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Moon GS, Choi YU, Shim H, Jang JY. Autoimmune Hemolytic Anemia Combined with Sepsis After Abdominal Trauma Surgery. JOURNAL OF ACUTE CARE SURGERY 2021. [DOI: 10.17479/jacs.2021.11.2.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Intra-abdominal infection is a common, serious complication in patients undergoing emergency abdominal surgery following blunt abdominal trauma. Infectious conditions increase the incidence of autoimmune hemolytic anemia (AIHA), but reports of AIHA occurring after abdominal trauma surgery are rare. Therefore, we report a case of sepsis due to fasciitis and AIHA after abdominal trauma surgery which was successfully managed following the appropriate treatment of both conditions.
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Abstract
Jaundice in the hospitalized patient is not an uncommon consultation for the general gastroenterologist. It is essential to explore the underlying cause of jaundice because management is largely aimed at addressing these causes rather than the jaundice itself. Although the diagnostic evaluation for jaundice can be broad, clinical judgment must be used to prioritize between various laboratory tests and imaging studies. Most importantly, clinicians must understand which conditions are emergent and/or require evaluation for liver transplantation. Further studies need to be performed to better understand the outcomes of hospitalized patients who develop jaundice.
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Affiliation(s)
- Priya Kathpalia
- Division of Gastroenterology and Hepatology, University of California, San Francisco, 513 Parnassus Avenue, Med Sci Room S-356, San Francisco, CA 94143, USA
| | - Joseph Ahn
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239-3098, USA.
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3
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Patel JJ, Taneja A, Niccum D, Kumar G, Jacobs E, Nanchal R. The Association of Serum Bilirubin Levels on the Outcomes of Severe Sepsis. J Intensive Care Med 2015; 30:23-29. [DOI: 10.1177/0885066613488739] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Purpose: Admission serum bilirubin levels have been incorporated into severity of illness scoring systems in critical illness as a marker of liver dysfunction. The purpose of our study is to determine the independent association of serum bilirubin with mortality in severe sepsis and septic shock. Methods: We conducted a retrospective study of adult patients admitted with severe sepsis and septic shock. We excluded patients with a prior history of liver disease. We identified the highest serum bilirubin within 72 hours of admission and stratified bilirubin levels into ≤1 mg/dL (normal), 1.1 to 2 mg/dL (abnormal up to 2 mg/dL), and >2 mg/dL. We sought to determine the independent association of hyperbilirubinemia with mortality and length of intensive care unit stay in persons with severe sepsis and septic shock. Results: A total of 251 patients met criteria for severe sepsis. In all, 200 patients had a bilirubin of <1 mg/dL, and 51 had a bilirubin of >1 mg/dL. Of these 51, 12 had a bilirubin >2 mg/dL. Mortality was 12%, 24%, and 42% in persons with a bilirubin ≤1, 1.1 to 2, and >2 mg/dL, respectively. Compared to those with a bilirubin ≤ 1 mg/dL, adjusted odds of mortality in patients were 3.85 (95% confidence interval [CI] 1.21-12.2) and 9.85 (95% CI 1.92-50.5) times higher in persons with bilirubin levels between 1.1 and 2 and >2 mg/dL, respectively. Conclusion: After multivariable adjustment for potential confounding factors, elevated serum bilirubin levels within 72 hours of admission are associated with an increased risk of mortality in patients with severe sepsis and septic shock. Prospective studies are warranted to further validate our findings.
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Affiliation(s)
- Jayshil J. Patel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Amit Taneja
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David Niccum
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Gagan Kumar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Elizabeth Jacobs
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rahul Nanchal
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Kaulen SA, Hübner C, Mieth J, Spindler K, Schwab R, Wimmer R, Wilhelm J, Amoury M, Girndt M, Werdan K, Ebelt H. [Indocyanine green elimination for the evaluation of liver function: prognostic value in patients with community-acquired sepsis]. Med Klin Intensivmed Notfmed 2014; 109:531-40. [PMID: 25179001 DOI: 10.1007/s00063-014-0374-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 02/26/2014] [Accepted: 04/06/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND The aim of our clinical study was to correlate liver function measured by indocyanine green (ICG) elimination and clinical outcomes in patients with an early stage of community-acquired sepsis (CAS). MATERIALS AND METHODS A total of 341 patients (≥ 18 years) presenting with suspicion of CAS or evidence of an infection and fulfillment of ≥ 2 systemic inflammatory response syndrome (SIRS) criteria were included in the observational study"Prognosis of early sepsis 2" (Prognose der frühen Sepsis 2, ProFS 2). Patients who had been hospitalized within the last 7 days were excluded. In a subgroup of these patients (n = 72) who were transferred to an intensive or intermediate care unit according to the clinical judgment of the treating physicians, ICG elimination (plasma disappearance rate, ICG-PDR; 15 min retention rate, ICG-R15) was assessed by using a noninvasive monitoring system (LiMON, PULSION Medical Systems, Germany). ICG-PDR and -R15 were determined on the day of admission (n = 72) and after 96 h (n = 34). The primary end point of the study was defined as death within 30 days. Secondary endpoints were need for renal replacement therapy, requirement for invasive mechanical ventilation, and length of stay in an intermediate or intensive care unit. RESULTS AND CONCLUSION In contrast to patients with sepsis or severe sepsis, ICG elimination was found to be significantly impaired in patients with septic shock. Furthermore, a significant predictive value of ICG-PDR and -R15 on the day of admission for the need for subsequent renal replacement therapy (n = 12) was observed. In addition, reduced ICG elimination was associated with a longer stay in an intermediate or intensive care unit. However, ICG elimination on admission could not predict 30-day mortality (n = 14) or requirement of mechanical ventilation (n = 20).
