/2023]
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6
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Verma K, Zhang T, Mueller D, Li J, Sanchorawala V, Staron A. Non-producer multiple myeloma presenting with acute hyperammonemic encephalopathy: case report. Diagn Pathol 2023; 18:1. [PMID: 36597112 PMCID: PMC9811762 DOI: 10.1186/s13000-022-01285-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 12/27/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Hyperammonemic encephalopathy (HE) is a rare and life-threatening complication of multiple myeloma, with underlying mechanisms that are not fully understood. In contrast to previously reported cases, most of which have been associated with IgG or IgA isotypes, we describe a patient with HE as the presenting symptom of non-producer multiple myeloma (NPMM). CASE PRESENTATION A 60-year-old man developed lethargy that progressed into coma. He was found to have an elevated ammonia level, despite normal hepatic function. He was diagnosed with HE secondary to NPMM, demonstrating 80% plasma cells without light chain expression in the bone marrow and absence of a monoclonal protein in the serum or urine, including by matrix-assisted laser desorption ionization time-of-flight mass-spectrometry (MASS-FIX). Myeloma-directed therapy with daratumumab, bortezomib, cyclophosphamide and dexamethasone successfully reversed his HE. At clinical relapse, he received salvage chemotherapy followed by venetoclax therapy, leading to a short period of neurological recovery. CONCLUSIONS This case demonstrates that HE can occur in a patient with NPMM and challenges the mechanism suggested by limited prior studies; i.e., that excess ammonia in multiple myeloma arises from degradation of M-proteins. We postulate that the neoplastic plasma cells in NPMM have amplified amino acid metabolism, despite lacking detectable intracellular or secreted immunoglobulins.
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Affiliation(s)
- Karina Verma
- grid.239424.a0000 0001 2183 6745Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA USA
| | - Tina Zhang
- grid.239424.a0000 0001 2183 6745Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA USA
| | - David Mueller
- grid.189504.10000 0004 1936 7558Boston University Chobanian & Avedisian School of Medicine, Boston, MA USA
| | - Julie Li
- grid.239424.a0000 0001 2183 6745Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA USA
| | - Vaishali Sanchorawala
- grid.239424.a0000 0001 2183 6745Section of Hematology and Medical Oncology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA USA
| | - Andrew Staron
- grid.239424.a0000 0001 2183 6745Section of Hematology and Medical Oncology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA USA
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7
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Undifferentiated non-hepatic hyperammonemia in the ICU: Diagnosis and management. J Crit Care 2022. [DOI: 10.1016/j.jcrc.2022.154042
expr 979693480 + 932749582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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8
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Rodríguez-Agudo R, Goikoetxea-Usandizaga N, Serrano-Maciá M, Fernández-Tussy P, Fernández-Ramos D, Lachiondo-Ortega S, González-Recio I, Gil-Pitarch C, Mercado-Gómez M, Morán L, Bizkarguenaga M, Lopitz-Otsoa F, Petrov P, Bravo M, Van Liempd SM, Falcon-Perez JM, Zabala-Letona A, Carracedo A, Castell JV, Jover R, Martínez-Cruz LA, Delgado TC, Cubero FJ, Lucena MI, Andrade RJ, Mabe J, Simón J, Martínez-Chantar ML. Methionine Cycle Rewiring by Targeting miR-873-5p Modulates Ammonia Metabolism to Protect the Liver from Acetaminophen. Antioxidants (Basel) 2022; 11:897. [PMID: 35624761 PMCID: PMC9137496 DOI: 10.3390/antiox11050897] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/27/2022] [Accepted: 04/27/2022] [Indexed: 02/06/2023] Open
Abstract
Drug-induced liver injury (DILI) development is commonly associated with acetaminophen (APAP) overdose, where glutathione scavenging leads to mitochondrial dysfunction and hepatocyte death. DILI is a severe disorder without effective late-stage treatment, since N-acetyl cysteine must be administered 8 h after overdose to be efficient. Ammonia homeostasis is altered during liver diseases and, during DILI, it is accompanied by decreased glycine N-methyltransferase (GNMT) expression and S-adenosylmethionine (AdoMet) levels that suggest a reduced methionine cycle. Anti-miR-873-5p treatment prevents cell death in primary hepatocytes and the appearance of necrotic areas in liver from APAP-administered mice. In our study, we demonstrate a GNMT and methionine cycle activity restoration by the anti-miR-873-5p that reduces mitochondrial dysfunction and oxidative stress. The lack of hyperammoniemia caused by the therapy results in a decreased urea cycle, enhancing the synthesis of polyamines from ornithine and AdoMet and thus impacting the observed recovery of mitochondria and hepatocyte proliferation for regeneration. In summary, anti-miR-873-5p appears to be an effective therapy against APAP-induced liver injury, where the restoration of GNMT and the methionine cycle may prevent mitochondrial dysfunction while activating hepatocyte proliferative response.
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Affiliation(s)
- Rubén Rodríguez-Agudo
- Liver Disease Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain; (R.R.-A.); (N.G.-U.); (M.S.-M.); (P.F.-T.); (D.F.-R.); (S.L.-O.); (I.G.-R.); (C.G.-P.); (M.M.-G.); (M.B.); (F.L.-O.); (P.P.); (M.B.); (L.A.M.-C.); (T.C.D.)
| | - Naroa Goikoetxea-Usandizaga
- Liver Disease Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain; (R.R.-A.); (N.G.-U.); (M.S.-M.); (P.F.-T.); (D.F.-R.); (S.L.-O.); (I.G.-R.); (C.G.-P.); (M.M.-G.); (M.B.); (F.L.-O.); (P.P.); (M.B.); (L.A.M.-C.); (T.C.D.)
| | - Marina Serrano-Maciá
- Liver Disease Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain; (R.R.-A.); (N.G.-U.); (M.S.-M.); (P.F.-T.); (D.F.-R.); (S.L.-O.); (I.G.-R.); (C.G.-P.); (M.M.-G.); (M.B.); (F.L.-O.); (P.P.); (M.B.); (L.A.M.-C.); (T.C.D.)
| | - Pablo Fernández-Tussy
- Liver Disease Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain; (R.R.-A.); (N.G.-U.); (M.S.-M.); (P.F.-T.); (D.F.-R.); (S.L.-O.); (I.G.-R.); (C.G.-P.); (M.M.-G.); (M.B.); (F.L.-O.); (P.P.); (M.B.); (L.A.M.-C.); (T.C.D.)
| | - David Fernández-Ramos
- Liver Disease Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain; (R.R.-A.); (N.G.-U.); (M.S.-M.); (P.F.-T.); (D.F.-R.); (S.L.-O.); (I.G.-R.); (C.G.-P.); (M.M.-G.); (M.B.); (F.L.-O.); (P.P.); (M.B.); (L.A.M.-C.); (T.C.D.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain; (J.V.C.); (R.J.); (F.J.C.); (M.I.L.); (R.J.A.)
- Precision Medicine and Metabolism Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain
| | - Sofía Lachiondo-Ortega
- Liver Disease Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain; (R.R.-A.); (N.G.-U.); (M.S.-M.); (P.F.-T.); (D.F.-R.); (S.L.-O.); (I.G.-R.); (C.G.-P.); (M.M.-G.); (M.B.); (F.L.-O.); (P.P.); (M.B.); (L.A.M.-C.); (T.C.D.)
| | - Irene González-Recio
- Liver Disease Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain; (R.R.-A.); (N.G.-U.); (M.S.-M.); (P.F.-T.); (D.F.-R.); (S.L.-O.); (I.G.-R.); (C.G.-P.); (M.M.-G.); (M.B.); (F.L.-O.); (P.P.); (M.B.); (L.A.M.-C.); (T.C.D.)
| | - Clàudia Gil-Pitarch
- Liver Disease Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain; (R.R.-A.); (N.G.-U.); (M.S.-M.); (P.F.-T.); (D.F.-R.); (S.L.-O.); (I.G.-R.); (C.G.-P.); (M.M.-G.); (M.B.); (F.L.-O.); (P.P.); (M.B.); (L.A.M.-C.); (T.C.D.)
| | - María Mercado-Gómez
- Liver Disease Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain; (R.R.-A.); (N.G.-U.); (M.S.-M.); (P.F.-T.); (D.F.-R.); (S.L.-O.); (I.G.-R.); (C.G.-P.); (M.M.-G.); (M.B.); (F.L.-O.); (P.P.); (M.B.); (L.A.M.-C.); (T.C.D.)
| | - Laura Morán
- Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, Instituto de Investigación Sanitaria Gregorio Marañon (IiSGM), 28040 Madrid, Spain;
| | - Maider Bizkarguenaga
- Liver Disease Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain; (R.R.-A.); (N.G.-U.); (M.S.-M.); (P.F.-T.); (D.F.-R.); (S.L.-O.); (I.G.-R.); (C.G.-P.); (M.M.-G.); (M.B.); (F.L.-O.); (P.P.); (M.B.); (L.A.M.-C.); (T.C.D.)
- Precision Medicine and Metabolism Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain
| | - Fernando Lopitz-Otsoa
- Liver Disease Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain; (R.R.-A.); (N.G.-U.); (M.S.-M.); (P.F.-T.); (D.F.-R.); (S.L.-O.); (I.G.-R.); (C.G.-P.); (M.M.-G.); (M.B.); (F.L.-O.); (P.P.); (M.B.); (L.A.M.-C.); (T.C.D.)
- Precision Medicine and Metabolism Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain
| | - Petar Petrov
- Liver Disease Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain; (R.R.-A.); (N.G.-U.); (M.S.-M.); (P.F.-T.); (D.F.-R.); (S.L.-O.); (I.G.-R.); (C.G.-P.); (M.M.-G.); (M.B.); (F.L.-O.); (P.P.); (M.B.); (L.A.M.-C.); (T.C.D.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain; (J.V.C.); (R.J.); (F.J.C.); (M.I.L.); (R.J.A.)
- Unidad de Hepatología Experimental, Health Research Institute Hospital La Fe, Av. Fernando Abril Martorell, 46026 Valencia, Spain
- Departamento de Bioquímica y Biología Molecular, Facultad de Medicina, Universidad de Valencia, Av. de Blasco Ibáñez 15, 46010 Valencia, Spain
| | - Miren Bravo
- Liver Disease Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain; (R.R.-A.); (N.G.-U.); (M.S.-M.); (P.F.-T.); (D.F.-R.); (S.L.-O.); (I.G.-R.); (C.G.-P.); (M.M.-G.); (M.B.); (F.L.-O.); (P.P.); (M.B.); (L.A.M.-C.); (T.C.D.)
| | - Sebastiaan Martijn Van Liempd
- Metabolomics Platform, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain; (S.M.V.L.); (J.M.F.-P.)
| | - Juan Manuel Falcon-Perez
- Metabolomics Platform, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain; (S.M.V.L.); (J.M.F.-P.)
- Ikerbasque, Basque Foundation for Science, 48013 Bilbao, Spain;
| | - Amaia Zabala-Letona
- Cancer Cell Signaling and Metabolism Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain;
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, 28029 Madrid, Spain
| | - Arkaitz Carracedo
- Ikerbasque, Basque Foundation for Science, 48013 Bilbao, Spain;
- Cancer Cell Signaling and Metabolism Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain;
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, 28029 Madrid, Spain
- Traslational prostate cancer Research Lab, CIC bioGUNE-Basurto, Biocruces Bizkaia Research Health Institute, 48903 Barakaldo, Spain
| | - Jose Vicente Castell
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain; (J.V.C.); (R.J.); (F.J.C.); (M.I.L.); (R.J.A.)
- Unidad de Hepatología Experimental, Health Research Institute Hospital La Fe, Av. Fernando Abril Martorell, 46026 Valencia, Spain
- Departamento de Bioquímica y Biología Molecular, Facultad de Medicina, Universidad de Valencia, Av. de Blasco Ibáñez 15, 46010 Valencia, Spain
| | - Ramiro Jover
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain; (J.V.C.); (R.J.); (F.J.C.); (M.I.L.); (R.J.A.)
- Unidad de Hepatología Experimental, Health Research Institute Hospital La Fe, Av. Fernando Abril Martorell, 46026 Valencia, Spain
- Departamento de Bioquímica y Biología Molecular, Facultad de Medicina, Universidad de Valencia, Av. de Blasco Ibáñez 15, 46010 Valencia, Spain
| | - Luis Alfonso Martínez-Cruz
- Liver Disease Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain; (R.R.-A.); (N.G.-U.); (M.S.-M.); (P.F.-T.); (D.F.-R.); (S.L.-O.); (I.G.-R.); (C.G.-P.); (M.M.-G.); (M.B.); (F.L.-O.); (P.P.); (M.B.); (L.A.M.-C.); (T.C.D.)
| | - Teresa Cardoso Delgado
- Liver Disease Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain; (R.R.-A.); (N.G.-U.); (M.S.-M.); (P.F.-T.); (D.F.-R.); (S.L.-O.); (I.G.-R.); (C.G.-P.); (M.M.-G.); (M.B.); (F.L.-O.); (P.P.); (M.B.); (L.A.M.-C.); (T.C.D.)
| | - Francisco Javier Cubero
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain; (J.V.C.); (R.J.); (F.J.C.); (M.I.L.); (R.J.A.)
- Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, Instituto de Investigación Sanitaria Gregorio Marañon (IiSGM), 28040 Madrid, Spain;
| | - María Isabel Lucena
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain; (J.V.C.); (R.J.); (F.J.C.); (M.I.L.); (R.J.A.)
- Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga—IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29010 Malaga, Spain
- UICEC IBIMA, Plataforma ISCiii de Investigación Clínica, 28020 Madrid, Spain
| | - Raúl Jesús Andrade
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain; (J.V.C.); (R.J.); (F.J.C.); (M.I.L.); (R.J.A.)
- Unidad de Gestión Clínica de Enfermedades Digestivas, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, 29010 Malaga, Spain
| | - Jon Mabe
- IK4-Tekniker, 20600 Eibar, Spain;
| | - Jorge Simón
- Liver Disease Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain; (R.R.-A.); (N.G.-U.); (M.S.-M.); (P.F.-T.); (D.F.-R.); (S.L.-O.); (I.G.-R.); (C.G.-P.); (M.M.-G.); (M.B.); (F.L.-O.); (P.P.); (M.B.); (L.A.M.-C.); (T.C.D.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain; (J.V.C.); (R.J.); (F.J.C.); (M.I.L.); (R.J.A.)
| | - María Luz Martínez-Chantar
- Liver Disease Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Bizkaia Technology Park, Building 801A, 48160 Derio, Spain; (R.R.-A.); (N.G.-U.); (M.S.-M.); (P.F.-T.); (D.F.-R.); (S.L.-O.); (I.G.-R.); (C.G.-P.); (M.M.-G.); (M.B.); (F.L.-O.); (P.P.); (M.B.); (L.A.M.-C.); (T.C.D.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain; (J.V.C.); (R.J.); (F.J.C.); (M.I.L.); (R.J.A.)
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9
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Undifferentiated non-hepatic hyperammonemia in the ICU: Diagnosis and management. J Crit Care 2022; 70:154042. [PMID: 35447602 DOI: 10.1016/j.jcrc.2022.154042] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/17/2022] [Accepted: 04/04/2022] [Indexed: 12/25/2022]
Abstract
Hyperammonemia occurs frequently in the critically ill but is largely confined to patients with hepatic dysfunction or failure. Non-hepatic hyperammonemia (NHHA) is far less common but can be a harbinger of life-threatening diagnoses that warrant timely identification and, sometimes, empiric therapy to prevent seizures, status epilepticus, cerebral edema, coma and death; in children, permanent cognitive impairment can result. Subsets of patients are at particular risk for developing NHHA, including the organ transplant recipient. Unique etiologies include rare infections, such as with Ureaplasma species, and unmasked inborn errors of metabolism, like urea cycle disorders, must be considered in the critically ill. Early recognition and empiric therapy, including directed therapies towards these rare etiologies, is crucial to prevent catastrophic demise. We review the etiologies of NHHA and highlight the first presentation of it associated with a concurrent Ureaplasma urealyticum and Mycoplasma hominis infection in a previously healthy individual with polytrauma. Based on this clinical review, a diagnostic and treatment algorithm to identify and manage NHHA is proposed.
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10
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Horvath A, Traub J, Aliwa B, Bourgeois B, Madl T, Stadlbauer V. Oral Intake of L-Ornithine-L-Aspartate Is Associated with Distinct Microbiome and Metabolome Changes in Cirrhosis. Nutrients 2022; 14:748. [PMID: 35215398 PMCID: PMC8875633 DOI: 10.3390/nu14040748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 12/10/2022] Open
Abstract
L-ornithine L-aspartate (LOLA) is administered as a therapeutic and/or preventive strategy against hepatic encephalopathy either intravenously or orally in patients with liver cirrhosis. Here, we analyzed how LOLA influences the microbiome and metabolome of patients with liver cirrhosis. We retrospectively analyzed the stool microbiome, stool, urine and serum metabolome as well as markers for gut permeability, inflammation and muscle metabolism of 15 cirrhosis patients treated orally with LOLA for at least one month and 15 propensity-score-matched cirrhosis patients without LOLA. Results were validated by comparing the LOLA-treated patients to a second set of controls. Patients with and without LOLA were comparable in age, sex, etiology and severity of cirrhosis as well as PPI and laxative use. In the microbiome, Flavonifractor and Oscillospira were more abundant in patients treated with LOLA compared to the control group, while alpha and beta diversity were comparable between groups. Differences in stool and serum metabolomes reflected the pathophysiology of hepatic encephalopathy and confirmed LOLA intake. In the urine metabolome, ethanol to acetic acid ratio was lower in patients treated with LOLA compared to controls. LOLA-treated patients also showed lower serum levels of insulin-like growth factor (IGF) 1 than patients without LOLA. No differences in gut permeability or inflammation markers were found. A higher abundance of Flavonifractor and Oscillospira in LOLA-treated patients could indicate LOLA as a potential microbiome modulating strategy in patients with liver disease. The lower levels of IGF1 in patients treated with LOLA suggest a possible link between the pathophysiology of hepatic encephalopathy and muscle health.
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Affiliation(s)
- Angela Horvath
- Department of Gastroenterology and Hepatology, Medical University of Graz, 8036 Graz, Austria; (A.H.); (B.A.)
- Center of Biomarker Research in Medicine, CBmed GmbH Graz, 8010 Graz, Austria
| | - Julia Traub
- Department of Clinical Medical Nutrition, University Hospital Graz, 8036 Graz, Austria;
| | - Benard Aliwa
- Department of Gastroenterology and Hepatology, Medical University of Graz, 8036 Graz, Austria; (A.H.); (B.A.)
| | - Benjamin Bourgeois
- Gottfried Schatz Research Center for Cell Signaling, Metabolism and Aging Molecular Biology and Biochemistry, Medical University of Graz, 8036 Graz, Austria; (B.B.); (T.M.)
- BioTechMed-Graz, 8010 Graz, Austria
| | - Tobias Madl
- Gottfried Schatz Research Center for Cell Signaling, Metabolism and Aging Molecular Biology and Biochemistry, Medical University of Graz, 8036 Graz, Austria; (B.B.); (T.M.)
- BioTechMed-Graz, 8010 Graz, Austria
| | - Vanessa Stadlbauer
- Department of Gastroenterology and Hepatology, Medical University of Graz, 8036 Graz, Austria; (A.H.); (B.A.)
- Center of Biomarker Research in Medicine, CBmed GmbH Graz, 8010 Graz, Austria
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11
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Fox R, Stenning K, Slee A, Macnaughtan J, Davies N. Sarcopenia in liver cirrhosis: Prevalence, pathophysiology and therapeutic strategies. Anal Biochem 2022; 647:114581. [DOI: 10.1016/j.ab.2022.114581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 01/31/2022] [Indexed: 11/01/2022]
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12
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Dalsania N, Kundu S, Patti RK, Somal N, Kupfer Y. Nonhepatic Hyperammonemia With Septic Shock: Case and Review of Literature. J Investig Med High Impact Case Rep 2022; 10:23247096221101855. [PMID: 35596541 PMCID: PMC9125049 DOI: 10.1177/23247096221101855] [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] [Indexed: 11/24/2022] Open
Abstract
Elevated ammonia levels lead to cerebral edema, encephalopathy, seizures, coma, and death. Hyperammonemia is primarily associated with liver disease; however, there are rare cases without liver disease. Noncirrhotic hyperammonemia is primarily due to increased production and/or decreased elimination of ammonia. We present a rare case of a 35-year-old female with severe acute noncirrhotic hyperammonemia associated with gram-negative septic shock and a suspected undiagnosed partial urea cycle enzyme deficiency. She had elevated blood and urine amino acid levels speculated to be due to an underlying urea cycle defect, which was unmasked in the setting of septic shock with urea splitting bacteria leading to severely elevated ammonia levels. Ammonia levels were rapidly corrected with hemodialysis, as other conventional treatments failed. We highlight the importance of considering noncirrhotic causes of hyperammonemia in patients with elevated ammonia levels and intact liver function. Prompt treatment should begin with reducing the catabolic state, nitrogen scavenging, replacing urea cycle substrates, decreasing intestinal absorption, and augmented removal of ammonia with renal replacement therapy.
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13
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Ponziani FR, Picca A, Marzetti E, Calvani R, Conta G, Del Chierico F, Capuani G, Faccia M, Fianchi F, Funaro B, Josè Coelho-Junior H, Petito V, Rinninella E, Paroni Sterbini F, Reddel S, Vernocchi P, Cristina Mele M, Miccheli A, Putignani L, Sanguinetti M, Pompili M, Gasbarrini A. Characterization of the gut-liver-muscle axis in cirrhotic patients with sarcopenia. Liver Int 2021; 41:1320-1334. [PMID: 33713524 DOI: 10.1111/liv.14876] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/25/2021] [Accepted: 03/06/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIM Sarcopenia is frequent in cirrhosis and is associated with unfavourable outcomes. The role of the gut-liver-muscle axis in this setting has been poorly investigated. The aim of this study was to identify gut microbiota, metabolic and inflammatory signatures associated with sarcopenia in cirrhotic patients. METHODS Fifty cirrhotic patients assessed for the presence of sarcopenia by the quantification of muscle mass and strength were compared with age- and sex-matched controls. A multiomic analysis, including gut microbiota composition and metabolomics, serum myokines and systemic and intestinal inflammatory mediators, was performed. RESULTS The gut microbiota of sarcopenic cirrhotic patients was poor in bacteria associated with physical function (Methanobrevibacter, Prevotella and Akkermansia), and was enriched in Eggerthella, a gut microbial marker of frailty. The abundance of potentially pathogenic bacteria, such as Klebsiella, was also increased, to the detriment of autochthonous ones. Sarcopenia was associated with elevated serum levels of pro-inflammatory mediators and of fibroblast growth factor 21 (FGF21) in cirrhotic patients. Gut microbiota metabolic pathways involved in amino acid, protein and branched-chain amino acid metabolism were up-regulated, in addition to ethanol, trimethylamine and dimethylamine production. Correlation networks and clusters of variables associated with sarcopenia were identified, including one centred on Klebsiella/ethanol/FGF21/Eggerthella/Prevotella. CONCLUSIONS Alterations in the gut-liver-muscle axis are associated with sarcopenia in patients with cirrhosis. Detrimental but also compensatory functions are involved in this complex network.
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Affiliation(s)
- Francesca Romana Ponziani
- Internal Medicine and Gastroenterology - Liver Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Anna Picca
- Department of Geriatrics, Neuroscience and Orthopedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Emanuele Marzetti
- Department of Geriatrics, Neuroscience and Orthopedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Riccardo Calvani
- Department of Geriatrics, Neuroscience and Orthopedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Giorgia Conta
- Department of Chemistry, Sapienza University of Rome, Rome, Italy
| | - Federica Del Chierico
- Area of Genetics and Rare Diseases, Unit of Human Microbiome, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giorgio Capuani
- Department of Chemistry, Sapienza University of Rome, Rome, Italy.,Area of Genetics and Rare Diseases, Unit of Human Microbiome, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,NMR-based Metabolomics Laboratory, Sapienza University of Rome, Rome, Italy
| | - Mariella Faccia
- Internal Medicine and Gastroenterology - Liver Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesca Fianchi
- Internal Medicine and Gastroenterology - Liver Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Barbara Funaro
- Internal Medicine and Gastroenterology - Liver Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Helio Josè Coelho-Junior
- Department of Geriatrics, Neuroscience and Orthopedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Valentina Petito
- Internal Medicine and Gastroenterology - Liver Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Emanuele Rinninella
- Clinical Nutrition, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Sofia Reddel
- Area of Genetics and Rare Diseases, Unit of Human Microbiome, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pamela Vernocchi
- Area of Genetics and Rare Diseases, Unit of Human Microbiome, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Maria Cristina Mele
- Advanced Nutrition in Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alfredo Miccheli
- NMR-based Metabolomics Laboratory, Sapienza University of Rome, Rome, Italy.,Clinical Nutrition, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Microbiology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Advanced Nutrition in Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Department of Environmental Biology, Sapienza University of Rome, Rome, Italy
| | - Lorenza Putignani
- Department of Laboratories, Unit of Parasitology and Area of Genetics and Rare Diseases, Unit of Human Microbiome, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Maurizio Sanguinetti
- Microbiology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Maurizio Pompili
- Internal Medicine and Gastroenterology - Liver Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Internal Medicine and Gastroenterology - Liver Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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14
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Kim Y. Emerging Treatment Options for Sarcopenia in Chronic Liver Disease. Life (Basel) 2021; 11:life11030250. [PMID: 33803020 PMCID: PMC8002763 DOI: 10.3390/life11030250] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/13/2021] [Accepted: 03/15/2021] [Indexed: 12/17/2022] Open
Abstract
Sarcopenia is characterized by a skeletal muscle disorder with progressive and generalized loss of muscle mass and function, and it increases the risk of adverse outcomes with considerable prevalence in patients with chronic liver disease. Sarcopenia in chronic liver disease underlies complicated and multifactorial mechanisms for pathogenesis, including alterations in protein turnover, hyperammonemia, energy disposal, hormonal changes, and chronic inflammation. The key contribution to sarcopenia in patients with chronic liver diseases can be the hyperammonemia-induced upregulation of myostatin, which causes muscle atrophy via the expression of atrophy-related genes. Several clinical studies on emerging treatment options for sarcopenia have been reported, but only a few have focused on patients with chronic liver diseases, with mostly nutritional and behavioral interventions being carried out. The inhibition of the myostatin-activin receptor signaling pathway and hormonal therapy might be the most promising therapeutic options in combination with an ammonia-lowering approach in sarcopenic patients with chronic liver diseases. This review focuses on current and emerging treatment options for sarcopenia in chronic liver diseases with underlying mechanisms to counteract this condition.
