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Mangini C, Zarantonello L, Formentin C, Giusti G, Angeli P, Montagnese S. Evolution of hepatic encephalopathy over time: ecological data from a tertiary referral centre for hepatology. Dig Liver Dis 2023; 55:93-98. [PMID: 35725551 DOI: 10.1016/j.dld.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/27/2022] [Accepted: 06/01/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Few data on hepatic encephalopathy (HE) over time are available, thus our aim was to study its evolution in patients with varying degree of HE on first assessment. METHODS Eighty-six patients with cirrhosis (age = 58 ± 11 years; males = 72) were evaluated 2-10 times for liver transplantation selection purposes, differential diagnosis or treatment optimization. The presence/severity of HE was assessed by clinical and neuropsychiatric indices [ Psychometric Hepatic Encephalopathy Score (PHES) and electroencephalography (EEG)] and the severity of liver disease by the Model for End-Stage Liver Disease (MELD) score. Treatment was instituted/modified after each evaluation. RESULTS Amongst 23 unimpaired patients, 56/6% remained unimpaired, 35/3% developed covert HE, 9/0% developed overt HE on second/third evaluation. Amongst 32 patients with covert HE, 25/10% became unimpaired, 44/19% remained covert, 31/13% developed overt HE. Finally, amongst 32 patients with overt HE, 19/16% became unimpaired, 25/13 % became covert and 56/25% remained overt. PHES results improved in patients with overt HE and EEG worsened over time (despite remaining normal) in unimpaired patients. In patients with multiple evaluations, HE evolution was manifold and difficult to predict. CONCLUSIONS HE evolution over time is variable and largely dependent on HE history/management. These data support the concept that HE is an essentially reversible condition.
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Affiliation(s)
- C Mangini
- Department of Medicine, University of Padova, Via Giustiniani 2, Padova 35128, Italy
| | - L Zarantonello
- Department of Medicine, University of Padova, Via Giustiniani 2, Padova 35128, Italy
| | - C Formentin
- Department of Medicine, University of Padova, Via Giustiniani 2, Padova 35128, Italy
| | - G Giusti
- Department of Medicine, University of Padova, Via Giustiniani 2, Padova 35128, Italy
| | - P Angeli
- Department of Medicine, University of Padova, Via Giustiniani 2, Padova 35128, Italy
| | - S Montagnese
- Department of Medicine, University of Padova, Via Giustiniani 2, Padova 35128, Italy.
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2
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Hoilat GJ, Suhail FK, Adhami T, John S. Evidence-based approach to management of hepatic encephalopathy in adults. World J Hepatol 2022; 14:670-681. [PMID: 35646276 PMCID: PMC9099111 DOI: 10.4254/wjh.v14.i4.670] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 08/07/2021] [Accepted: 03/27/2022] [Indexed: 02/06/2023] Open
Abstract
Hepatic encephalopathy (HE) is a reversible syndrome of impaired brain function and represents one of the many complications of portal hypertension and decompensated liver disease. Although ammonia is clearly implicated in the pathogenesis of HE, the pathogenesis of HE is multifactorial with numerous mechanisms that results in functional impairment of neuronal cells. The initial management of HE focuses on supportive care and stabilization which includes providing appropriate nutritional support. Thereafter, focus should be on identifying and treating the precipitating factors. There are many therapeutic agents available for the management of HE, most of which are directed towards lowering the gut nitrogen load and thus the serum ammonia level. This review aims to provide an update on the conventional and emerging treatment options for HE.