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Affiliation(s)
- S A Kaulen
- Universitätsklinik und Poliklinik für Innere Medizin III, Universitätsklinikum Halle (Saale), Ernst-Grube-Str. 40, 06097, Halle (Saale), Deutschland,
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Sevastos N, Manesis EK, Savvas SP, Galiatsatos N, Papatheodoridis GV, Archimandritis AJ. Changes of liver and muscle enzymes activity in patients with rigor. Eur J Intern Med 2008; 19:109-14. [PMID: 18249306 DOI: 10.1016/j.ejim.2007.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2006] [Revised: 03/22/2007] [Accepted: 05/10/2007] [Indexed: 11/25/2022]
Abstract
AIM We investigated whether changes of liver and muscle enzymes activity are associated with rigor of several causes and have any prognostic significance. METHODS Seventy-five patients with rigor were prospectively evaluated. Serum enzymes were measured at the onset of rigor and during the three following days. RESULTS Causes of rigor were bacteremia (n=28), cholangiitis (n=12), protozoan infections (n=9), viral infections (n=10) and platelet transfusions (n=16). Increases in enzymes activity were observed with rigors from infectious causes, but not with that following platelet transfusions. Patients with cholangiitis demonstrated the highest ALT elevations, while those with viral infections the highest CPK levels. In bacteremia, CPK values increased significantly only in cases with dehydration and hypokalemia. CONCLUSIONS Rigor per se does not cause increases in muscle or liver enzymes activities. Rather these changes are associated with the rigor's causative agent (infectious or not), the patient's general condition and the severity and extent of the underlying disease.
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Affiliation(s)
- Nikolaos Sevastos
- 2nd Department of Internal Medicine, National University of Athens Medical School, Hippokration General Hospital, 114 Vas. Sophias ave., 11527 Athens, Greece.
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Chen YH, Hong IC, Kuo KK, Hsu HK, Hsu C. Role of retinoid-X receptor-alpha in the suppression of rat bile acid coenzyme A-amino acid N-acyltransferase in liver during sepsis. Shock 2007; 28:65-70. [PMID: 17483744 DOI: 10.1097/shk.0b013e31802ec5d2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Sepsis causes intrahepatic cholestasis and leads to hepatic failure. However, the pathophysiology of hepatic events is unclear. Expression of rat hepatic bile acid coenzyme A-amino acid N-acyltransferase (rBAT), a major enzyme for the conjugation of bile acids, is significantly decreased during sepsis. rBAT transcriptional regulation is mainly by a heterodimer of farnesoid-X receptor (FXR) and retinoid-X receptor-alpha (RXR-alpha) via the inverted repeat 1 sequence. During sepsis, nuclear receptors and translocation of RXR-alpha from cytosol to nucleus decrease. The purpose of this study was to further clarify the mechanisms of RXR-alpha-mediated rBAT regulation during polymicrobial sepsis and with dexamethasone treatment. Polymicrobial sepsis was induced in rats by cecal ligation and puncture (CLP). Liver tissues obtained 3, 6, 9, and 18 h after CLP were studied, and hepatocytes were isolated from rats with sepsis. Post-CLP decreases were observed in mRNA levels of rBAT (6 h), protein levels of rBAT (6 h), RXR-alpha (6 h), and FXR (9 h). DNA binding activity of FXR/RXR significantly decreased at 6 h after CLP. Dexamethasone reversed sepsis-inhibited RXR-alpha expression and the binding activity of FXR/RXR to rBAT DNA as well as rBAT protein expression. The results suggest that suppression of rBAT occurs at the transcriptional level, and the decrease in RXR-alpha by septic insult may play a critical role in rBAT suppression at the early stage of polymicrobial sepsis.