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Affiliation(s)
- Yun Kim
- Hanyang Medicine-Engineering-Bio Collaborative & Comprehensive Center for Drug Development, Hanyang University, Seoul 04763, Korea
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15
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Hongxing G, Xiafei L, Jialing L, Zhenquan C, Luoyu G, Lei L, Yuxuan S, Zhiguo D, Min W. Effects of acute ammonia exposure on antioxidant and detoxification metabolism in clam Cyclina sinensis. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2021; 211:111895. [PMID: 33476851 DOI: 10.1016/j.ecoenv.2021.111895] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/15/2020] [Accepted: 01/03/2021] [Indexed: 06/12/2023]
Abstract
To investigate the defensive strategies of clam Cyclina sinensis in response to environmental ammonia exposure, we investigate the 96 h median lethal concentration (LC50-96 h) and the 96 h safe concentration (SC) of total ammonia nitrogen (TAN) for C. sinensis, and on the basis we examined glutamine synthetase (GS) activity, glutamine content, urea content and the antioxidant enzyme activities of super oxide dismutase (SOD) and catalase (CAT) in 96 h at three different levels of TAN as 0 (control), 73.94 (T1) and 227.04 mg/L (T2). Results showed that LC50-96 h and SC for C. sinensis were 65.79 and 6.58 mg/L, respectively. The LC50-96 h and SC of NH3 were 1.70 and 0.17 mg/L, respectively. Ammonia exposure had significantly effects on SOD and CAT activities in the hepatopancreas tissue. Both the level of SOD activity and CAT activity increased with increasing concentration of TAN. No significant differences between T1 and T2 were found in GS activity from 3 h to 96 h after exposed to ammonia, whereas they were significantly higher than those in the control. Both the level of glutamine content in T1 and T2 increased significantly from 6 h to 24 h after exposed to ammonia and they were significantly higher than those in the control. There were no significantly differences were found in the level of urea concentration between T1 and T2 from 6 h to 96 h, while they were significantly higher those in the control. In conclusion, enhancing hepatopancreas antioxidant responses as well as converting ammonia into glutamine and urea worked in combination to allow C. sinensi to defend against acute ammonia exposure.
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Affiliation(s)
- Ge Hongxing
- Jiangsu Key Laboratory of Marine Bioresources and Environment, Jiangsu Ocean University, Lianyungang, Jiangsu Province 222005, China; Jiangsu Key Laboratory of Marine Biotechnolog, Jiangsu Ocean University, Lianyungang, Jiangsu Province 222005, China; Co-Innovation Center of Jiangsu Marine Bio-industry Technology, Jiangsu Ocean University, Lianyungang, Jiangsu Province 222005, China
| | - Liang Xiafei
- Jiangsu Key Laboratory of Marine Bioresources and Environment, Jiangsu Ocean University, Lianyungang, Jiangsu Province 222005, China
| | - Liu Jialing
- Jiangsu Key Laboratory of Marine Bioresources and Environment, Jiangsu Ocean University, Lianyungang, Jiangsu Province 222005, China
| | - Cui Zhenquan
- Jiangsu Key Laboratory of Marine Bioresources and Environment, Jiangsu Ocean University, Lianyungang, Jiangsu Province 222005, China
| | - Guo Luoyu
- Jiangsu Key Laboratory of Marine Bioresources and Environment, Jiangsu Ocean University, Lianyungang, Jiangsu Province 222005, China
| | - Li Lei
- Jiangsu Key Laboratory of Marine Bioresources and Environment, Jiangsu Ocean University, Lianyungang, Jiangsu Province 222005, China
| | - Sun Yuxuan
- Jiangsu Key Laboratory of Marine Bioresources and Environment, Jiangsu Ocean University, Lianyungang, Jiangsu Province 222005, China
| | - Dong Zhiguo
- Jiangsu Key Laboratory of Marine Bioresources and Environment, Jiangsu Ocean University, Lianyungang, Jiangsu Province 222005, China.
| | - Wei Min
- Jiangsu Key Laboratory of Marine Bioresources and Environment, Jiangsu Ocean University, Lianyungang, Jiangsu Province 222005, China
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16
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Allen SL, Quinlan JI, Dhaliwal A, Armstrong MJ, Elsharkawy AM, Greig CA, Lord JM, Lavery GG, Breen L. Sarcopenia in chronic liver disease: mechanisms and countermeasures. Am J Physiol Gastrointest Liver Physiol 2021; 320:G241-G257. [PMID: 33236953 PMCID: PMC8609568 DOI: 10.1152/ajpgi.00373.2020] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Sarcopenia, a condition of low muscle mass, quality, and strength, is commonly found in patients with cirrhosis and is associated with adverse clinical outcomes including reduction in quality of life, increased mortality, and posttransplant complications. In chronic liver disease (CLD), sarcopenia is most commonly defined through the measurement of the skeletal muscle index of the third lumbar spine. A major contributor to sarcopenia in CLD is the imbalance in muscle protein turnover, which likely occurs due to a decrease in muscle protein synthesis and an elevation in muscle protein breakdown. This imbalance is assumed to arise due to several factors including accelerated starvation, hyperammonemia, amino acid deprivation, chronic inflammation, excessive alcohol intake, and physical inactivity. In particular, hyperammonemia is a key mediator of the liver-gut axis and is known to contribute to mitochondrial dysfunction and an increase in myostatin expression. Currently, the use of nutritional interventions such as late-evening snacks, branched-chain amino acid supplementation, and physical activity have been proposed to help the management and treatment of sarcopenia. However, little evidence exists to comprehensively support their use in clinical settings. Several new pharmacological strategies, including myostatin inhibition and the nutraceutical Urolithin A, have recently been proposed to treat age-related sarcopenia and may also be of use in CLD. This review highlights the potential molecular mechanisms contributing to sarcopenia in CLD alongside a discussion of existing and potential new treatment strategies.
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Affiliation(s)
- Sophie L. Allen
- 1School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom,2National Institute for Health Research, Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Jonathan I. Quinlan
- 1School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom,2National Institute for Health Research, Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Amritpal Dhaliwal
- 2National Institute for Health Research, Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom,3Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom,4Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Matthew J. Armstrong
- 2National Institute for Health Research, Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom,4Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Ahmed M. Elsharkawy
- 2National Institute for Health Research, Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom,3Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom,4Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Carolyn A. Greig
- 1School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom,2National Institute for Health Research, Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom,5MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, University of Birmingham, Birmingham, United Kingdom
| | - Janet M. Lord
- 2National Institute for Health Research, Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom,3Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom,5MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, University of Birmingham, Birmingham, United Kingdom
| | - Gareth G. Lavery
- 2National Institute for Health Research, Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom,6Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom,7Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partner, Birmingham, United Kingdom
| | - Leigh Breen
- 1School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom,2National Institute for Health Research, Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom,5MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, University of Birmingham, Birmingham, United Kingdom
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17
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Kelly VW, Liang BK, Sirk SJ. Living Therapeutics: The Next Frontier of Precision Medicine. ACS Synth Biol 2020; 9:3184-3201. [PMID: 33205966 DOI: 10.1021/acssynbio.0c00444] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Modern medicine has long studied the mechanism and impact of pathogenic microbes on human hosts, but has only recently shifted attention toward the complex and vital roles that commensal and probiotic microbes play in both health and dysbiosis. Fueled by an enhanced appreciation of the human-microbe holobiont, the past decade has yielded countless insights and established many new avenues of investigation in this area. In this review, we discuss advances, limitations, and emerging frontiers for microbes as agents of health maintenance, disease prevention, and cure. We highlight the flexibility of microbial therapeutics across disease states, with special consideration for the rational engineering of microbes toward precision medicine outcomes. As the field advances, we anticipate that tools of synthetic biology will be increasingly employed to engineer functional living therapeutics with the potential to address longstanding limitations of traditional drugs.
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Affiliation(s)
- Vince W. Kelly
- Department of Bioengineering, University of Illinois at Urbana−Champaign, Urbana, Illinois 61801, United States
| | - Benjamin K. Liang
- Department of Bioengineering, University of Illinois at Urbana−Champaign, Urbana, Illinois 61801, United States
| | - Shannon J. Sirk
- Department of Bioengineering, University of Illinois at Urbana−Champaign, Urbana, Illinois 61801, United States
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18
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Lee YS, Choi YJ, Park KH, Park BS, Son JM, Park JY, Ri HS, Ryu JH. Liver Transplant Patients with High Levels of Preoperative Serum Ammonia Are at Increased Risk for Postoperative Acute Kidney Injury: A Retrospective Study. J Clin Med 2020; 9:jcm9061629. [PMID: 32481585 PMCID: PMC7356740 DOI: 10.3390/jcm9061629] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/18/2020] [Accepted: 05/18/2020] [Indexed: 01/09/2023] Open
Abstract
Acute kidney injury (AKI) is one of the most frequent postoperative complications after liver transplantation (LT). Increased serum ammonia levels due to the liver disease itself may affect postoperative renal function. This study aimed to compare the incidence of postoperative AKI according to preoperative serum ammonia levels in patients after LT. Medical records from 436 patients who underwent LT from January 2010 to February 2020 in a single university hospital were retrospectively reviewed. The patients were then categorized according to changes in plasma creatinine concentrations within 48 h of LT using the Acute Kidney Injury Network criteria. A preoperative serum ammonia level above 45 mg/dL was associated with postoperative AKI (p < 0.0001). Even in patients with a normal preoperative creatinine level, when the ammonia level was greater than 45 μg/dL, the incidence of postoperative AKI was significantly higher (p < 0.0001); the AKI stage was also higher in this group than in the group with preoperative ammonia levels less than or equal to 45 μg/dL (p < 0.0001). Based on the results of our research, an elevation in preoperative serum ammonia levels above 45 μg/dL is related to postoperative AKI after LT.
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Affiliation(s)
- Yoon Sook Lee
- Department of Anaesthesiology and Pain Medicine, Ansan Hospital, Korea University, College of Medicine, Ansan 15355, Korea; (Y.S.L.); (B.S.P.)
| | - Yoon Ji Choi
- Department of Anaesthesiology and Pain Medicine, Ansan Hospital, Korea University, College of Medicine, Ansan 15355, Korea; (Y.S.L.); (B.S.P.)
- Correspondence: ; Tel.: +82-10-7900-7825
| | - Kyu Hee Park
- Department of Pediatrics, Korea University Hospital, Ansan 15355, Korea;
| | - Byeong Seon Park
- Department of Anaesthesiology and Pain Medicine, Ansan Hospital, Korea University, College of Medicine, Ansan 15355, Korea; (Y.S.L.); (B.S.P.)
| | - Jung-Min Son
- Department of Biostatistics, Clinical Trial Center, Biomedical Research Institute, Pusan National University Hospital, Pusan 49241, Korea;
| | - Ju Yeon Park
- Department of Anesthesiology and Pain Medicine, Daedong Hospital, Busan 47737, Korea;
| | - Hyun-Su Ri
- Department of Anaesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan 50612, Korea;
| | - Je Ho Ryu
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan 50612, Korea;
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19
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Barbero-Becerra VJ, López-Méndez I, Romo-Araiza A, Visag-Castillo V, Chávez-Tapia NC, Uribe M, Juárez-Hernandez E. Sarcopenia in chronic liver diseases: a translational overview. Expert Rev Gastroenterol Hepatol 2020; 14:355-366. [PMID: 32299261 DOI: 10.1080/17474124.2020.1757427] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Sarcopenia refers to a progressive and generalized muscle mass and strength loss. In liver diseases, it has been related to worse outcomes and high risk of decompensations. AREAS COVERED Sarcopenia is caused by a set of cellular processes in the muscle such as denervation, mitochondrial dysfunction, endotoxemia and inflammation; which are manifested through the alteration of several proteolytic pathways such as lysosomal, proteasomal and caspase systems. In autophagy, myostatin and oxidative stress; such as hyperammonemia, contributes importantly to liver sarcopenia through loss of muscle mass already demonstrated in in vitro and in vivo models. In addition, hormones and the regulation of the intestinal microbiota, influence in a not less important magnitude. In the clinical setting, early identification of sarcopenia has been established as a mandatory item to prevent progression of muscle mass loss; however, diagnostic methods have extreme variation according to methodology, population, etiology and severity of liver disease. Reversing sarcopenia should be an integral therapeutic strategy. EXPERT OPINION Clinical and nutritional interventions should be adapted to liver injury etiology and stage of disease, each of them shares a similar sarcopenia development pathway. There are specific biomarkers that condition or exacerbate loss of skeletal muscle.