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Affiliation(s)
- Gilles Jadd Hoilat
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Fathima Keshia Suhail
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Talal Adhami
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Savio John
- Department of Gastroenterology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
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3
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Cheng Y, Li JL, Zhou JM, Zhang GY, Shen W, Zhang XD. Renormalization of Thalamic Sub-Regional Functional Connectivity Contributes to Improvement of Cognitive Function after Liver Transplantation in Cirrhotic Patients with Overt Hepatic Encephalopathy. Korean J Radiol 2021; 22:2052-2061. [PMID: 34564958 PMCID: PMC8628146 DOI: 10.3348/kjr.2020.1432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 06/15/2021] [Accepted: 07/07/2021] [Indexed: 11/18/2022] Open
Abstract
Objective The role of preoperative overt hepatic encephalopathy (OHE) in the neurophysiological mechanism of cognitive improvement after liver transplantation (LT) remains elusive. This study aimed to explore changes in sub-regional thalamic functional connectivity (FC) after LT and their relationship with neuropsychological improvement using resting-state functional MRI (rs-fMRI) data in cirrhotic patients with and without a history of OHE. Materials and Methods A total of 51 cirrhotic patients, divided into the OHE group (n = 21) and no-OHE group (n = 30), and 30 healthy controls were enrolled in this prospective study. Each patient underwent rs-fMRI before and 1 month after LT. Using 16 bilateral thalamic subregions as seeds, we conducted a seed-to-voxel FC analysis to compare the thalamic FC alterations before and after LT between the OHE and no-OHE groups, as well as differences in FC between the two groups of cirrhotic patients and the control group. Correction for multiple comparisons was conducted using the false discovery rate (p < 0.05). Results We found abnormally increased FC between the thalamic sub-region and prefrontal cortex, as well as an abnormally decreased FC between the bilateral thalamus in both OHE and no-OHE cirrhotic patients before LT, which returned to normal levels after LT. Compared with the no-OHE group, the OHE group exhibited more extensive abnormalities prior to LT, and the increased FC between the right thalamic subregions and right inferior parietal lobe was markedly reduced to normal levels after LT. Conclusion The renormalization of FC in the cortico-thalamic loop might be a neuro-substrate for the recovery of cognitive function after LT in cirrhotic patients. In addition, hyperconnectivity between thalamic subregions and the inferior parietal lobe might be an important feature of OHE. Changes in FC in the thalamus might be used as potential biomarkers for recovery of cognitive function after LT in cirrhotic patients.
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Affiliation(s)
- Yue Cheng
- Department of Radiology, Tianjin First Central Hospital, Tianjin, China
| | - Jing-Li Li
- Department of Radiology, Tianjin First Central Hospital, Tianjin, China
| | - Jia-Min Zhou
- Department of Radiology, Tianjin First Central Hospital, Tianjin, China
| | - Gao-Yan Zhang
- Tianjin Key Lab of Cognitive Computing and Application, College of Intelligence and Computing, Tianjin University, Tianjin, China
| | - Wen Shen
- Department of Radiology, Tianjin First Central Hospital, Tianjin, China
| | - Xiao-Dong Zhang
- Department of Radiology, Tianjin First Central Hospital, Tianjin, China.
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4
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Zimmermann M, Reichert AS. Rapid metabolic and bioenergetic adaptations of astrocytes under hyperammonemia - a novel perspective on hepatic encephalopathy. Biol Chem 2021; 402:1103-1113. [PMID: 34331848 DOI: 10.1515/hsz-2021-0172] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 07/18/2021] [Indexed: 12/17/2022]
Abstract
Hepatic encephalopathy (HE) is a well-studied, neurological syndrome caused by liver dysfunctions. Ammonia, the major toxin during HE pathogenesis, impairs many cellular processes within astrocytes. Yet, the molecular mechanisms causing HE are not fully understood. Here we will recapitulate possible underlying mechanisms with a clear focus on studies revealing a link between altered energy metabolism and HE in cellular models and in vivo. The role of the mitochondrial glutamate dehydrogenase and its role in metabolic rewiring of the TCA cycle will be discussed. We propose an updated model of ammonia-induced toxicity that may also be exploited for therapeutic strategies in the future.
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Affiliation(s)
- Marcel Zimmermann
- Institute of Biochemistry and Molecular Biology I, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Universitätsstraße 1, D-40225 Düsseldorf, Germany
| | - Andreas S Reichert
- Institute of Biochemistry and Molecular Biology I, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Universitätsstraße 1, D-40225 Düsseldorf, Germany
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5
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Rose CF, Amodio P, Bajaj JS, Dhiman RK, Montagnese S, Taylor-Robinson SD, Vilstrup H, Jalan R. Hepatic encephalopathy: Novel insights into classification, pathophysiology and therapy. J Hepatol 2020; 73:1526-1547. [PMID: 33097308 DOI: 10.1016/j.jhep.2020.07.013] [Citation(s) in RCA: 172] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023]
Abstract
Hepatic encephalopathy (HE) is a frequent and serious complication of both chronic liver disease and acute liver failure. HE manifests as a wide spectrum of neuropsychiatric abnormalities, from subclinical changes (mild cognitive impairment) to marked disorientation, confusion and coma. The clinical and economic burden of HE is considerable, and it contributes greatly to impaired quality of life, morbidity and mortality. This review will critically discuss the latest classification of HE, as well as the pathogenesis and pathophysiological pathways underlying the neurological decline in patients with end-stage liver disease. In addition, management strategies, diagnostic approaches, currently available therapeutic options and novel treatment strategies are discussed.