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Affiliation(s)
- Yen-Hsu Chen
- Department of Internal Medicine, Division of Infectious Diseases, Kaohsiung Medical University, Kaohsiung, Taiwan
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Abstract
Hyperbilirubinemia, or jaundice, is common in the ICU, with incidence up to 40% among critically ill patients. Unfortunately, it is poorly understood in the critically ill, and too often presents a diagnostic dilemma to the ICU physician. Causes of jaundice in the ICU are multiple; the etiology in any given patient, multifactorial. Acute jaundice can be a harbinger or marker of sepsis, multisystem organ failure (MSOF), or a reflection of transient hypotension (shock liver), right-sided heart failure, the metabolic breakdown of red blood cells, or pharmacologic toxicity. Acute ICU jaundice is best divided into obstructive and nonobstructive. This stratification directs subsequent management and therapeutic decisions.
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Affiliation(s)
- Vishal Bansal
- Department of Surgery, University of California at San Diego, San Diego, CA, USA
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Affiliation(s)
- Nisha Chand
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, VA 23298-0341, USA
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Gu X, Ke S, Liu D, Sheng T, Thomas PE, Rabson AB, Gallo MA, Xie W, Tian Y. Role of NF-kappaB in regulation of PXR-mediated gene expression: a mechanism for the suppression of cytochrome P-450 3A4 by proinflammatory agents. J Biol Chem 2006; 281:17882-9. [PMID: 16608838 DOI: 10.1074/jbc.m601302200] [Citation(s) in RCA: 235] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
It is a long-standing observation that inflammatory responses and infections decrease drug metabolism capacity in human and experimental animals. Cytochrome P-450 3A4 cyp304 is responsible for the metabolism of over 50% of current prescription drugs, and cyp3a4 expression is transcriptionally regulated by pregnane X receptor (PXR), which is a ligand-dependent transcription factor. In this study, we report that NF-kappaB activation by lipopolysaccharide and tumor necrosis factor-alpha plays a pivotal role in the suppression of cyp3a4 through interactions of NF-kappaB with the PXR.retinoid X receptor (RXR) complex. Inhibition of NF-kappaB by NF-kappaB-specific suppressor SRIkappaBalpha reversed the suppressive effects of lipopolysaccharide and tumor necrosis factor-alpha. Furthermore, we showed that NF-kappaB p65 disrupted the association of the PXR.RXRalpha complex with DNA sequences as determined by electrophoretic mobility shift assay and chromatin immunoprecipitation assays. NF-kappaB p65 directly interacted with the DNA-binding domain of RXRalpha and may prevent its binding to the consensus DNA sequences, thus inhibiting the transactivation by the PXR.RXRalpha complex. This mechanism of suppression by NF-kappaB activation may be extended to other nuclear receptor-regulated systems where RXRalpha is a dimerization partner.
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Affiliation(s)
- Xinsheng Gu
- Department of Veterinary Physiology and Pharmacology, Texas A & M University, College Station, TX 77843, USA
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Brienza N, Dalfino L, Cinnella G, Diele C, Bruno F, Fiore T. Jaundice in critical illness: promoting factors of a concealed reality. Intensive Care Med 2006; 32:267-274. [PMID: 16450099 DOI: 10.1007/s00134-005-0023-3] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2005] [Accepted: 11/28/2005] [Indexed: 12/24/2022]
Abstract
OBJECTIVE In critical illness, liver dysfunction (LD) is associated with a poor outcome independently of other organ dysfunctions. Since strategies to support liver function are not available, a timely and accurate identification of factors promoting LD may lead to prevention or attenuation of its consequences. The aim of this study was to assess risk factors for LD in critically ill patients. DESIGN Prospective, observational study. SETTING A multidisciplinary intensive care unit (ICU) of a university hospital. PATIENTS All patients consecutively admitted over a 6-month period. INTERVENTION None. MEASUREMENTS AND RESULTS LD was defined as serum bilirubin levels >or=2 mg/dl and lasting for at least 48 h. Out of 283 patients, 141 matched inclusion criteria. Forty-four patients (31.2%) showed LD (LD group), while 97 (68.8%) were included in control group (C group). A binomial analysis showed that LD occurrence was associated with moderate (odds ratio [OR] 3.11; p=0.04) and severe shock (OR 3.46; p= 0.05), sepsis (OR 3.03; p=0.04), PEEP ventilation (OR 4.25; p=0.006), major surgery (OR 4.03; p=0.03), and gram-negative infections (OR 3.94; p=0.002). In stepwise multivariate analysis, the single independent predictive factors of LD resulted in severe shock (p=0.002), sepsis (p=0.03), PEEP ventilation (p=0.04), and major surgery (p=0.05). CONCLUSIONS In critically ill patients jaundice is common, and severe shock states, sepsis, mechanical ventilation with PEEP and major surgery are critical risk factors for its onset. Since there is no specific treatment, prompt resuscitation, treatment of sepsis and meticulous supportive care will likely reduce its incidence and severity.