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Affiliation(s)
| | - Iván López-Méndez
- Transplants and Hepatology Unit, Medica Sur Clinic & Foundation , Mexico City, Mexico
| | | | - Víctor Visag-Castillo
- Gastroenterology and Obesity Unit, Medica Sur Clinic & Foundation , Mexico City, Mexico
| | - Norberto C Chávez-Tapia
- Translational Research Unit, Medica Sur Clinic & Foundation , Mexico City, Mexico.,Gastroenterology and Obesity Unit, Medica Sur Clinic & Foundation , Mexico City, Mexico
| | - Misael Uribe
- Gastroenterology and Obesity Unit, Medica Sur Clinic & Foundation , Mexico City, Mexico
| | - Eva Juárez-Hernandez
- Translational Research Unit, Medica Sur Clinic & Foundation , Mexico City, Mexico.,Facultad de Ciencias de la Salud, Universidad Anáhuac México , Mexico City, Mexico
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20
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Kurtz CB, Millet YA, Puurunen MK, Perreault M, Charbonneau MR, Isabella VM, Kotula JW, Antipov E, Dagon Y, Denney WS, Wagner DA, West KA, Degar AJ, Brennan AM, Miller PF. An engineered E. coli Nissle improves hyperammonemia and survival in mice and shows dose-dependent exposure in healthy humans. Sci Transl Med 2020; 11:11/475/eaau7975. [PMID: 30651324 DOI: 10.1126/scitranslmed.aau7975] [Citation(s) in RCA: 198] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 10/08/2018] [Accepted: 12/19/2018] [Indexed: 12/30/2022]
Abstract
The intestine is a major source of systemic ammonia (NH3); thus, capturing part of gut NH3 may mitigate disease symptoms in conditions of hyperammonemia such as urea cycle disorders and hepatic encephalopathy. As an approach to the lowering of blood ammonia arising from the intestine, we engineered the orally delivered probiotic Escherichia coli Nissle 1917 to create strain SYNB1020 that converts NH3 to l-arginine (l-arg). We up-regulated arginine biosynthesis in SYNB1020 by deleting a negative regulator of l-arg biosynthesis and inserting a feedback-resistant l-arg biosynthetic enzyme. SYNB1020 produced l-arg and consumed NH3 in an in vitro system. SYNB1020 reduced systemic hyperammonemia, improved survival in ornithine transcarbamylase-deficient spfash mice, and decreased hyperammonemia in the thioacetamide-induced liver injury mouse model. A phase 1 clinical study was conducted including 52 male and female healthy adult volunteers. SYNB1020 was well tolerated at daily doses of up to 1.5 × 1012 colony-forming units administered for up to 14 days. A statistically significant dose-dependent increase in urinary nitrate, plasma 15N-nitrate (highest dose versus placebo, P = 0.0015), and urinary 15N-nitrate was demonstrated, indicating in vivo SYNB1020 activity. SYNB1020 concentrations reached steady state by the second day of dosing, and excreted cells were alive and metabolically active as evidenced by fecal arginine production in response to added ammonium chloride. SYNB1020 was no longer detectable in feces 2 weeks after the last dose. These results support further clinical development of SYNB1020 for hyperammonemia disorders including urea cycle disorders and hepatic encephalopathy.
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Affiliation(s)
| | - Yves A Millet
- Synlogic Inc., 301 Binney Street, Cambridge, MA 02142, USA
| | | | | | | | | | | | - Eugene Antipov
- Synlogic Inc., 301 Binney Street, Cambridge, MA 02142, USA
| | - Yossi Dagon
- Synlogic Inc., 301 Binney Street, Cambridge, MA 02142, USA
| | | | - David A Wagner
- Metabolic Solutions Inc., 460 Amherst Street, Nashua, NH 03063, USA
| | - Kip A West
- Synlogic Inc., 301 Binney Street, Cambridge, MA 02142, USA
| | | | | | - Paul F Miller
- Synlogic Inc., 301 Binney Street, Cambridge, MA 02142, USA
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21
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MRI Findings in Acute Hyperammonemic Encephalopathy: Three Cases of Different Etiologies: Teaching Point: To recognize MRI findings in acute hyperammonemic encephalopathy. J Belg Soc Radiol 2020; 104:9. [PMID: 32025625 PMCID: PMC6993592 DOI: 10.5334/jbsr.2017] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Acute hyperammonemic encephalopathy is a rare but life-threatening condition that might complicate liver disease as well as non-hepatic conditions. It can lead to coma and death, secondary to brain edema and intracranial hypertension. We present three cases of acute hyperammonemic encephalopathy of different etiologies and the observed brain MRI findings. Symmetrical extensive cortical signal abnormalities, typically involving the insular and cingulate cortices, often showing restricted diffusion, are commonly described. These specific imaging features should be recognized by the radiologist since prompt treatment of the condition is paramount.
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22
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Soria LR, Nitzahn M, Angelis AD, Khoja S, Attanasio S, Annunziata P, Palmer DJ, Ng P, Lipshutz GS, Brunetti-Pierri N. Hepatic glutamine synthetase augmentation enhances ammonia detoxification. J Inherit Metab Dis 2019; 42:1128-1135. [PMID: 30724386 PMCID: PMC6684872 DOI: 10.1002/jimd.12070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 01/28/2019] [Indexed: 12/18/2022]
Abstract
The urea cycle and glutamine synthetase (GS) are the two main pathways for waste nitrogen removal and their deficiency results in hyperammonemia. Here, we investigated the efficacy of liver-specific GS overexpression for therapy of hyperammonemia. To achieve hepatic GS overexpression, we generated a helper-dependent adenoviral (HDAd) vector expressing the murine GS under the control of a liver-specific expression cassette (HDAd-GS). Compared to mice injected with a control vector expressing an unrelated reporter gene (HDAd-alpha-fetoprotein), wild-type mice with increased hepatic GS showed reduced blood ammonia levels and a concomitant increase of blood glutamine after intraperitoneal injections of ammonium chloride, whereas blood urea was unaffected. Moreover, injection of HDAd-GS reduced blood ammonia levels at baseline and protected against acute hyperammonemia following ammonia challenge in a mouse model with conditional hepatic deficiency of carbamoyl phosphate synthetase 1 (Cps1), the initial and rate-limiting step of ureagenesis. In summary, we found that upregulation of hepatic GS reduced hyperammonemia in wild-type and Cps1-deficient mice, thus confirming a key role of GS in ammonia detoxification. These results suggest that hepatic GS augmentation therapy has potential for treatment of both primary and secondary forms of hyperammonemia.
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Affiliation(s)
| | - Matthew Nitzahn
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, United States
- Molecular Biology Institute at UCLA, Los Angeles, United States
| | | | - Suhail Khoja
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, United States
- Molecular Biology Institute at UCLA, Los Angeles, United States
| | | | | | - Donna J. Palmer
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, United States
| | - Philip Ng
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, United States
| | - Gerald S. Lipshutz
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, United States
- Molecular Biology Institute at UCLA, Los Angeles, United States
| | - Nicola Brunetti-Pierri
- Telethon Institute of Genetics and Medicine, Pozzuoli, Italy
- Department of Translational Medicine, Federico II University, Naples, Italy
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23
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Leidi A, Pisaturo M, Fumeaux T. Malnutrition-related hyperammonemic encephalopathy presenting with burst suppression: a case report. J Med Case Rep 2019; 13:248. [PMID: 31399120 PMCID: PMC6689163 DOI: 10.1186/s13256-019-2185-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 07/02/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Hyperammonemia is a common cause of metabolic encephalopathy, mainly related to hepatic cirrhosis. Numerous nonhepatic etiologies exist but they are infrequent and not well known, thus, leading to misdiagnosis and inadequate care. Electroencephalography has a proven diagnostic and prognostic role in comatose patients. Burst suppression is a preterminal pattern found in deep coma states and is rarely associated with metabolic causes. CASE PRESENTATION We report the case of an 81-year-old Caucasian man presenting with rapidly progressive somnolence and mutism. Soon after his arrival in our hospital, he developed profound coma. A comprehensive diagnostic workup was unremarkable except for admission electroencephalography showing diffuse slowing of cerebral activity with an intermittent pattern of burst suppression. He was admitted to our intensive care unit for supportive care where malnutrition-related hyperammonemia was diagnosed. His clinical course was spontaneously favorable and follow-up electroencephalography demonstrated normal cerebral activity. CONCLUSIONS Nonhepatic hyperammonemia is a rare and potentially reversible cause of encephalopathy. Ammonia level measurement should be part of the diagnostic workup in patients with unexplained coma, particularly in the setting of nutritional deficiencies or nutritional supply. Detection of diffuse and nonspecific mild to moderate slowing of cerebral activity (theta-delta ranges) on electroencephalography is common. In contrast, to the best of our knowledge, burst suppression has never been described in association with hyperammonemia.
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Affiliation(s)
- Antonio Leidi
- Department of Internal Medicine, GHOL-Nyon Hospital, Chemin Monastier 10, 1260, Nyon, Switzerland.
| | - Marisa Pisaturo
- Department of Internal Medicine, GHOL-Nyon Hospital, Chemin Monastier 10, 1260, Nyon, Switzerland
| | - Thierry Fumeaux
- Department of Internal Medicine and Critical Care Medicine, GHOL-Nyon Hospital, Chemin Monastier 10, 1260, Nyon, Switzerland
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24
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Golshani M, Basiri M, Shabani M, Aghaei I, Asadi-Shekaari M. Effects of erythropoietin on bile duct ligation-induced neuro-inflammation in male rats. AIMS Neurosci 2019; 6:43-53. [PMID: 32341967 PMCID: PMC7179341 DOI: 10.3934/neuroscience.2019.2.43] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 03/18/2019] [Indexed: 01/11/2023] Open
Abstract
Hepatic encephalopathy (HE) is a brain disorder as a result of liver failure. Previous studies have indicated that erythropoietin (EPO) has neuroprotective effects in different neurological diseases. This study addressed the therapeutic effect of a four-week treatment with EPO on neuronal damages in bile duct-ligated rats. Forty male Wistar rats (250–280 g) were used in the present study. The animals were randomly divided into four groups consisting of 10 animals each, including sham, sham + EPO, bile duct ligation (BDL), and BDL + EPO. EPO was intraperitoneally administered every other day (5,000 U/Kg) in the last four weeks after BDL. Biochemical and histological studies were performed to evaluate neurodegeneration. The results revealed that BDL increases the level of hepatic enzymes and total bilirubin. Furthermore, neurodegeneration was significantly increased in the BDL group compared to sham groups. EPO preserved hepatic enzymes and total bilirubin in the treated group. In addition, EPO significantly decreased the neurodegeneration in BDL + EPO compared to the BDL group. Results of this study showed that EPO has neuroprotective effects in the rat model of HE, possibly due to its anti-inflammatory and anti-oxidant properties. Complementary studies are required to clarify the exact mechanisms.
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Affiliation(s)
- Moazameh Golshani
- Department of Anatomical Sciences, Afzalipour School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohsen Basiri
- Neuroscience Research Center, Neuropharmacology Institute, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohammad Shabani
- Neuroscience Research Center, Neuropharmacology Institute, Kerman University of Medical Sciences, Kerman, Iran
| | - Iraj Aghaei
- Neuroscience Research Center, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Majid Asadi-Shekaari
- Neuroscience Research Center, Neuropharmacology Institute, Kerman University of Medical Sciences, Kerman, Iran
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25
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Seethapathy H, Fenves AZ. Pathophysiology and Management of Hyperammonemia in Organ Transplant Patients. Am J Kidney Dis 2019; 74:390-398. [PMID: 31040091 DOI: 10.1053/j.ajkd.2019.03.419] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 03/04/2019] [Indexed: 01/28/2023]
Abstract
Neurologic complications are common after solid-organ transplantation, occurring in one-third of patients. Immunosuppression-related neurotoxicity (involving calcineurin inhibitors and corticosteroids), opportunistic central nervous system infections, seizures, and delirium are some of the causes of neurologic symptoms following solid-organ transplantation. An uncommon often missed complication posttransplantation involves buildup of ammonia levels that can lead to rapid clinical deterioration even when treated. Ammonia levels are not routinely checked due to the myriad of other explanations for encephalopathy in a transplant recipient. A treatment of choice for severe hyperammonemia involves renal replacement therapy (RRT), but there are no guidelines on the mode or parameters of RRT for reducing ammonia levels. Hyperammonemia in a transplant recipient poses specific challenges beyond the actual condition because the treatment (RRT) involves significant hemodynamic fluctuations that may affect the graft. In this review, we describe a patient with posttransplantation hyperammonemia and discuss the pathways of ammonia metabolism, potential factors underlying the development of hyperammonemia posttransplantation, and choice of appropriate therapeutic options in these patients.