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Affiliation(s)
- Christopher F Rose
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montreal, Canada.
| | - Piero Amodio
- Department of Medicine, University of Padova, Padova, Italy
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - Radha Krishan Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Simon D Taylor-Robinson
- Department of Surgery and Cancer, St. Mary's Hospital Campus, Imperial College London, London, United Kingdom
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom; European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.
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6
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Abstract
Research increasingly shows that the gut-liver-brain axis is a crucial component in the pathophysiology of hepatic encephalopathy (HE). Due to the limitations of current standard-of-care medications, non-pharmacological treatments that target gut dysbiosis, including probiotics, nutritional management, and fecal microbiota transplants, are being considered as alternative and adjunct therapies. Meta-analyses note that probiotics could offer benefits in HE treatment, but have not shown superiority over lactulose. Emerging literature suggests that fecal microbiota transplants could offer a novel strategy to treat gut dysbiosis and favorably impact HE. Finally, liver support devices and liver transplantation could offer a last-resort treatment option for persistent HE.
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Affiliation(s)
- Vanessa Weir
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, 7 South Pavilion, 3400 Civic Center Boulevard, HUP, Philadelphia, PA 19104, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, HUP, Philadelphia, PA 19104, USA.
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Pflugrad H, Tryc AB, Goldbecker A, Barg-Hock H, Strassburg C, Klempnauer J, Lanfermann H, Weissenborn K, Raab P. Cerebral metabolite alterations in patients with posttransplant encephalopathy after liver transplantation. PLoS One 2019; 14:e0221626. [PMID: 31442276 PMCID: PMC6707570 DOI: 10.1371/journal.pone.0221626] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 08/12/2019] [Indexed: 12/13/2022] Open
Abstract
Background In the first weeks after liver transplantation about 30% of the patients develop a posttransplant encephalopathy. A posttransplant encephalopathy comprises metabolic-toxic caused symptoms such as disorientation, confusion, hallucinations, cognitive dysfunction and seizures. We hypothesize that alterations of cerebral metabolites before liver transplantation predispose posttransplant encephalopathy development after liver transplantation. Methods 31 patients with chronic liver disease underwent magnetic resonance spectroscopy (MRS) before liver transplantation to assess glutamine/glutamate (Glx), myo-Inositol (mI), choline (Cho), creatine/phosphocreatine- and N-acetyl-aspartate/N-acetyl-aspartate-glutamate concentrations in the thalamus, lentiform nucleus and white matter. Of these, 14 patients underwent MRS additionally after liver transplantation. Furthermore, 15 patients received MRS only after liver transplantation. Patients’ data were compared to 20 healthy age adjusted controls. Results Patients showed significantly increased Glx and decreased mI and Cho concentrations compared to controls before liver transplantation (p≤0.01). The MRS values before liver transplantation of patients with posttransplant encephalopathy showed no significant difference compared to patients without posttransplant encephalopathy. Patients after liver transplantation showed increased Glx concentrations (p≤0.01) compared to controls, however, patients with and without posttransplant encephalopathy did not differ. Patients with posttransplant encephalopathy who underwent MRS before and after liver transplantation showed a significant mI increase in all three brain regions (p<0.04) and Glx decrease in the lentiform nucleus after liver transplantation (p = 0.04) while patients without posttransplant encephalopathy only showed a mI increase in the thalamus (p = 0.04). Conclusion Patients with and without posttransplant encephalopathy showed no significant difference in cerebral metabolites before liver transplantation. However, the paired sub-analysis indicates that the extent of cerebral metabolite alterations in patients with liver cirrhosis might be critical for the development of posttransplant encephalopathy after liver transplantation.