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Affiliation(s)
- Nicola Brienza
- Emergency and Organ Transplantation Department, Anaesthesia and Intensive Care Unit, University of Bari, P.zza G. Cesare 11, 70124, Bari, Italy.
| | - Lidia Dalfino
- Emergency and Organ Transplantation Department, Anaesthesia and Intensive Care Unit, University of Bari, P.zza G. Cesare 11, 70124, Bari, Italy
| | - Gilda Cinnella
- Anaesthesia and Intensive Care Unit, University of Foggia, Foggia, Italy
| | - Caterina Diele
- Emergency and Organ Transplantation Department, Anaesthesia and Intensive Care Unit, University of Bari, P.zza G. Cesare 11, 70124, Bari, Italy
| | - Francesco Bruno
- Emergency and Organ Transplantation Department, Anaesthesia and Intensive Care Unit, University of Bari, P.zza G. Cesare 11, 70124, Bari, Italy
| | - Tommaso Fiore
- Emergency and Organ Transplantation Department, Anaesthesia and Intensive Care Unit, University of Bari, P.zza G. Cesare 11, 70124, Bari, Italy
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Cherrington NJ, Slitt AL, Li N, Klaassen CD. Lipopolysaccharide-mediated regulation of hepatic transporter mRNA levels in rats. Drug Metab Dispos 2005; 32:734-41. [PMID: 15205389 DOI: 10.1124/dmd.32.7.734] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The function of hepatic transporters is to move organic substances across sinusoidal and canalicular membranes. During extrahepatic cholestasis, transporters involved in the movement of substances from blood to bile, such as sodium/taurocholate-cotransporting polypeptide (Ntcp) and multidrug resistance protein 2 (Mrp2), are down-regulated, whereas others that transport chemicals from liver to blood, such as Mrp3, are up-regulated. Unlike extrahepatic cholestasis, where transporter expression responds to the stress of accumulating bile constituents, lipopolysaccharide (LPS)-induced intrahepatic cholestasis may be directly caused by alterations in transporter expression. The aim of this study was to quantitatively determine the effect of LPS on transporter expression and study the mechanism(s) by which LPS alters mRNA levels of major hepatic transporters in Sprague-Dawley rats. Hepatic mRNA levels of Mrp2, Mrp6, multiple drug resistance protein 1a (Mdr1a), organic anion-transporting polypeptide 1 (Oatp1), Oatp2, Oatp4, Ntcp, bile salt export pump, organic cation transporter 1 (Oct1), and organic anion transporter 3 (Oat3) were dramatically decreased, beginning approximately 6 h after LPS administration, whereas Mrp5 and Oat2 levels were unchanged. In contrast, LPS increased mRNA levels of Mrp1, Mrp3, and Mdr1b concurrently with the down-regulated transporters. Pretreatment with dexamethasone, which decreases the release of cytokines, reversed the reduction of Mdr1a, Oatp1, Oatp2, Oct1, and Ntcp mRNA following LPS administration. Furthermore, dexamethasone pretreatment also prevented the LPS-mediated increase in Mrp1, Mrp3, and Mdr1b, whereas pretreatment with aminoguanidine or gadolinium chloride, an inhibitor of inducible nitric oxide synthetase and a Kupffer cell toxicant, respectively, had no effect on the LPS-induced changes. The concurrent repression and induction of various transporters, as well as dexamethasone abatement of both LPS-mediated repression and induction, indicates that these responses may be mediated through similar pathways.