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Affiliation(s)
- Harish Seethapathy
- Division of Nephrology, Department of Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
| | - Andrew Z Fenves
- Division of Nephrology, Department of Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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26
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Jindal A, Jagdish RK. Sarcopenia: Ammonia metabolism and hepatic encephalopathy. Clin Mol Hepatol 2019; 25:270-279. [PMID: 31006226 PMCID: PMC6759436 DOI: 10.3350/cmh.2019.0015] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/07/2019] [Indexed: 12/15/2022] Open
Abstract
Sarcopenia (loss of muscle mass and/or strength) frequently complicates liver cirrhosis and adversely affects the quality of life; cirrhosis related liver decompensation and significantly decreases wait-list and post-liver transplantation survival. The main therapeutic strategies to improve or reverse sarcopenia include dietary interventions (supplemental calorie and protein intake), increased physical activity (supervised resistance and endurance exercises), hormonal therapy (testosterone), and ammonia lowering agents (L-ornithine L-aspartate, branch chain amino acids) as well as mechanistic approaches that target underlying molecular and metabolic abnormalities. Besides other factors, hyperammonemia has recently gained attention and increase sarcopenia by various mechanisms including increased expression of myostatin, increased phosphorylation of eukaryotic initiation factor 2a, cataplerosis of α ketoglutarate, mitochondrial dysfunction, increased reactive oxygen species that decrease protein synthesis and increased autophagy-mediated proteolysis. Sarcopenia contributes to frailty and increases the risk of minimal and overt hepatic encephalopathy.
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Affiliation(s)
- Ankur Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakesh Kumar Jagdish
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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27
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Asensio I, Vaquero J. Growing muscle against cirrhosis: In the quest for models to revealing mechanisms. Liver Int 2019; 39:625-627. [PMID: 30916864 DOI: 10.1111/liv.14032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/13/2018] [Indexed: 02/13/2023]
Affiliation(s)
- Iris Asensio
- Laboratorio de Investigación en Hepatología y Gastroenterología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Javier Vaquero
- Laboratorio de Investigación en Hepatología y Gastroenterología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
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28
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Kant S, Davuluri G, Alchirazi KA, Welch N, Heit C, Kumar A, Gangadhariah M, Kim A, McMullen MR, Willard B, Luse DS, Nagy LE, Vasiliou V, Marini AM, Weiner ID, Dasarathy S. Ethanol sensitizes skeletal muscle to ammonia-induced molecular perturbations. J Biol Chem 2019; 294:7231-7244. [PMID: 30872403 DOI: 10.1074/jbc.ra118.005411] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 03/12/2019] [Indexed: 12/27/2022] Open
Abstract
Ethanol causes dysregulated muscle protein homeostasis while simultaneously causing hepatocyte injury. Because hepatocytes are the primary site for physiological disposal of ammonia, a cytotoxic cellular metabolite generated during a number of metabolic processes, we determined whether hyperammonemia aggravates ethanol-induced muscle loss. Differentiated murine C2C12 myotubes, skeletal muscle from pair-fed or ethanol-treated mice, and human patients with alcoholic cirrhosis and healthy controls were used to quantify protein synthesis, mammalian target of rapamycin complex 1 (mTORC1) signaling, and autophagy markers. Alcohol-metabolizing enzyme expression and activity in mouse muscle and myotubes and ureagenesis in hepatocytes were quantified. Expression and regulation of the ammonia transporters, RhBG and RhCG, were quantified by real-time PCR, immunoblots, reporter assays, biotin-tagged promoter pulldown with proteomics, and loss-of-function studies. Alcohol and aldehyde dehydrogenases were expressed and active in myotubes. Ethanol exposure impaired hepatocyte ureagenesis, induced muscle RhBG expression, and elevated muscle ammonia concentrations. Simultaneous ethanol and ammonia treatment impaired protein synthesis and mTORC1 signaling and increased autophagy with a consequent decreased myotube diameter to a greater extent than either treatment alone. Ethanol treatment and withdrawal followed by ammonia exposure resulted in greater impairment in muscle signaling and protein synthesis than ammonia treatment in ethanol-naive myotubes. Of the three transcription factors that were bound to the RhBG promoter in response to ethanol and ammonia, DR1/NC2 indirectly regulated transcription of RhBG during ethanol and ammonia treatment. Direct effects of ethanol were synergistic with increased ammonia uptake in causing dysregulated skeletal muscle proteostasis and signaling perturbations with a more severe sarcopenic phenotype.
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Affiliation(s)
- Sashi Kant
- From the Departments of Inflammation and Immunity
| | | | | | - Nicole Welch
- From the Departments of Inflammation and Immunity
| | - Claire Heit
- the Department of Pharmaceutical Sciences, School of Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, Colorado 80045
| | | | | | - Adam Kim
- From the Departments of Inflammation and Immunity
| | | | - Belinda Willard
- Metabolomic and Proteomics Core, Cleveland Clinic, Cleveland, Ohio 44195
| | | | - Laura E Nagy
- From the Departments of Inflammation and Immunity
| | - Vasilis Vasiliou
- the Department of Environmental Health Sciences, Yale School of Public Health, New Haven, Connecticut 06510
| | - Anna Maria Marini
- the Biology of Membrane Transport Laboratory, Department of Molecular Biology, Institut de Biologie et de Médecine Moléculaires (IBMM), Université Libre de Bruxelles CP300, 6041 Gosselies, Belgium
| | - I David Weiner
- the Division of Nephrology, Hypertension, and Renal Transplantation, Department of Medicine, School of Medicine, University of Florida, Gainesville, Florida 32610, and.,the Nephrology and Hypertension Section, North Florida/South Georgia Veterans Health System, Gainesville, Florida 32608
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29
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Liu T, Zhou J, Cui H, Li P, Li H, Wang Y, Tang T. Quantitative proteomic analysis of intracerebral hemorrhage in rats with a focus on brain energy metabolism. Brain Behav 2018; 8:e01130. [PMID: 30307711 PMCID: PMC6236229 DOI: 10.1002/brb3.1130] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 08/31/2018] [Accepted: 09/05/2018] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Intracerebral hemorrhage (ICH) is a lethal cerebrovascular disorder with a high mortality and morbidity. The pathophysiological mechanisms underlying ICH-induced secondary injury remain unclear. METHODS To examine one of the gaps in the knowledge about ICH pathological mechanisms, isobaric tag for relative and absolute quantification (iTRAQ)-based liquid chromatography-tandem mass spectrometry (LC-MS/MS) was used in collagenase-induced ICH rats on the 2nd day. RESULTS A total of 6,456 proteins were identified with a 1% false discovery rate (FDR). Of these proteins, 126 and 75 differentially expressed proteins (DEPs) were substantially increased and decreased, respectively. Based on Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and STRING analyses, the protein changes in cerebral hemorrhage were comprehensively evaluated, and the energy metabolism in ICH was anchored. The core position of the nitrogen metabolism pathway in brain metabolism in ICH was found for the first time. Carbonic anhydrase 1 (Ca1), carbonic anhydrase 2 (Ca2), and glutamine synthetase (Glul) participated in this pathway. We constructed the protein-protein interaction (PPI) networks for the energy metabolism of ICH, including the Atp6v1a-Atp6v0c-Atp6v0d1-Ppa2-Atp6ap2 network. CONCLUSIONS It seems that dysregulation of energy metabolism, especially nitrogen metabolism, may be a major cause in secondary ICH injury. This information provides novel insights into secondary events following ICH.
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Affiliation(s)
- Tao Liu
- Institute of Integrative MedicineXiangya Hospital, Central South UniversityChangshaChina
- Department of GerontologyTraditional Chinese Medicine Hospital Affiliated to Xinjiang Medical UniversityUrumqiChina
| | - Jing Zhou
- Institute of Integrative MedicineXiangya Hospital, Central South UniversityChangshaChina
| | - Hanjin Cui
- Institute of Integrative MedicineXiangya Hospital, Central South UniversityChangshaChina
| | - Pengfei Li
- Institute of Integrative MedicineXiangya Hospital, Central South UniversityChangshaChina
| | - Haigang Li
- Department of PharmacyChangsha Medical UniversityChangshaChina
| | - Yang Wang
- Institute of Integrative MedicineXiangya Hospital, Central South UniversityChangshaChina
| | - Tao Tang
- Institute of Integrative MedicineXiangya Hospital, Central South UniversityChangshaChina
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30
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Ponziani FR, Zocco MA, Cerrito L, Gasbarrini A, Pompili M. Bacterial translocation in patients with liver cirrhosis: physiology, clinical consequences, and practical implications. Expert Rev Gastroenterol Hepatol 2018; 12:641-656. [PMID: 29806487 DOI: 10.1080/17474124.2018.1481747] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The gut liver axis is an operative unit that works to protect the human body against potentially harmful substances and microorganisms, maintaining the homeostasis of the immune system. Liver cirrhosis profoundly alters this complex system. The intestine becomes more permeable allowing the translocation of bacteria, bacterial products and fragments into the portal circulation, triggering an abnormal local and systemic inflammatory response and a condition of perpetual immunologic alarm. This immune-inflammatory disorder related to dysbiosis is involved in the development of liver damage and liver cirrhosis complications and increases intestinal permeability in a vicious circle. Areas covered: The most relevant studies on bacterial translocation, the mechanism of intestinal barrier dysfunction and its consequences in patients with liver cirrhosis have been revised through a PubMed search. Data have been discussed with particular regard to their significance in clinical practice. Expert commentary: The assessment of bacterial translocation and intestinal permeability is not currently used in clinical practice but may be useful to stratify patients' prognosis.
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Affiliation(s)
- Francesca Romana Ponziani
- a Internal Medicine, Gastroenterology and Hepatology , Fondazione Agostino Gemelli Hospital , Rome , Italy
| | - Maria Assunta Zocco
- a Internal Medicine, Gastroenterology and Hepatology , Fondazione Agostino Gemelli Hospital , Rome , Italy
| | - Lucia Cerrito
- a Internal Medicine, Gastroenterology and Hepatology , Fondazione Agostino Gemelli Hospital , Rome , Italy
| | - Antonio Gasbarrini
- a Internal Medicine, Gastroenterology and Hepatology , Fondazione Agostino Gemelli Hospital , Rome , Italy
| | - Maurizio Pompili
- a Internal Medicine, Gastroenterology and Hepatology , Fondazione Agostino Gemelli Hospital , Rome , Italy
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Zhang JY, Kong LH, Lai D, Jin ZX, Gu XM, Zhou JJ. Glutamate protects against Ca(2+) paradox-induced injury and inhibits calpain activity in isolated rat hearts. Clin Exp Pharmacol Physiol 2017; 43:951-9. [PMID: 27279457 DOI: 10.1111/1440-1681.12605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 04/25/2016] [Accepted: 06/02/2016] [Indexed: 01/13/2023]
Abstract
This study determined the effects of glutamate on the Ca(2+) paradoxical heart, which is a model for Ca(2+) overload-induced injury during myocardial ischaemia and reperfusion, and evaluated its effect on a known mediator of injury, calpain. An isolated rat heart was retrogradely perfused in a Langendorff apparatus. Ca(2+) paradox was elicited via perfusion with a Ca(2+) -free Krebs-Henseleit (KH) solution for 3 minutes followed by Ca(2+) -containing normal KH solution for 30 minutes. The Ca(2+) paradoxical heart exhibited almost no viable tissue on triphenyltetrazolium chloride staining and markedly increased LDH release, caspase-3 activity, cytosolic cytochrome c content, and apoptotic index. These hearts also displayed significantly increased LVEDP and a disappearance of LVDP. Glutamate (5 and 20 mmol/L) significantly alleviated Ca(2+) paradox-induced injury. In contrast, 20 mmol/L mannitol had no effect on Ca(2+) paradox. Ca(2+) paradox significantly increased the extent of the translocation of μ-calpain to the sarcolemmal membrane and the proteolysis of α-fodrin, which suggests calpain activation. Glutamate also blocked these effects. A non-selective inhibitor of glutamate transporters, dl-TBOA (10 μmol/L), had no effect on control hearts, but it reversed glutamate-induced cardioprotection and reduction in calpain activity. Glutamate treatment significantly increased intracellular glutamate content in the Ca(2+) paradoxical heart, which was also blocked by dl-TBOA. We conclude that glutamate protects the heart against Ca(2+) overload-induced injury via glutamate transporters, and the inhibition of calpain activity is involved in this process.