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Affiliation(s)
- Henning Pflugrad
- Department of Neurology, Hannover Medical School, Hannover, Germany
- Integrated Research and Treatment Centre Transplantation, Hannover, Germany
- * E-mail:
| | - Anita Blanka Tryc
- Department of Neurology, Hannover Medical School, Hannover, Germany
- Integrated Research and Treatment Centre Transplantation, Hannover, Germany
| | - Annemarie Goldbecker
- Department of Neurology, Hannover Medical School, Hannover, Germany
- Integrated Research and Treatment Centre Transplantation, Hannover, Germany
| | - Hannelore Barg-Hock
- Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Strassburg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- Integrated Research and Treatment Centre Transplantation, Hannover, Germany
- Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Heinrich Lanfermann
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Karin Weissenborn
- Department of Neurology, Hannover Medical School, Hannover, Germany
- Integrated Research and Treatment Centre Transplantation, Hannover, Germany
| | - Peter Raab
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
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8
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Relationship Between Intraoperative Bispectral Index and Consciousness Recovery in Patients With Hepatic Encephalopathy Undergoing Liver Transplant: A Retrospective Analysis. Transplant Proc 2019; 51:798-804. [DOI: 10.1016/j.transproceed.2018.10.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/30/2018] [Accepted: 10/30/2018] [Indexed: 12/27/2022]
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9
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Anand AC, Singh P. Neurological Recovery After Recovery From Acute Liver Failure: Is it Complete? J Clin Exp Hepatol 2019; 9:99-108. [PMID: 30765942 PMCID: PMC6363962 DOI: 10.1016/j.jceh.2018.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 06/11/2018] [Indexed: 12/12/2022] Open
Abstract
Neurologic dysfunction characterised by Hepatic Encephalopathy (HE) and cerebral oedema are the most dramatic presentations of Acute Liver Failure (ALF) and signify poor outcome. Improved critical care and wider availability of emergency Liver Transplantation (LT) has improved survivability in ALF. In most cases absence of clinically overt encephalopathy after spontaneous recovery from ALF or after LT is thought to indicate complete neurologic recovery. Recent data suggests that neurologic recovery may not always be complete. Instances of persistent neurologic dysfunction as well as neuropsychiatric abnormalities are now being recognised and warrant active follow up of these patients. Although evidences irreversible neurologic damage is uncommon after ALF, neuropsychiatric disturbances are not uncommon. Complex pathogenesis is involved in neurocognitive disorders seen after many other conditions including LT that require critical care. Structural damage and persistent neurological abnormalities seen after ALF are more likely to be related to cerebral edema, raised intracranial tension and cerebral hypoxemia, while neurocognitive dysfunctions may be a part of a wider spectrum of disorders commonly seen among those who recover from any critical illness.
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Key Words
- ALF, Acute Liver Failure
- APAP, Acetaminophen
- BBB, Blood Brain Barrier
- CARS, Compensatory Anti-Inflammatory Response Syndrome
- CVVH, Continuous Veno-Venous Hemodialysis
- DAMPS, Damage Associated Molecular Pattern
- DWI, Diffusion-Weighted Imaging
- EEG, Electroencephalography
- FLAIR, Fluid-Attenuated Inversion Recovery
- HE, Hepatic Encephalopathy
- LT, Liver Transplantation
- MPT, Mitochondrial Permeability Transition
- PET, Positron Emission Tomography
- SIRS, Systemic Inflammatory Response Syndrome
- acute liver failure
- cerebral oedema
- hepatic encephalopathy
- neurological dysfunction
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Affiliation(s)
- Anil C. Anand
- Address for correspondence: Anil C. Anand, Senior Consultant, Gastroenterology & Hepatology, Indraprastha Apollo Hospital, New Delhi 110076, India.
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10
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Ning Q. Main Complications of AECHB and Severe Hepatitis B (Liver Failure). ACUTE EXACERBATION OF CHRONIC HEPATITIS B 2019. [PMCID: PMC7498917 DOI: 10.1007/978-94-024-1603-9_2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Qin Ning
- Department of Infectious Disease, Tongji Hospital, Wuhan, China
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11
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Kornerup LS, Gluud LL, Vilstrup H, Dam G. Update on the Therapeutic Management of Hepatic Encephalopathy. Curr Gastroenterol Rep 2018; 20:21. [PMID: 29644492 PMCID: PMC5895665 DOI: 10.1007/s11894-018-0627-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
PURPOSE OF REVIEW Hepatic encephalopathy (HE) is a common and devastating complication to chronic liver disease. In this paper, we summarize the latest research and evidence of both conventional and up-coming treatments. RECENT FINDINGS Meta-analyses report beneficial effects of lactulose, branched-chain amino acids, rifaximin, and to some degree L-ornithine L-aspartate on the manifestations of HE in patients with cirrhosis, and generally the numbers needed to treat are low. Recent studies on newer HE treatments including ornithine phenylacetate, spherical carbon, and fecal microbiota transplant also report potentially beneficial effects on HE manifestations. The conventional treatments benefit patients with HE. Newer treatments are under study and more research is needed for their validation.