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Affiliation(s)
- Nathan J Cherrington
- Department of Pharmacology, Toxicology & Therapeutics, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS 66160, USA
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12
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Wang WW, Smith DLH, Zucker SD. Bilirubin inhibits iNOS expression and NO production in response to endotoxin in rats. Hepatology 2004; 40:424-33. [PMID: 15368447 DOI: 10.1002/hep.20334] [Citation(s) in RCA: 169] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The inducible isoform of heme oxygenase (HO), HO-1, has been shown to play an important role in attenuating tissue injury. Because HO-1 catalyzes the rate-limiting step in bilirubin synthesis, we examined the hypothesis that bilirubin is a key mediator of HO-1 cytoprotection, employing a rat model of endotoxemia. Bilirubin treatment resulted in improved survival and attenuated liver injury in response to lipopolysaccharide infusion. Serum levels of NO and tumor necrosis factor alpha, key mediators of endotoxemia, and hepatic inducible nitric oxide synthase (iNOS) expression were significantly lower in bilirubin-treated rodents versus control animals. Both intraperitoneal and local administration of bilirubin also was found to ameliorate hindpaw inflammation induced by the injection of lambda-carrageenan. Consistent with in vivo results, bilirubin significantly inhibited iNOS expression and suppressed NO production in lipopolysaccharide (LPS)-stimulated RAW 264.7 murine macrophages. In contrast, bilirubin treatment induced a threefold increase in LPS-mediated prostaglandin synthesis in the absence of significant changes in cyclooxygenase expression or activity, suggesting that bilirubin enhances substrate availability for eicosanoid synthesis. Bilirubin had no effect on LPS-mediated activation of nuclear factor kappaB or p38 mitogen-activated protein kinase, consistent with a nuclear factor kappaB-independent mechanism of action. Taken together, these data support a cytoprotective role for bilirubin that is mediated, at least in part, through the inhibition of iNOS expression and, potentially, through stimulation of local prostaglandin E2 production. In conclusion, our findings suggest a role for bilirubin in mollifying tissue injury in response to inflammatory stimuli and support the possibility that the phenomenon of "jaundice of sepsis" represents an adaptive physiological response to endotoxemia. Supplementary material for this article can be found on the HEPATOLOGY website (http://interscience.wiley.com/jpages/0270-9139/suppmat/index.html).
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Affiliation(s)
- Weizheng W Wang
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH 45267-0595, USA
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Mesotten D, Van den Berghe G, Liddle C, Coulter S, McDougall F, Baxter RC, Delhanty PJD. Growth hormone modulation of the rat hepatic bile transporter system in endotoxin-induced cholestasis. Endocrinology 2003; 144:4008-17. [PMID: 12933675 DOI: 10.1210/en.2003-0139] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Treatment with high dose human GH, although an effective anabolic agent, has been associated with increased incidence of sepsis, inflammation, multiple organ failure, and death in critically ill patients. We hypothesized that GH might increase mortality by exacerbating cholestasis through modulation of bile acid transporter expression. High dose GH was continuously infused over 4 d into rats, and on the final day lipopolysaccharides were injected. Hepatic bile acid transporter expression was measured by Northern analysis and immunoblotting and compared with serum markers of cholestasis and endotoxinemia. Compared with non-GH-treated controls, GH increased endotoxin-induced markers of cholestasis and liver damage as well as augmented IL-6 induction. In endotoxinemia, GH treatment significantly induced multidrug resistance-associated protein 1 mRNA and protein and suppressed organic anion transporting polypeptides, Oatp1 and Oatp4, mRNA, suggesting impaired uptake of bilirubin and bile acids at the basolateral surface of the hepatocyte, which could contribute to the observed worsening of cholestasis by GH. This study of endotoxinemia may thus provide a mechanistic link between GH treatment and exacerbation of cholestasis through modulation of basolateral bile acid transporter expression in the rat hepatocyte.
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Affiliation(s)
- Dieter Mesotten
- Kolling Institute of Medical Research, University of Sydney, Royal North Shore Hospital, St. Leonards, New South Wales 2065, Australia.
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14
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Abstract
The relationship between the sepsis syndrome and the development of jaundice is intriguing, with jaundice having been described as the presenting sign of septicaemia in very few cases. We describe a patient who developed a deep jaundice with conjugated hyperbilirubinaemia caused by Staphylococcus aureus during the early course of septicaemia, when no other sign of the sepsis syndrome could be recognised. It is generally accepted that a mild jaundice may complicate the course of the sepsis syndrome, but it is most unusual to observe such a protracted phase of jaundice before the emergence of other specific clinical signs and laboratory abnormalities. Clinicians should be aware of this presentation of the sepsis syndrome in order to avoid a potentially harmful delay in diagnosis and treatment.
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Affiliation(s)
- Giuseppe Famularo
- Department of Internal Medicine, San Camillo Hospital, Circonvallazione Gianicolense, 00152, Rome, Italy
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Narita R, Murata M, Kihara Y, Abe S, Tabaru A, Yoshikawa I, Otsuki M. Sepsis presenting with severe jaundice. Am J Gastroenterol 2001; 96:3214-5. [PMID: 11721785 DOI: 10.1111/j.1572-0241.2001.05292.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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16
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Abstract
Inflammatory cytokines produced in response to various infectious and non-infectious stimuli are potent inducers of intrahepatic cholestasis (inflammation-induced cholestasis). The cholestatic effect of cytokines results mainly from inhibition of expression and function of hepatocellular transport systems which normally mediate hepatic uptake and biliary excretion of bile salts and various non-bile salt organic anions (e.g. bilirubin). These cytokine effects are reversible and bile secretory function is restored upon disappearance of the inflammatory injury. This review summarizes the clinical, pathophysiological and molecular aspects of inflammation-induced cholestasis.