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Affiliation(s)
- Jian-Ying Zhang
- Department of Physiology, The Fourth Military Medical University, Xi'an, China
| | - Ling-Heng Kong
- Department of Physiology, The Fourth Military Medical University, Xi'an, China.,Institute of Basic Medical Science, Xi'an Medical College, Xi'an, China
| | - Dong Lai
- Department of Physiology, The Fourth Military Medical University, Xi'an, China
| | - Zhen-Xiao Jin
- Department of Cardiovascular Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Xiao-Ming Gu
- Department of Physiology, The Fourth Military Medical University, Xi'an, China
| | - Jing-Jun Zhou
- Department of Physiology, The Fourth Military Medical University, Xi'an, China
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32
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Bajaj JS, O'Leary JG, Tandon P, Wong F, Garcia-Tsao G, Kamath PS, Maliakkal B, Biggins SW, Thuluvath PJ, Fallon MB, Subramanian RM, Vargas HE, Lai J, Thacker LR, Reddy KR. Hepatic Encephalopathy Is Associated With Mortality in Patients With Cirrhosis Independent of Other Extrahepatic Organ Failures. Clin Gastroenterol Hepatol 2017; 15:565-574.e4. [PMID: 27720916 DOI: 10.1016/j.cgh.2016.09.157] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 09/09/2016] [Accepted: 09/16/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although survival times have increased for patients with cirrhosis, hepatic encephalopathy (HE) remains a major complication and its relative contribution toward mortality in North America is unclear. We investigated whether HE is associated with mortality independent of extrahepatic organ failures (EHOFs). METHODS We collected data from the North American Consortium for Study of End-stage Liver Disease database of hospitalized patients with cirrhosis at tertiary-care centers. EHOFs were defined as need for ventilation (respiratory failure), dialysis (renal failure), or shock (circulatory failure). We analyzed in-hospital and 30-day mortality for patients with varying HE grades and EHOF using adjusted models. RESULTS We analyzed data from 1560 patients, 516 with HE (371 grade 1-2 and 145 grade 3-4). Patients with maximum HE grade 3-4 HE during hospitalization had a higher median model for end-stage liver disease (MELD) score (22) than patients with HE grade 1-2 (MELD score, 19) or no HE (MELD score, 18) (P < .0001). Thirty-day mortality for patients with HE grade 3-4 was significantly higher (38%) than for patients with HE grade 1-2 (8%) or no HE (7%). A total of 107 patients had 2 or more EHOFs, with or without HE; 151 had 1 EHOF and 1302 had no organ failure. Unadjusted mortality was highest for patients with HE of grade 3-4 with 2 EHOFs (n = 44). On regression analysis, HE severity was significantly associated with in-hospital and 30-day mortality, independent of any EHOF, white blood cell count, systemic inflammatory response syndrome, or MELD score (odds ratio, 3.3; P < .0001). CONCLUSIONS In an analysis of more than 1500 patients hospitalized for cirrhosis, HE of grade 3 or 4 was associated with higher in-hospital and 30-day mortality, independently of failure of other organs.
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Affiliation(s)
- Jasmohan S Bajaj
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia.
| | | | | | | | | | | | | | | | | | | | | | | | - Jennifer Lai
- University of California, San Francisco, California
| | - Leroy R Thacker
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia
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Sarcopenia from mechanism to diagnosis and treatment in liver disease. J Hepatol 2016; 65:1232-1244. [PMID: 27515775 PMCID: PMC5116259 DOI: 10.1016/j.jhep.2016.07.040] [Citation(s) in RCA: 372] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 07/09/2016] [Accepted: 07/25/2016] [Indexed: 12/12/2022]
Abstract
Sarcopenia or loss of skeletal muscle mass is the major component of malnutrition and is a frequent complication in cirrhosis that adversely affects clinical outcomes. These include survival, quality of life, development of other complications and post liver transplantation survival. Radiological image analysis is currently utilized to diagnose sarcopenia in cirrhosis. Nutrient supplementation and physical activity are used to counter sarcopenia but have not been consistently effective because the underlying molecular and metabolic abnormalities persist or are not influenced by these treatments. Even though alterations in food intake, hypermetabolism, alterations in amino acid profiles, endotoxemia, accelerated starvation and decreased mobility may all contribute to sarcopenia in cirrhosis, hyperammonemia has recently gained attention as a possible mediator of the liver-muscle axis. Increased muscle ammonia causes: cataplerosis of α-ketoglutarate, increased transport of leucine in exchange for glutamine, impaired signaling by leucine, increased expression of myostatin (a transforming growth factor beta superfamily member) and an increased phosphorylation of eukaryotic initiation factor 2α. In addition, mitochondrial dysfunction, increased reactive oxygen species that decrease protein synthesis and increased autophagy mediated proteolysis, also play a role. These molecular and metabolic alterations may contribute to the anabolic resistance and inadequate response to nutrient supplementation in cirrhosis. Central and skeletal muscle fatigue contributes to impaired exercise capacity and responses. Use of proteins with low ammoniagenic potential, leucine enriched amino acid supplementation, long-term ammonia lowering strategies and a combination of resistance and endurance exercise to increase muscle mass and function may target the molecular abnormalities in the muscle. Strategies targeting endotoxemia and the gut microbiome need further evaluation.
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34
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Souto PA, Marcotegui AR, Orbea L, Skerl J, Perazzo JC. Hepatic encephalopathy: Ever closer to its big bang. World J Gastroenterol 2016; 22:9251-9256. [PMID: 27895414 PMCID: PMC5107690 DOI: 10.3748/wjg.v22.i42.9251] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 09/15/2016] [Accepted: 10/19/2016] [Indexed: 02/06/2023] Open
Abstract
Hepatic encephalopathy (HE) is a neuropsychiatric disorder that commonly complicates the course of patients with liver disease. Despite the fact that the syndrome was probably first recognized hundreds of years ago, the exact pathogenesis still remains unclear. Minimal hepatic encephalopathy (MHE) is the earliest form of HE and is estimated to affect more that 75% of patients with liver cirrhosis. It is characterized by cognitive impairment predominantly attention, reactiveness and integrative function with very subtle clinical manifestations. The development of MHE is associated with worsen in driving skills, daily activities and the increase of overall mortality. Skeletal muscle has the ability to shift from ammonia producer to ammonia detoxifying organ. Due to its large size, becomes the main ammonia detoxifying organ in case of chronic liver failure and muscular glutamine-synthase becomes important due to the failing liver and brain metabolic activity. Gut is the major glutamine consumer and ammonia producer organ in the body. Hepatocellular dysfunction due to liver disease, results in an impaired clearance of ammonium and in its inter-organ trafficking. Intestinal bacteria, can also represent an extra source of ammonia production and in cirrhosis, small intestinal bacterial overgrowth and symbiosis can be observed. In the study of HE, to get close to MHE is to get closer to its big bang; and from here, to travel less transited roads such as skeletal muscle and intestine, is to go even closer. The aim of this editorial is to expose this road for further and deeper work.
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35
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Davuluri G, Allawy A, Thapaliya S, Rennison JH, Singh D, Kumar A, Sandlers Y, Van Wagoner DR, Flask CA, Hoppel C, Kasumov T, Dasarathy S. Hyperammonaemia-induced skeletal muscle mitochondrial dysfunction results in cataplerosis and oxidative stress. J Physiol 2016; 594:7341-7360. [PMID: 27558544 DOI: 10.1113/jp272796] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 08/12/2016] [Indexed: 12/18/2022] Open
Abstract
KEY POINTS Hyperammonaemia occurs in hepatic, cardiac and pulmonary diseases with increased muscle concentration of ammonia. We found that ammonia results in reduced skeletal muscle mitochondrial respiration, electron transport chain complex I dysfunction, as well as lower NAD+ /NADH ratio and ATP content. During hyperammonaemia, leak of electrons from complex III results in oxidative modification of proteins and lipids. Tricarboxylic acid cycle intermediates are decreased during hyperammonaemia, and providing a cell-permeable ester of αKG reversed the lower TCA cycle intermediate concentrations and increased ATP content. Our observations have high clinical relevance given the potential for novel approaches to reverse skeletal muscle ammonia toxicity by targeting the TCA cycle intermediates and mitochondrial ROS. ABSTRACT Ammonia is a cytotoxic metabolite that is removed primarily by hepatic ureagenesis in humans. Hyperammonaemia occurs in advanced hepatic, cardiac and pulmonary disease, and in urea cycle enzyme deficiencies. Increased skeletal muscle ammonia uptake and metabolism are the major mechanism of non-hepatic ammonia disposal. Non-hepatic ammonia disposal occurs in the mitochondria via glutamate synthesis from α-ketoglutarate resulting in cataplerosis. We show skeletal muscle mitochondrial dysfunction during hyperammonaemia in a comprehensive array of human, rodent and cellular models. ATP synthesis, oxygen consumption, generation of reactive oxygen species with oxidative stress, and tricarboxylic acid (TCA) cycle intermediates were quantified. ATP content was lower in the skeletal muscle from cirrhotic patients, hyperammonaemic portacaval anastomosis rat, and C2C12 myotubes compared to appropriate controls. Hyperammonaemia in C2C12 myotubes resulted in impaired intact cell respiration, reduced complex I/NADH oxidase activity and electron leak occurring at complex III of the electron transport chain. Consistently, lower NAD+ /NADH ratio was observed during hyperammonaemia with reduced TCA cycle intermediates compared to controls. Generation of reactive oxygen species resulted in increased content of skeletal muscle carbonylated proteins and thiobarbituric acid reactive substances during hyperammonaemia. A cell-permeable ester of α-ketoglutarate reversed the low TCA cycle intermediates and ATP content in myotubes during hyperammonaemia. However, the mitochondrial antioxidant MitoTEMPO did not reverse the lower ATP content during hyperammonaemia. We provide for the first time evidence that skeletal muscle hyperammonaemia results in mitochondrial dysfunction and oxidative stress. Use of anaplerotic substrates to reverse ammonia-induced mitochondrial dysfunction is a novel therapeutic approach.
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Affiliation(s)
- Gangarao Davuluri
- Department of Pathobiology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Allawy Allawy
- Department of Pathobiology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Samjhana Thapaliya
- Department of Pathobiology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Julie H Rennison
- Department of Pathobiology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Dharmvir Singh
- Department of Pathobiology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Avinash Kumar
- Department of Pathobiology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Yana Sandlers
- Department of Chemistry, Cleveland State University, SR 364, 2351 Euclid Avenue, Cleveland, OH, 44115, USA
| | - David R Van Wagoner
- Department of Molecular Cardiology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Chris A Flask
- Department of Biomedical Engineering, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Charles Hoppel
- Department of Pharmacology and Medicine, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Takhar Kasumov
- Department of Pharmaceutical Sciences, Northeast Ohio Medical University, 4209 State Route 44, Rootstown, OH, 44272
| | - Srinivasan Dasarathy
- Department of Pathobiology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.,Department of Gastroenterology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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Hyperammonemia: What Urea-lly Need to Know: Case Report of Severe Noncirrhotic Hyperammonemic Encephalopathy and Review of the Literature. Case Rep Med 2016; 2016:8512721. [PMID: 27738433 PMCID: PMC5050374 DOI: 10.1155/2016/8512721] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 08/28/2016] [Indexed: 12/12/2022] Open
Abstract
Purpose. A 66-year-old man who presented with coma was found to have isolated severe hyperammonemia and diagnosed with a late-onset urea-cycle disorder. He was treated successfully and had full recovery. Methods. We report a novel case of noncirrhotic hyperammonemia and review the literature on this topic. Selected literature for review included English-language articles concerning hyperammonemia using the search terms “hyperammonemic encephalopathy”, “non-cirrhotic encephalopathy”, “hepatic encephalopathy”, “urea-cycle disorders”, “ornithine transcarbamylase (OTC) deficiency”, and “fulminant hepatic failure”. Results. A unique case of isolated hyperammonemia diagnosed as late-onset OTC deficiency is presented. Existing evidence about hyperammonemia is organized to address pathophysiology, clinical presentation, diagnosis, and treatment. The case report is discussed in context of the reviewed literature. Conclusion. Late-onset OTC deficiency presenting with severe hyperammonemic encephalopathy and extensive imaging correlate can be fully reversible if recognized promptly and treated aggressively.