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Affiliation(s)
- Linda Skibsted Kornerup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 44 Norrebrogade, 8000, Aarhus, Denmark.
| | - Lise Lotte Gluud
- Gastrounit, Medical Division, Copenhagen University Hospital, Kettegaard Allé 30, Hvidovre, 2650, Denmark
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 44 Norrebrogade, 8000, Aarhus, Denmark
| | - Gitte Dam
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 44 Norrebrogade, 8000, Aarhus, Denmark
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12
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Tsai CY, Su CH, Chan JYH, Chan SHH. Nitrosative Stress-Induced Disruption of Baroreflex Neural Circuits in a Rat Model of Hepatic Encephalopathy: A DTI Study. Sci Rep 2017; 7:40111. [PMID: 28079146 PMCID: PMC5228038 DOI: 10.1038/srep40111] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 12/02/2016] [Indexed: 12/11/2022] Open
Abstract
The onset of hepatic encephalopathy (HE) in liver failure is associated with high mortality; the underlying mechanism is undecided. Here we report that in an acute liver failure model employing intraperitoneal administration of thioacetamide in Sprague-Dawley rats, diffusion weighted imaging revealed a progressive reduction in apparent diffusion coefficient in the brain stem. Diffusion tensor imaging further showed that the connectivity between nucleus tractus solitarii (NTS), the terminal site of baroreceptor afferents in brain stem and rostral ventrolateral medulla (RVLM), the origin of sympathetic innervation of blood vessels, was progressively disrupted until its disappearance, coincidental with the irreversible cessation of baroreflex-mediated sympathetic vasomotor tone signifying clinically the occurrence of brain death. In addition, superoxide, nitric oxide, peroxynitrite and ammonia levels in the NTS or RVLM were elevated, alongside swelling of astroctytes. A scavenger of peroxynitrite, but not an antioxidant, delivered intracisternally reversed all these events. We conclude that nitrosative stress because of augmented peroxynitrite related to accumulation of ammonia and swelling of astrocytes in the NTS or RVLM, leading to cytotoxic edema in the brain stem and severance of the NTS-RVLM connectivity, underpins the defunct baroreflex-mediated sympathetic vasomotor tone that accounts for the high mortality associated with HE.
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Affiliation(s)
- Ching-Yi Tsai
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, Republic of China
| | - Chia-Hao Su
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, Republic of China
| | - Julie Y H Chan
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, Republic of China
| | - Samuel H H Chan
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, Republic of China
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13
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Dadsetan S, Balzano T, Forteza J, Agusti A, Cabrera-Pastor A, Taoro-Gonzalez L, Hernandez-Rabaza V, Gomez-Gimenez B, ElMlili N, Llansola M, Felipo V. Infliximab reduces peripheral inflammation, neuroinflammation, and extracellular GABA in the cerebellum and improves learning and motor coordination in rats with hepatic encephalopathy. J Neuroinflammation 2016; 13:245. [PMID: 27623772 PMCID: PMC5022234 DOI: 10.1186/s12974-016-0710-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 09/06/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Peripheral inflammation contributes to the neurological alterations in hepatic encephalopathy (HE). Neuroinflammation and altered GABAergic neurotransmission mediate cognitive and motor alterations in rats with HE. It remains unclear (a) if neuroinflammation and neurological impairment in HE are a consequence of peripheral inflammation and (b) how neuroinflammation impairs GABAergic neurotransmission. The aims were to assess in rats with HE whether reducing peripheral inflammation with anti-TNF-α (1) prevents cognitive impairment and motor in-coordination, (2) normalizes neuroinflammation and extracellular GABA in the cerebellum and also (3) advances the understanding of mechanisms linking neuroinflammation and increased extracellular GABA. METHODS Rats with HE due to portacaval shunt (PCS) were treated with infliximab. Astrocytes and microglia