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Affiliation(s)
- M Trauner
- Department of Internal Medicine, Karl-Franzens University School of Medicine, Graz, Austria.
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17
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Lund M, Kang L, Tygstrup N, Wolkoff AW, Ott P. Effects of LPS on transport of indocyanine green and alanine uptake in perfused rat liver. THE AMERICAN JOURNAL OF PHYSIOLOGY 1999; 277:G91-100. [PMID: 10409155 DOI: 10.1152/ajpgi.1999.277.1.g91] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Lipopolysaccharide (LPS) initiates cholestasis. Whether this process is mediated by tumor necrosis factor-alpha (TNF-alpha) and whether the cholestatic response to LPS is associated with intrahepatic accumulation of possibly toxic substances are under debate. To study these questions the hepatic uptake and biliary excretion of indocyanine green (ICG) was examined in the isolated perfused rat liver 18 h after intravenous treatment of rats with either saline, 1 mg/kg body wt LPS, or LPS and intraperitoneal pentoxifylline (POF) (n = 6 in each group). POF inhibits TNF-alpha release after LPS administration. LPS induced a typical acute-phase response with increased mRNA for acute-phase proteins, reduced albumin mRNA, and increased hepatic uptake of alanine. Intrinsic hepatic clearance of ICG in controls (1.01 +/- 0.05 ml. min(-1). g liver(-1)) was similarly decreased by LPS alone (0.62 +/- 0.04 ml. min(-1). g(-1); P = 0.002 vs. control) or combined with POF (0.66 +/- 0.06 ml. min(-1). g(-1)). A kinetic analysis indicated that LPS reduced both uptake and excretion processes in a balanced manner, so that intrahepatic ICG content was unaffected or even slightly reduced, as confirmed by measurement of ICG contents in the perfused livers. In livers from parallel-treated nonperfused rats, mRNA for the organic anion transporting protein-1 (Oatp1, which is likely to mediate ICG uptake) was unaffected by LPS, whereas the concentration of Oatp1 protein was reduced. Thus LPS induced an acute-phase response that included downregulation of ICG uptake by reduction of Oatp1 protein concentration, possibly at a posttranscriptional level. TNF-alpha appears not to be the mediator because POF did not modify these LPS effects.
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Affiliation(s)
- M Lund
- Medical Department A, National University Hospital, 2100 O Copenhagen, Denmark
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18
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Koopen NR, Müller M, Vonk RJ, Zimniak P, Kuipers F. Molecular mechanisms of cholestasis: causes and consequences of impaired bile formation. BIOCHIMICA ET BIOPHYSICA ACTA 1998; 1408:1-17. [PMID: 9784591 DOI: 10.1016/s0925-4439(98)00053-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- N R Koopen
- Groningen Institute for Drug Studies, Center for Liver, Digestive and Metabolic Diseases, CMC IV, Room Y2115, University Hospital Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
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19
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Nishida T, Huang TP, Seiyama A, Hamada E, Kamiike W, Ueshima S, Kazuo H, Matsuda H. Endothelin A-receptor blockade worsens endotoxin-induced hepatic microcirculatory changes and necrosis. Gastroenterology 1998; 115:412-20. [PMID: 9679047 DOI: 10.1016/s0016-5085(98)70208-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS Endothelin 1 is considered to be an important regulator of sinusoidal blood flow and increases during endotoxemia. The purpose of this study was to investigate the role of endothelin 1 in hepatic microcirculation, oxygen transport, and liver injury during endotoxemia. METHODS Male Sprague-Dawley rats were continuously infused with 2.5 mL/h of saline, 0.8 mg . kg-1 . h-1 of lipopolysaccharide (LPS), 3 mg . kg-1 . h-1 of BQ-485, an endothelin A-receptor antagonist, or LPS plus BQ-485 for 7 hours. RESULTS BQ-485 infusion had no significant effect on hepatic microcirculation and liver injury. LPS increased the plasma levels of aspartate aminotransferase (AST) and total bilirubin and decreased the hepatic adenosine triphosphate (ATP) level and bile flow rate. LPS + BQ-485 infusion further increased the plasma levels of AST and total bilirubin and decreased the bile flow rate and the hepatic ATP level. Dual-spot microspectroscopy revealed mild decreases in sinusoidal erythrocyte velocity and oxygen transport in the LPS group and profound decreases in these parameters in the LPS + BQ-485 group. Histological examinations revealed massive necrotic changes in the pericentral regions of the LPS + BQ-485 group. CONCLUSIONS These results suggest that blockade of endothelin A receptors disturbs hepatic microcirculation and oxygen transport and aggravates the necrotic injury induced by endotoxin.