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37
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Li Z, Ji X, Wang W, Liu J, Liang X, Wu H, Liu J, Eggert US, Liu Q, Zhang X. Ammonia Induces Autophagy through Dopamine Receptor D3 and MTOR. PLoS One 2016; 11:e0153526. [PMID: 27077655 PMCID: PMC4831814 DOI: 10.1371/journal.pone.0153526] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 03/30/2016] [Indexed: 12/25/2022] Open
Abstract
Hyperammonemia is frequently seen in tumor microenvironments as well as in liver diseases where it can lead to severe brain damage or death. Ammonia induces autophagy, a mechanism that tumor cells may use to protect themselves from external stresses. However, how cells sense ammonia has been unclear. Here we show that culture medium alone containing Glutamine can generate milimolar of ammonia at 37 degrees in the absence of cells. In addition, we reveal that ammonia acts through the G protein-coupled receptor DRD3 (Dopamine receptor D3) to induce autophagy. At the same time, ammonia induces DRD3 degradation, which involves PIK3C3/VPS34-dependent pathways. Ammonia inhibits MTOR (mechanistic target of Rapamycin) activity and localization in cells, which is mediated by DRD3. Therefore, ammonia has dual roles in autophagy: one to induce autophagy through DRD3 and MTOR, the other to increase autophagosomal pH to inhibit autophagic flux. Our study not only adds a new sensing and output pathway for DRD3 that bridges ammonia sensing and autophagy induction, but also provides potential mechanisms for the clinical consequences of hyperammonemia in brain damage, neurodegenerative diseases and tumors.
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Affiliation(s)
- Zhiyuan Li
- High Magnetic Field Laboratory, Chinese Academy of Sciences, Hefei, Anhui, P. R. China
| | - Xinmiao Ji
- High Magnetic Field Laboratory, Chinese Academy of Sciences, Hefei, Anhui, P. R. China
| | - Wenchao Wang
- High Magnetic Field Laboratory, Chinese Academy of Sciences, Hefei, Anhui, P. R. China
| | - Juanjuan Liu
- High Magnetic Field Laboratory, Chinese Academy of Sciences, Hefei, Anhui, P. R. China
- University of Science and Technology of China, Hefei, Anhui, P. R. China
| | - Xiaofei Liang
- High Magnetic Field Laboratory, Chinese Academy of Sciences, Hefei, Anhui, P. R. China
| | - Hong Wu
- High Magnetic Field Laboratory, Chinese Academy of Sciences, Hefei, Anhui, P. R. China
- University of Science and Technology of China, Hefei, Anhui, P. R. China
| | - Jing Liu
- High Magnetic Field Laboratory, Chinese Academy of Sciences, Hefei, Anhui, P. R. China
| | - Ulrike S Eggert
- Department of Chemistry and Randall Division of Cell and Molecular Biophysics, King's College London, London, United Kingdom
| | - Qingsong Liu
- High Magnetic Field Laboratory, Chinese Academy of Sciences, Hefei, Anhui, P. R. China
- University of Science and Technology of China, Hefei, Anhui, P. R. China
| | - Xin Zhang
- High Magnetic Field Laboratory, Chinese Academy of Sciences, Hefei, Anhui, P. R. China
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Brannelly NT, Hamilton-Shield JP, Killard AJ. The Measurement of Ammonia in Human Breath and its Potential in Clinical Diagnostics. Crit Rev Anal Chem 2016; 46:490-501. [PMID: 26907707 DOI: 10.1080/10408347.2016.1153949] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Ammonia is an important component of metabolism and is involved in many physiological processes. During normal physiology, levels of blood ammonia are between 11 and 50 µM. Elevated blood ammonia levels are associated with a variety of pathological conditions such as liver and kidney dysfunction, Reye's syndrome and a variety of inborn errors of metabolism including urea cycle disorders (UCD), organic acidaemias and hyperinsulinism/hyperammonaemia syndrome in which ammonia may reach levels in excess of 1 mM. It is highly neurotoxic and so effective measurement is critical for assessing and monitoring disease severity and treatment. Ammonia is also a potential biomarker in exercise physiology and studies of drug metabolism. Current ammonia testing is based on blood sampling, which is inconvenient and can be subject to significant analytical errors due to the quality of the sample draw, its handling and preparation for analysis. Blood ammonia is in gaseous equilibrium with the lungs. Recent research has demonstrated the potential use of breath ammonia as a non-invasive means of measuring systemic ammonia. This requires measurement of ammonia in real breath samples with associated temperature, humidity and gas characteristics at concentrations between 50 and several thousand parts per billion. This review explores the diagnostic applications of ammonia measurement and the impact that the move from blood to breath analysis could have on how these processes and diseases are studied and managed.
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Affiliation(s)
- N T Brannelly
- a Department of Biological Biomedical and Analytical Science , University of the West of England , Bristol , UK
| | | | - A J Killard
- a Department of Biological Biomedical and Analytical Science , University of the West of England , Bristol , UK
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McDaniel J, Davuluri G, Hill EA, Moyer M, Runkana A, Prayson R, van Lunteren E, Dasarathy S. Hyperammonemia results in reduced muscle function independent of muscle mass. Am J Physiol Gastrointest Liver Physiol 2016; 310:G163-70. [PMID: 26635319 PMCID: PMC4971815 DOI: 10.1152/ajpgi.00322.2015] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 11/14/2015] [Indexed: 01/31/2023]
Abstract
The mechanism of the nearly universal decreased muscle strength in cirrhosis is not known. We evaluated whether hyperammonemia in cirrhosis causes contractile dysfunction independent of reduced skeletal muscle mass. Maximum grip strength and muscle fatigue response were determined in cirrhotic patients and controls. Blood and muscle ammonia concentrations and grip strength normalized to lean body mass were measured in the portacaval anastomosis (PCA) and sham-operated pair-fed control rats (n = 5 each). Ex vivo contractile studies in the soleus muscle from a separate group of Sprague-Dawley rats (n = 7) were performed. Skeletal muscle force of contraction, rate of force development, and rate of relaxation were measured. Muscles were also subjected to a series of pulse trains at a range of stimulation frequencies from 20 to 110 Hz. Cirrhotic patients had lower maximum grip strength and greater muscle fatigue than control subjects. PCA rats had a 52.7 ± 13% lower normalized grip strength compared with control rats, and grip strength correlated with the blood and muscle ammonia concentrations (r(2) = 0.82). In ex vivo muscle preparations following a single pulse, the maximal force, rate of force development, and rate of relaxation were 12.1 ± 3.5 g vs. 6.2 ± 2.1 g; 398.2 ± 100.4 g/s vs. 163.8 ± 97.4 g/s; -101.2 ± 22.2 g/s vs. -33.6 ± 22.3 g/s in ammonia-treated compared with control muscle preparation, respectively (P < 0.001 for all comparisons). Tetanic force, rate of force development, and rate of relaxation were depressed across a range of stimulation from 20 to 110 Hz. These data provide the first direct evidence that hyperammonemia impairs skeletal muscle strength and increased muscle fatigue and identifies a potential therapeutic target in cirrhotic patients.
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Affiliation(s)
- John McDaniel
- 1Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio; ,2Department of Exercise Science, Kent State University Kent, Ohio;
| | | | | | - Michelle Moyer
- 1Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio;
| | - Ashok Runkana
- 3Department of Pathobiology, Cleveland Clinic, Cleveland, Ohio; ,4Department of Medicine, Cleveland Clinic, Cleveland, Ohio;
| | - Richard Prayson
- 5Department of Pathology, Cleveland Clinic, Cleveland, Ohio;
| | - Erik van Lunteren
- 1Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio; ,6Case Western Reserve University Cleveland, Ohio
| | - Srinivasan Dasarathy
- Department of Pathobiology, Cleveland Clinic, Cleveland, Ohio; Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio; and
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40
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Mayer LB, Krawczyk M, Grünhage F, Lammert F, Stokes CS. A genetic variant in the promoter of phosphate-activated glutaminase is associated with hepatic encephalopathy. J Intern Med 2015; 278:313-22. [PMID: 25880019 DOI: 10.1111/joim.12374] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hepatic encephalopathy (HE) is a serious complication of liver cirrhosis. Recently, a microsatellite in the promoter region of the phosphate-activated glutaminase (GLS ) gene was associated with the risk of HE. The aim of the present study was to investigate, using the critical flicker frequency (CFF) test, whether the described GLS variant increases the risk of developing HE in patients with cirrhosis. METHODS We recruited 158 patients (66% men; mean age 59 years, range 23-86) with liver cirrhosis. Mean model for end-stage liver disease score was 13.8 (range 5-35); 48% of patients presented with Child-Pugh score B or C. The presence and severity of HE were determined by the CFF test, with frequencies ≤39 Hz denoting cases. GLS variants were genotyped by sequencing the microsatellite in the promoter region and were classified as short, long or short-long forms (depending on the length of the macrosatellite alleles). RESULTS In total, 53% of patients had abnormal CFF results (i.e. ≤39 Hz; range for entire cohort 26-57). The GLS microsatellite distribution amongst patients was short form (20%), long form (32%) and short-long form (48%) and was consistent with Hardy-Weinberg equilibrium. CFF values differed significantly between groups (P = 0.043). Carriers of the GLS long microsatellite had a significantly higher risk of HE according to multivariate analyses (odds ratio 3.23, 95% confidence interval 1.46-7.13, P = 0.004). CONCLUSION CFF results were significantly lower amongst carriers of the GLS long microsatellite. Our findings support the role of the GLS long microsatellite in the development of HE; this could be important for identifying susceptible patients and for the prevention of this condition.
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Affiliation(s)
- L B Mayer
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - M Krawczyk
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany.,Laboratory of Metabolic Liver Diseases, Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - F Grünhage
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - F Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - C S Stokes
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
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41
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Chandar J, Garcia J, Jorge L, Tekin A. Transplantation in autosomal recessive polycystic kidney disease: liver and/or kidney? Pediatr Nephrol 2015; 30:1233-42. [PMID: 25115876 DOI: 10.1007/s00467-014-2887-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 05/13/2014] [Accepted: 06/11/2014] [Indexed: 12/19/2022]
Abstract
Autosomal recessive polycystic kidney disease (ARPKD) is characterized by enlarged kidneys with dilated collecting ducts and congenital hepatic fibrosis. There is a variable rate of progression of kidney and liver disease. Portal hypertension and Caroli's disease occur from liver involvement that contributes to morbidity and mortality. Approximately 40 % of patients have a severe disease phenotype leading to rapid onset of end-stage kidney disease (ESKD) and signs of portal hypertension and the rest may have predominant involvement of either the kidney or liver. It is important for the physician to establish the extent of organ involvement before deciding on the ultimate plan of management, especially when transplantation is required. Isolated renal transplantation can be considered when liver involvement is minimal. If hepatobiliary disease is prominent, and kidney function is preserved, management options are based on individual characteristics. In the presence of significant liver disease and ESKD, consideration should be given to combined liver kidney transplantation, which can be beneficial in eliminating the consequences of both kidney and liver disease. However, this is a complex surgical procedure that needs to be performed at experienced transplant centers. Improvement in surgical techniques has considerably improved short-term graft survival with the added advantage of the liver offering immunologic protection to the kidney allograft.
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Affiliation(s)
- Jayanthi Chandar
- Department of Pediatrics, Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami Miller School of Medicine, PO Box 016960 (M-714), Miami, FL, 33101, USA,
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Ahmadi S, Poureidi M, Rostamzadeh J. Hepatic encephalopathy induces site-specific changes in gene expression of GluN1 subunit of NMDA receptor in rat brain. Metab Brain Dis 2015; 30:1035-41. [PMID: 25896221 DOI: 10.1007/s11011-015-9669-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 04/01/2015] [Indexed: 01/08/2023]
Abstract
We investigate changes in gene expression of GluN1 subunit of N-Methyl-D-Aspartate (NMDA) receptor in the prefrontal cortex (PFC), hippocampus and striatum in a rat model of hepatic encephalopathy (HE). We used male Wistar rats in which HE was induced after a common bile duct ligation (BDL). The animals were divided into three sets, and each set included three groups of control, sham operated and BDL. In the first set of animals, blood samples collected for biochemical analysis on day 21 of BDL. In the second set, changes in nociception threshold was assessed on day 21 of BDL using a hotplate test. In the third set, whole brain extracted, and the PFC, the hippocampus and the striatum in each rat were immediately dissected. We used a semi-quantitative RT-PCR method for evaluating the GluN1 gene expression. The biochemical analyses showed that plasma levels of ammonia and bilirubin in BDL rats were significantly increased compared to the sham control group on day 21 of BDL (P < 0.01). Nociception threshold was also increased in rats with BDL compared to sham group (P < 0.001). The results revealed that the GluN1 gene expression at mRNA levels in BDL group was decreased by 19 % in the PFC (P < 0.05) but increased by 82 % in the hippocampus (P < 0.01) compared to the sham control group; however, no significant change was observed in the striatum. It can be concluded that HE affects the GluN1 gene expression in rat brain with a site-specific pattern, and the PFC and hippocampus are more sensitive areas than striatum.