activation and TNF-α and IL-1β were analyzed by immunohistochemistry. Membrane expression of the GABA transporters GAT-3 and GAT-1 was analyzed by cross-linking with BS3. Extracellular GABA was analyzed by microdialysis. Motor coordination was tested using the beam walking and learning ability using the Y maze task. RESULTS PCS rats show peripheral inflammation, activated astrocytes, and microglia and increased levels of TNF-α and IL-1β. Membrane expression of GAT-3 and extracellular GABA are increased, leading to impaired motor coordination and learning ability. Infliximab reduces peripheral inflammation, microglia, and astrocyte activation and neuroinflammation and normalizes GABAergic neurotransmission, motor coordination, and learning ability. CONCLUSIONS Neuroinflammation is associated with altered GABAergic neurotransmission and increased GAT-3 membrane expression and extracellular GABA (a); peripheral inflammation is a main contributor to the impairment of motor coordination and of the ability to learn the Y maze task in PCS rats (b); and reducing peripheral inflammation using safe procedures could be a new therapeutic approach to improve cognitive and motor function in patients with HE
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Affiliation(s)
- Sherry Dadsetan
- Laboratorio de Neurobiología, Centro Investigación Príncipe Felipe de Valencia, Eduardo Primo Yufera, 3, 46012 Valencia, Spain
| | - Tiziano Balzano
- Laboratorio de Neurobiología, Centro Investigación Príncipe Felipe de Valencia, Eduardo Primo Yufera, 3, 46012 Valencia, Spain
| | - Jerónimo Forteza
- Instituto Valenciano de Patología, Unidad Mixta de Patología Molecular, Centro de Investigación Príncipe Felipe/Universidad Católica de Valencia, Valencia, Spain
| | - Ana Agusti
- Laboratorio de Neurobiología, Centro Investigación Príncipe Felipe de Valencia, Eduardo Primo Yufera, 3, 46012 Valencia, Spain
| | - Andrea Cabrera-Pastor
- Laboratorio de Neurobiología, Centro Investigación Príncipe Felipe de Valencia, Eduardo Primo Yufera, 3, 46012 Valencia, Spain
| | - Lucas Taoro-Gonzalez
- Laboratorio de Neurobiología, Centro Investigación Príncipe Felipe de Valencia, Eduardo Primo Yufera, 3, 46012 Valencia, Spain
| | - Vicente Hernandez-Rabaza
- Laboratorio de Neurobiología, Centro Investigación Príncipe Felipe de Valencia, Eduardo Primo Yufera, 3, 46012 Valencia, Spain
| | - Belen Gomez-Gimenez
- Laboratorio de Neurobiología, Centro Investigación Príncipe Felipe de Valencia, Eduardo Primo Yufera, 3, 46012 Valencia, Spain
| | - Nisrin ElMlili
- Laboratorio de Neurobiología, Centro Investigación Príncipe Felipe de Valencia, Eduardo Primo Yufera, 3, 46012 Valencia, Spain
| | - Marta Llansola
- Laboratorio de Neurobiología, Centro Investigación Príncipe Felipe de Valencia, Eduardo Primo Yufera, 3, 46012 Valencia, Spain
| | - Vicente Felipo
- Laboratorio de Neurobiología, Centro Investigación Príncipe Felipe de Valencia, Eduardo Primo Yufera, 3, 46012 Valencia, Spain
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Long-and short-range functional connectivity density alteration in non-alcoholic cirrhotic patients one month after liver transplantation: A resting-state fMRI study. Brain Res 2015; 1620:177-87. [DOI: 10.1016/j.brainres.2015.04.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 04/14/2015] [Accepted: 04/17/2015] [Indexed: 02/08/2023]
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15
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Bosoi CR, Rose CF. Elevated cerebral lactate: Implications in the pathogenesis of hepatic encephalopathy. Metab Brain Dis 2014; 29:919-25. [PMID: 24916505 DOI: 10.1007/s11011-014-9573-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 05/28/2014] [Indexed: 01/31/2023]
Abstract
Hepatic encephalopathy (HE), a complex neuropsychiatric syndrome, is a frequent complication of liver failure/disease. Increased concentrations of lactate are commonly observed in HE patients, in the systemic circulation, but also in the brain. Traditionally, increased cerebral lactate is considered a marker of energy failure/impairment however alterations in lactate homeostasis may also lead to a rise in brain lactate and result in neuronal dysfunction. The latter may involve the development of brain edema. This review will target the significance of increased cerebral lactate in the pathogenesis of HE.