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Affiliation(s)
- T Nishida
- First Department of Surgery, Osaka University Medical School, Osaka, Japan
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20
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Trauner M, Arrese M, Lee H, Boyer JL, Karpen SJ. Endotoxin downregulates rat hepatic ntcp gene expression via decreased activity of critical transcription factors. J Clin Invest 1998; 101:2092-100. [PMID: 9593765 PMCID: PMC508797 DOI: 10.1172/jci1680] [Citation(s) in RCA: 206] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Sodium-dependent uptake of bile acids across the hepatic basolateral membrane is rapidly and profoundly diminished during sepsis, thus contributing to the pathogenesis of sepsis-associated cholestasis. This effect is mediated by endotoxin or effector cytokines, which reduce expression of several hepatobiliary transporters, including the sodium-dependent bile acid transporter gene, ntcp. We test here the hypothesis that endotoxin treatment leads to impaired binding activity of ntcp promoter trans-acting factors, resulting in reduction of ntcp mRNA expression. After endotoxin administration, ntcp mRNA levels reached their nadir by 16 h, and nuclear run-on assays demonstrated a marked reduction in ntcp gene transcription. At 16 h after treatment, nuclear binding activities of two key factors that transactivate the ntcp promoter, hepatocyte nuclear factor (HNF) 1 and Footprint B binding protein (FpB BP), decreased to 44 and 47% of pretreatment levels, respectively, while levels of the other known ntcp promoter transactivator, signal transducer and activator of transcription 5, were unaffected. In contrast, the universal inflammatory response factors nuclear factor kappaB and activating protein 1 were both upregulated significantly. Examination of nuclear extracts obtained at sequential time points revealed that the maximal decrease in nuclear activities of both HNF1 and FpB BP preceded the nadir of ntcp mRNA expression by 6-10 h. Furthermore, these two nuclear factors returned towards normal levels before the recovery of ntcp mRNA levels observed by 48 h. Since HNF1alpha mRNA levels were unchanged at all time points, HNF1 is likely to be regulated posttranscriptionally by endotoxin. We conclude that the downregulation of ntcp gene expression by endotoxin is mediated at the level of transcription through tandem reductions in the nuclear binding activity of two critical transcription factors. These findings provide new insight into the coordinated downregulation of hepatobiliary transporters during sepsis.
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Affiliation(s)
- M Trauner
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut 06520, USA
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21
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Denaro CP, Jacob P, Benowitz NL. Evaluation of pharmacokinetic methods used to estimate caffeine clearance and comparison with a Bayesian forecasting method. Ther Drug Monit 1998; 20:78-87. [PMID: 9485560 DOI: 10.1097/00007691-199802000-00015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Simplified pharmacokinetic methods have been used to estimate caffeine clearance in subjects with liver disease. There is a need to have a reliable, easy to implement method for research and possible clinical use. This study evaluates the use of Bayesian pharmacokinetic forecasting techniques to estimate caffeine clearance and compares its performance to other published methods. Commonly used published methods include the two-concentration overnight salivary clearance method (Jost method) and a method that samples caffeine concentrations over a 4-hour time period (Nagel method). Both have been used in studies incorporating serial measurements of caffeine clearance to predict clinical outcomes in subjects with liver disease, but these approaches have not been proven useful. However, neither method has been formally evaluated for accuracy in estimating caffeine clearance in subjects with cirrhosis. The performance of the Jost, Nagel, and Bayesian methods was compared to a Gold Standard method that accurately measured caffeine clearance in healthy subjects and subjects with cirrhosis using an intravenous infusion of stable isotope-labeled caffeine. The Bayesian method, even when only one measured concentration of caffeine was used, was more accurate, better correlated to the Gold Standard method, and had less intraindividual variation than the two previously published methods. Before the idea of using serial measurements of caffeine clearance for clinical usefulness is rejected, a reevaluation using methods of estimating caffeine clearance that are more accurate than previous paradigms is needed.