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Affiliation(s)
- Shamseddin Ahmadi
- Department of Biological Science and Biotechnology, Faculty of Science, University of Kurdistan, P.O. Box 416, Sanandaj, Iran,
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Rai R, Saraswat VA, Dhiman RK. Gut microbiota: its role in hepatic encephalopathy. J Clin Exp Hepatol 2015; 5:S29-36. [PMID: 26041954 PMCID: PMC4442863 DOI: 10.1016/j.jceh.2014.12.003] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 12/09/2014] [Indexed: 02/08/2023] Open
Abstract
Ammonia, a key factor in the pathogenesis of hepatic encephalopathy (HE), is predominantly derived from urea breakdown by urease producing large intestinal bacteria and from small intestine and kidneys, where the enzyme glutaminases releases ammonia from circulating glutamine. Non-culture techniques like pyrosequencing of bacterial 16S ribosomal ribonucleic acid are used to characterize fecal microbiota. Fecal microbiota in patients with cirrhosis have been shown to alter with increasing Child-Turcotte-Pugh (CTP) and Model for End stage Liver Disease (MELD) scores, and with development of covert or overt HE. Cirrhosis dysbiosis ratio (CDR), the ratio of autochthonous/good bacteria (e.g. Lachnospiraceae, Ruminococcaceae and Clostridiales) to non-autochthonous/pathogenic bacteria (e.g. Enterobacteriaceae and Streptococcaceae), is significantly higher in controls and patients with compensated cirrhosis than patients with decompensated cirrhosis. Although their stool microbiota do not differ, sigmoid colonic mucosal microbiota in liver cirrhosis patients with and without HE, are different. Linkage of pathogenic colonic mucosal bacteria with poor cognition and inflammation suggests that important processes at the mucosal interface, such as bacterial translocation and immune dysfunction, are involved in the pathogenesis of HE. Fecal microbiome composition does not change significantly when HE is treated with lactulose or when HE recurs after lactulose withdrawal. Despite improving cognition and endotoxemia as well as shifting positive correlation of pathogenic bacteria with metabolites, linked to ammonia, aromatic amino acids and oxidative stress, to a negative correlation, rifaximin changes gut microbiome composition only modestly. These observations suggest that the beneficial effects of lactulose and rifaximin could be associated with a change in microbial metabolic function as well as an improvement in dysbiosis.
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Key Words
- CDR, cirrhosis dysbiosis ratio
- HE, hepatic encephalopathy
- IL, interleukin
- LGG, Lactobacillus GG strain
- LPO, left parietal operculum
- MELD, model for end stage liver disease
- MHE, minimal hepatic encephalopathy
- MRS, magnetic resonance spectroscopy
- PAMPs, pathogen-associated molecular patterns
- PCR, polymerase chain reaction
- RCT, randomized controlled trial
- RNA, ribonucleic acid
- SBP, spontaneous bacterial peritonitis
- SIBO, small intestinal bacterial overgrowth
- SIRS, systemic inflammatory response syndrome
- TNF, tumor necrosis factor
- cirrhosis
- dysbiosis
- fMRI, functional MRI
- gut microbiome
- inflammation
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Affiliation(s)
- Rahul Rai
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Vivek A. Saraswat
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh 226014, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India,Address for correspondence: Radha K. Dhiman, Tel.: +91 9914209337; fax: +91 1722744401.
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Schliess F, Hoehme S, Henkel SG, Ghallab A, Driesch D, Böttger J, Guthke R, Pfaff M, Hengstler JG, Gebhardt R, Häussinger D, Drasdo D, Zellmer S. Integrated metabolic spatial-temporal model for the prediction of ammonia detoxification during liver damage and regeneration. Hepatology 2014; 60:2040-51. [PMID: 24677161 DOI: 10.1002/hep.27136] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 03/14/2014] [Indexed: 01/09/2023]
Abstract
UNLABELLED The impairment of hepatic metabolism due to liver injury has high systemic relevance. However, it is difficult to calculate the impairment of metabolic capacity from a specific pattern of liver damage with conventional techniques. We established an integrated metabolic spatial-temporal model (IM) using hepatic ammonia detoxification as a paradigm. First, a metabolic model (MM) based on mass balancing and mouse liver perfusion data was established to describe ammonia detoxification and its zonation. Next, the MM was combined with a spatial-temporal model simulating liver tissue damage and regeneration after CCl4 intoxication. The resulting IM simulated and visualized whether, where, and to what extent liver damage compromised ammonia detoxification. It allowed us to enter the extent and spatial patterns of liver damage and then calculate the outflow concentrations of ammonia, glutamine, and urea in the hepatic vein. The model was validated through comparisons with (1) published data for isolated, perfused livers with and without CCl4 intoxication and (2) a set of in vivo experiments. Using the experimentally determined portal concentrations of ammonia, the model adequately predicted metabolite concentrations over time in the hepatic vein during toxin-induced liver damage and regeneration in rodents. Further simulations, especially in combination with a simplified model of blood circulation with three ammonia-detoxifying compartments, indicated a yet unidentified process of ammonia consumption during liver regeneration and revealed unexpected concomitant changes in amino acid metabolism in the liver and at extrahepatic sites. CONCLUSION The IM of hepatic ammonia detoxification considerably improves our understanding of the metabolic impact of liver disease and highlights the importance of integrated modeling approaches on the way toward virtual organisms.
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Affiliation(s)
- Freimut Schliess
- Clinic for Gastroenterology, Hepatology, and Infectiology, Heinrich Heine University, Düsseldorf, Germany
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Abstract
INTRODUCTION Hepatic encephalopathy (HE) is a serious neuropsychiatric complication that is seen in patients with liver failure. The pathogenesis of HE is not entirely understood, but several hypotheses have emerged and persisted during the years. Despite the many prevalent hypotheses, most of the existing evidence point to ammonia as the main culprit behind primary and secondary symptoms making it the center of potential therapeutic options for the treatment of HE. Most treatments of hyperammonemia target the organs and metabolic processes involved in ammonia detoxification. AREAS COVERED This article provides a review of the current targets of therapy as well as the drugs used for hyperammonemia treatment. EXPERT OPINION Lactulose and rifaximin have a proven role as measures to use for secondary prophylaxis and are the mainstay of current therapy. The use of molecular adsorbent recirculating system in patients with severe HE has been proven to be efficacious, but through mechanisms that appear to be independent of ammonia. The main challenge that faces the further development of treatments for HE is finding appropriate end points, and the next step would be to provide evidence of the effectiveness of established treatments and define the role of emerging new treatments.
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Affiliation(s)
- Anna Hadjihambi
- UCL Institute for Liver and Digestive Health, UCL Medical School , Upper Third Floor, Royal Free Campus, Pond Street, NW3 2PF, London , UK +44 207 4332 794 ;
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Abstract
Human adults produce around 1000 mmol of ammonia daily. Some is reutilized in biosynthesis. The remainder is waste and neurotoxic. Eventually most is excreted in urine as urea, together with ammonia used as a buffer. In extrahepatic tissues, ammonia is incorporated into nontoxic glutamine and released into blood. Large amounts are metabolized by the kidneys and small intestine. In the intestine, this yields ammonia, which is sequestered in portal blood and transported to the liver for ureagenesis, and citrulline, which is converted to arginine by the kidneys. The amazing developments in NMR imaging and spectroscopy and molecular biology have confirmed concepts derived from early studies in animals and cell cultures. The processes involved are exquisitely tuned. When they are faulty, ammonia accumulates. Severe acute hyperammonemia causes a rapidly progressive, often fatal, encephalopathy with brain edema. Chronic milder hyperammonemia causes a neuropsychiatric illness. Survivors of severe neonatal hyperammonemia have structural brain damage. Proposed explanations for brain edema are an increase in astrocyte osmolality, generally attributed to glutamine accumulation, and cytotoxic oxidative/nitrosative damage. However, ammonia neurotoxicity is multifactorial, with disturbances also in neurotransmitters, energy production, anaplerosis, cerebral blood flow, potassium, and sodium. Around 90% of hyperammonemic patients have liver disease. Inherited defects are rare. They are being recognized increasingly in adults. Deficiencies of urea cycle enzymes, citrin, and pyruvate carboxylase demonstrate the roles of isolated pathways in ammonia metabolism. Phenylbutyrate is used routinely to treat inherited urea cycle disorders, and its use for hepatic encephalopathy is under investigation.
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Affiliation(s)
- Valerie Walker
- Department of Clinical Biochemistry, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
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Solga SF, Mudalel M, Spacek LA, Lewicki R, Tittel FK, Loccioni C, Russo A, Ragnoni A, Risby TH. Changes in the concentration of breath ammonia in response to exercise: a preliminary investigation. J Breath Res 2014; 8:037103. [PMID: 25189784 DOI: 10.1088/1752-7155/8/3/037103] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Breath ammonia has proven to be a difficult compound to measure accurately. The goal of this study was to evaluate the effects that the physiological intervention, exercise, had on the levels of breath ammonia. The effects of vigorous exercise (4000 m indoor row) in 13 participants were studied and increases in breath ammonia were observed in all participants. Mean pre-exercise concentrations of ammonia were 670 pmol ml(-1) CO2 (SD, 446) and these concentrations increased to post-exercise maxima of 1499 pmol ml(-1) CO2 (SD, 730), p < 0.0001. The mean increase in ammonia concentrations from pre-exercise to maximum achieved in conditioned (1362 pmol ml(-1) CO2) versus non-conditioned rowers (591 pmol ml(-1) CO2) were found to be statistically different, p = 0.029. Taken together, these results demonstrate our ability to repeatedly measure the influence of exercise on the concentration of breath ammonia.
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Affiliation(s)
- Steven F Solga
- Solga Gastroenterology, Bethlehem, PA, USA. St. Luke's University Hospital/Temple School of Medicine, Bethlehem, PA, USA. School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Savlan I, Liakina V, Valantinas J. Concise review of current concepts on nomenclature and pathophysiology of hepatic encephalopathy. MEDICINA-LITHUANIA 2014; 50:75-81. [PMID: 25172600 DOI: 10.1016/j.medici.2014.06.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 04/24/2014] [Indexed: 01/18/2023]
Abstract
Hepatic encephalopathy is a neuropsychiatric complication of liver cirrhosis the symptoms of which may vary from imperceptible to severe, invaliding, and even lethal. Minimal hepatic encephalopathy is also important because of its tendency to impair patients' cognitive functions and quality of life. The polyetiological pathogenesis of hepatic encephalopathy is intensively studied. A general consensus exists that not only excess of ammonia but also inflammatory, oxidative, and other processes are significant in the development of hepatic encephalopathy.
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Affiliation(s)
- Ilona Savlan
- Centre of Hepatology, Gastroenterology and Dietetics, Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Valentina Liakina
- Centre of Hepatology, Gastroenterology and Dietetics, Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania; Department of Biomechanics, Faculty of Mechanics, Vilnius Gediminas Technical University, Vilnius, Lithuania
| | - Jonas Valantinas
- Centre of Hepatology, Gastroenterology and Dietetics, Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.
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Abstract
Hepatic encephalopathy (HE), which consists of minimal (MHE) and overt (OHE) stages, is a model for impaired gut-liver-brain axis in cirrhosis. Microbiota changes in both stages have been associated with impaired cognition, endotoxemia, and inflammation. There is dysbiosis (reduced autochthonous taxa [Lachnospiraceae, Ruminococcaceae, and Clostridiales XIV] and increased Enterobacteriaceae and Streptococcaceae) with disease progression. In MHE, there is an increased abundance of Streptococcus salivarius linked to cognition and ammonia. In OHE, stool Alcaligenaceae and Porphyromonadaceae are associated with poor cognition. Colonic mucosal microbiome in cirrhosis is significantly different compared with stool and independently related to cognition. HE treatment can affect microbial composition and function; cognitive improvement in MHE after rifaximin, a non-absorbable antibiotic, occurred without significant stool microbiota composition change but improved metabolic linkages. Similarly, there are only modest lactulose and rifaximin-associated changes on microbiota composition in OHE. HE represents an important model to study microbiome-brain interactions.
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Sturgeon JP, Shawcross DL. Recent insights into the pathogenesis of hepatic encephalopathy and treatments. Expert Rev Gastroenterol Hepatol 2014; 8:83-100. [PMID: 24236755 DOI: 10.1586/17474124.2014.858598] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hepatic encephalopathy (HE) encompasses a spectrum of neuropsychiatric disorders related to liver failure. The development of HE can have a profound impact on mortality as well as quality of life for patients and carers. Ammonia is central in the disease process contributing to alteration in neurotransmission, oxidative stress, and cerebral edema and astrocyte swelling in acute liver failure. Inflammation in the presence of ammonia coactively worsens HE. Inflammation can result from hyperammonemic responses, endotoxemia, innate immune dysfunction or concurrent infection. This review summarizes the current processes implicated in the pathogenesis of HE, as well as current and potential treatments. Treatments currently focus on reducing inflammation and/or blood ammonia levels and provide varying degrees of success. Optimization of current treatments and initial testing of novel therapies will provide the basis of improvement of care in the near future.
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Affiliation(s)
- Jonathan P Sturgeon
- Institute of Liver Studies, King's College London School of Medicine at King's College Hospital, Denmark Hill, London, SE5 9RS, UK
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