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Affiliation(s)
- Cristina R Bosoi
- Hepato-Neuro Laboratory, Centre Hospitalier de l'Université de Montréal (CRCHUM), 900, rue Saint-Denis - Tour Viger R08.422, Québec, H2X 0A9, Canada,
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16
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Impact of pretransplant hepatic encephalopathy on liver posttransplantation outcomes. Int J Hepatol 2013; 2013:952828. [PMID: 24324895 PMCID: PMC3845329 DOI: 10.1155/2013/952828] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 10/01/2013] [Indexed: 12/14/2022] Open
Abstract
Patients with cirrhosis commonly experience hepatic encephalopathy (HE), a condition associated with alterations in behavior, cognitive function, consciousness, and neuromuscular function of varying severity. HE occurring before liver transplant can have a substantial negative impact on posttransplant outcomes, and preoperative history of HE may be a predictor of posttransplant neurologic complications. Even with resolution of previous episodes of overt or minimal HE, some patients continue to experience cognitive deficits after transplant. Because HE is one of the most frequent pretransplant complications, improving patient HE status before transplant may improve outcomes. Current pharmacologic therapies for HE, whether for the treatment of minimal or overt HE or for prevention of HE relapse, are primarily directed at reducing cerebral exposure to systemic levels of gut-derived toxins (e.g., ammonia). The current mainstays of HE therapy are nonabsorbable disaccharides and antibiotics. The various impacts of adverse effects (such as diarrhea, abdominal distention, and dehydration) on patient's health and nutritional status should be taken into consideration when deciding the most appropriate HE management strategy in patients awaiting liver transplant. This paper reviews the potential consequences of pretransplant HE on posttransplant outcomes and therapeutic strategies for the pretransplant management of HE.
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Atluri DK, Prakash R, Mullen KD. Pathogenesis, diagnosis, and treatment of hepatic encephalopathy. J Clin Exp Hepatol 2011; 1:77-86. [PMID: 25755319 PMCID: PMC3940085 DOI: 10.1016/s0973-6883(11)60126-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 09/02/2011] [Indexed: 02/07/2023] Open
Abstract
Hepatic encephalopathy (HE) is a neuropsychiatric disorder seen in patients with advanced liver disease or porto-systemic shunts. Based on etiology and severity of HE, the World Congress of Gastroenterology has divided HE into categories and sub-categories. Many user-friendly computer-based neuropsychiatric tests are being validated for diagnosing covert HE. Currently, emphasis is being given to view HE deficits as a continuous spectrum rather than distinct stages. Ammonia is believed to play crucial role in pathogenesis of HE via astrocyte swelling and cerebral edema. However, evidence has been building up which supports the synergistic role of oxidative stress, inflammation and neurosteroids in pathogenesis of HE. At present, treatment of HE aims at decreasing the production and intestinal absorption of ammonia. But as the role of new pathogenetic mechanisms becomes clear, many potential new treatment strategies may become available for clinician.
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Key Words
- AAA, aromatic amino acid
- BAUR, brain ammonia utilization rate
- BCAA, branched-chain amino acids
- CFF, critical flicker fusion
- DBI, diazepam binding inhibitor
- DST, digit symbol test
- DWI, diffusion weighted imaging
- Diagnosis
- ECAD, extra-corporeal albumin dialysis
- EEC, electroencephalogram
- FLAIR, fluid attenuation inversion recovery
- HE, hepatic encephalopathy
- HESA, hepatic encephalopathy scoring algorithm
- ICT, inhibitory control test
- IL, interleukin
- LOLA, L-ornithine L-aspartate
- LTT, line tracing test
- MARS, molecular adsorbent reticulating system
- MHE, minimal hepatic encephalopathy
- MRI, magnetic resonance imaging
- NAC, N-acetyl cysteine
- NO, nitric oxide
- NS, neurosteroids
- NSAID, non-steroidal anti-inflammatory drugs
- ODN, octadecaneuropeptide
- OHE, overt hepatic encephalopathy
- PTBR, peripheral-type benzodiaze-pine receptor
- QOL, quality of life
- SDT, serial dotting test
- SEDACA, short epoch, dominant activity, and cluster analysis
- SIBO, small intestinal bacterial overgrowth
- SIRS, systemic inflammatory response syndrome
- SOD, Superoxide dismutase
- SONIC, spectrum of neurological impairment
- TLP, TransLocator Protein
- TNF, tumor necrosis factor
- hepatic encephalopathy
- pathogenesis
- treatment
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Affiliation(s)