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Affiliation(s)
- C P Denaro
- Division of Clinical Pharmacology and Experimental Therapeutics, San Francisco General Hospital Medical Center 94100, USA
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22
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Roelofsen H, van der Veere CN, Ottenhoff R, Schoemaker B, Jansen PL, Oude Elferink RP. Decreased bilirubin transport in the perfused liver of endotoxemic rats. Gastroenterology 1994; 107:1075-84. [PMID: 7926459 DOI: 10.1016/0016-5085(94)90232-1] [Citation(s) in RCA: 80] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND/AIMS Hyperbilirubinemia associated with sepsis is frequently observed in humans. In this study, an experimental rat model was developed to study bilirubin metabolism and transport during endotoxemia. METHODS Rats were injected intravenously with a single bolus of lipopolysaccharide (1 mg/kg); after 18 hours, the liver was removed for single-pass perfusion. Unconjugated bilirubin, bilirubin ditaurate (125 nmol/min), and/or taurocholate (1.5 mumol/min) were infused. Rate constants for uptake were determined from the disappearance of a bolus of bilirubin ditaurate in a recirculating perfusion. RESULTS In endotoxemic livers, biliary excretion of bilirubin-glucuronides was reduced by 49% (2.04 +/- 0.2 and 3.99 +/- 0.24 nmol.min-1.g liver-1). Similar results were obtained with bilirubin ditaurate, indicating that the reduced transport is not caused by a reduced conjugation capacity. The rate constant of sinusoidal uptake was significantly reduced during endotoxemia (0.191 +/- 0.034 vs. 0.090 +/- 0.035, respectively). Secretion of taurocholate into bile was also reduced (92 +/- 22 vs. 127 +/- 10 nmol.min-1.g liver-1). CONCLUSIONS In endotoxemic rats, biliary clearance of bilirubin and taurocholate is substantially decreased, suggesting that decreased output of bilirubin-glucuronides is not caused by impaired conjugation but by a reduction in transport.
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Affiliation(s)
- H Roelofsen
- Division of Gastrointestinal and Liver Diseases, Academic Medical Center, Amsterdam, The Netherlands
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von Allmen D, Hasselgren PO, Higashiguchi T, Fischer JE. Individual regulation of different hepatocellular functions during sepsis. Metabolism 1992; 41:961-9. [PMID: 1518425 DOI: 10.1016/0026-0495(92)90121-p] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The purpose of this study was to test the hypothesis that different hepatocellular functions are regulated individually during sepsis. This was done by simultaneously measuring bile production, release of liver transaminases, and synthesis of secreted proteins in perfused livers from control and septic rats. Sepsis was induced by cecal ligation and puncture (CLP); control rats were sham-operated. After 16 hours, livers were perfused in situ, and bile flow, synthesis rates of albumin and alpha 1-acid glycoprotein (a major acute-phase protein in rats), and release of glutamic-oxaloacetic transaminase (GOT) and glutamic-pyruvic transaminase (GPT) into perfusate were determined. Within the same livers, sepsis resulted in a 54% increase in the synthesis of alpha 1-acid glycoprotein and approximately 30% inhibition of albumin synthesis concomitant with 50% lower bile flow. The concentrations of GOT and GPT in the perfusate increased slightly during the experiments, both when control and septic livers were perfused. The maintained tissue levels of adenosine triphosphate (ATP) and the uptake of Evans blue dye by less than 1% of the hepatocytes, although a late test of viability, suggest that both control and septic livers remained viable during perfusion. The results are consistent with the concept that different hepatocellular functions are individually regulated during sepsis. Thus, impairment of certain hepatocellular functions does not necessarily imply generalized liver failure.
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Affiliation(s)
- D von Allmen
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati 45267-0558
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Abstract
Abnormal liver function commonly accompanies critical illness. Ischaemic hepatitis occurs with shock and is characterised by elevated plasma aminotransferase concentrations. 'ICU jaundice' occurs later in critical illness, especially after trauma and sepsis. The major biochemical abnormality is conjugated hyperbilirubinaemia. The clinical setting suggests that hepatic ischaemia and hepatotoxic actions of inflammatory mediators are the major aetiological factors. Massive blood transfusion, effects of nutritional support and drug toxicity may contribute. Both the presence and degree of jaundice are associated with increased mortality in several nonhepatic diseases. It is proposed that Kupffer cell phagocytic depression associated with liver dysfunction permits systemic spread of endotoxin and inflammatory mediators and thus predisposes to multiple organ failure. Immunosuppression, metabolic abnormalities, impaired drug oxidation and myocardial depression may contribute to the poor prognosis. There is no specific treatment, but prompt resuscitation, definitive treatment of sepsis and meticulous supportive care will likely reduce the incidence and severity.
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Affiliation(s)
- F Hawker
- Intensive Care Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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