| | | | - Kevin D Mullen
- Address for correspondence: Dr Kevin D Mullen, Gastroenterology Department, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH-44109, USA
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Zemtsova I, Görg B, Keitel V, Bidmon HJ, Schrör K, Häussinger D. Microglia activation in hepatic encephalopathy in rats and humans. Hepatology 2011; 54:204-15. [PMID: 21452284 DOI: 10.1002/hep.24326] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
UNLABELLED Astrocytes play an important role in the pathogenesis of hepatic encephalopathy (HE) and ammonia toxicity, whereas little is known about microglia and neuroinflammation under these conditions. We therefore studied the effects of ammonia on rat microglia in vitro and in vivo and analyzed markers of neuroinflammation in post mortem brain tissue from patients with cirrhosis with and without HE and non-cirrhotic controls. In cultured rat microglia, ammonia stimulated cell migration and induced oxidative stress and an up-regulation of the microglial activation marker ionized calcium-binding adaptor molecule-1 (Iba-1). Up-regulation of Iba-1 was also found in the cerebral cortex from acutely ammonia-intoxicated rats and in the cerebral cortex from patients with cirrhosis who have HE, but not from patients with cirrhosis who do not have HE. However, ammonia had no effect on microglial glutamate release, prostaglandin synthesis, and messenger RNA (mRNA) levels of inducible nitric oxide synthase (iNOS), cyclooxygenase-2 (COX-2), and the proinflammatory cytokines interleukin (IL)-1α/β, tumor necrosis factor α, or IL-6, whereas in cultured astrocytes ammonia induced the release of glutamate, prostaglandins, and increased IL-1β mRNA. mRNA and protein expression of iNOS and COX-2 or mRNA expression of proinflammatory cytokines and chemokine monocyte chemoattractive protein-1 in cerebral cortex from patients with liver cirrhosis and HE were not different from those found in patients with cirrhosis who did not have HE or control patients without cirrhosis. CONCLUSION These data suggest that microglia become activated in experimental hyperammonemia and HE in humans and may contribute to the generation of oxidative stress. However, HE in patients with liver cirrhosis is not associated with an up-regulation of inflammatory cytokines in cerebral cortex, despite microglia activation.
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Affiliation(s)
- Irina Zemtsova
- Clinic for Gastroenterology, Hepatology, and Infectiology, Heinrich-Heine University, Düsseldorf, Germany
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Garcia-Martinez R, Rovira A, Alonso J, Jacas C, Simón-Talero M, Chavarria L, Vargas V, Córdoba J. Hepatic encephalopathy is associated with posttransplant cognitive function and brain volume. Liver Transpl 2011; 17:38-46. [PMID: 21254343 DOI: 10.1002/lt.22197] [Citation(s) in RCA: 111] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Hepatic encephalopathy (HE) is a common complication of cirrhosis that is associated with brain atrophy and may participate in impaired cognitive function after liver transplantation. This study analyzes the relationship of HE with cognitive function and brain volume after transplantation. A total of 52 consecutive patients with cirrhosis (24 alcohol abuse, 24 prior HE, 14 diabetes mellitus) completed a neuropsychological assessment before liver transplantation and again, 6 to 12 months after transplantation. In 24 patients who underwent the posttransplant assessment, magnetic resonance imaging was performed in addition, with measurement of brain volume and relative concentration of N-acetylaspartate (NAA) and creatine/phosphocreatine (Cr), a neuronal marker, by magnetic resonance spectroscopy. Neuropsychological assessment prior to transplantation identified minimal HE in 28 patients. All cognitive indexes improved after liver transplantation, but 7 patients (13%) showed persistent mild cognitive impairment. Global cognitive function after transplantation was poorer in patients with the following variables before liver transplantation: alcohol etiology, diabetes mellitus, and HE. Brain volume after transplantation was smaller in patients with prior HE. Brain volume correlated to NAA/Cr values (r = 0.498, P = 0.013) and poor motor function (r = 0.41, P = 0.049). In conclusion, the association of HE with cognitive function and brain volume suggests that having experienced HE before liver transplantation impairs the posttransplantation neurological outcome.
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Affiliation(s)
- Rita Garcia-Martinez
- Internal Medicine Hepatology Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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