The molecular basis of halothane-induced hepatitis

Hypoxia and oxidative stress: The role of the anaerobic gut, the hepatic arterial buffer response and other defence mechanisms of the liver

The liver is considered a vital organ and is the hub for multiple chemical functions, such as intermediary metabolism and the detoxification of ingested toxins, which are essential for the preservation of life, hence, the origin or the word “liver”. The liver has enormous, highly diversified catalytic potential. This enormous catalytic potential generates massive oxidative stress, which is important for the functions of the liver but is detrimental to the viability of the liver. The liver receives approximately 80% of its blood supply from the portal vein, which brings less saturated blood from the gastrointestinal tract. Hepatocytes operate in a relatively hypoxic microenvironment due to this portal inflow. The development of this hypoxic microenvironment of the liver is an important evolutionary adaptation for its detoxification function that is not recognized in the literature as a defence mechanism against the oxidative stress generated during the detoxification process. This review describes liver function in relation to its oxidative catalytic potential and the oxidative stress generated by it as well as the evolutionary defence mechanisms present in the liver against this oxidative stress to provide new insights into liver function.

Mechanisms, chemical structures and drug metabolism

From the studies that have been done by many laboratories over the last 2 decades, it is now clear that the toxicities produced by many drugs are due to their reactive metabolites. It is though that, in many cases, reactive metabolites cause toxicity by binding covalently to tissue proteins. However, until recently it was difficult to identify these protein targets. Due to the development of an immunochemical approach, this problem has been overcome, as is illustrated here by studies that have been conducted on the metabolic basis of the idiosyncratic hepatitis caused by the inhalation anaesthetic halothane. The major problem to solve in the future will be to determine how protein adduct formation leads to toxicity. It is possible that protein adduct formation may alter an important cellular function or may lead to immunopathology, as is thought to occur in the case of halothane hepatitis. If an allergic reaction is suspected, purified protein targets of reactive metabolites can serve as antigens for identifying sensitized individuals. This information can be used to prevent not only an allergic reaction to the drug, but possible cross-reactions to other drugs that are structurally related. Another important application of these studies is the design of safer alternative drugs that will not produce structurally similar toxic reactive metabolites.

Ca2+ cytochemical changes of hepatotoxicity caused by halothane and sevoflurane in enzyme-induced hypoxic rats

AIM: To investigat the relation between hepatotoxicity of halothane and sevoflurane and altered hepatic calcium homeostasis in enzyme-induced hypoxic rats.

METHODS: Forty-eight rats were pretreated with phen-obarbital and randomly divided into six groups (eight in each group) and exposed to O₂/ N₂/1.2 MAC anesthetics for 1 h: normal control (NC), 21% O₂/79% N₂; hypoxic control (HC), 14% O₂/86%N₂; normal sevoflurane (NS), 21% O₂/ N₂/1.2MAC sevoflurane; hypoxic sevoflurane (HS), 14% O₂/ N₂/1.2MAC sevoflurane; normal halothane (NH)21%O₂/79%N₂/1.2MAC halothane; hypoxic halothane (HH), 14% O₂/N₂/1.2MAC halothane. Liver specimens and blood were taken 24 h after exposure to calcium and determined by EDX microanalysis.

RESULTS: The liver of all rats given halothane (14% O₂) had extensive centrilobular necrosis and denaturation. Morphologic damage was accompanied with an increase in serum glutamic pyruvic transminase. In groups NH and HH, more calcium was precipitated in cytoplasm and mitochondria.

CONCLUSION: These results suggest that halothane increases cytosolic Ca²⁺ concentration in hepatocytes. Elevation in Ca²⁺ concentration is implicated in the mechanism of halothane-induced hepatotoxicity. sevoflurane is less effective in affecting hepatic calcium homeostasis than halothane.

Understanding drug allergies

At this time, the incidence of adverse drug reactions can only be estimated because the intensive monitoring and documenting that is required to make this determination does not exist at most hospitals and clinics. Despite these limitations, a meta-analysis of prospective studies has estimated the incidence of serious adverse drug reactions in hospitalized patients to be 6.7% and the incidence of fatal adverse drug reactions to be 0.32%. When evaluating and managing the condition of a patient who has experienced an adverse drug reaction, the physician first obtains an accurate history and performs a careful physical examination to determine whether the reaction was immunologic in nature. Drug reactions that are immunologically mediated (1) require a period of sensitization, (2) occur in a small proportion of the population, (3) are elicited at drug doses far below the therapeutic range, and (4) subside after drug discontinuation in most instances. All possible culprit drugs should be identified, with dosages and dates of administration and discontinuation, and the patient should be asked about any previous drug exposure history. Although immunodiagnostic tests for allergic drug reactions are limited, several tests do exist and may be useful in the identification of drug-specific antibodies, drug-specific T lymphocytes, or mediators from activated cells. If the reaction was not consistent with an IgE-mediated event and if it did not involve serious organ damage, cautious rechallenge may be considered. For those reactions that appear to be IgE-mediated and for which there is no reliable skin test reagent, drug desensitization may be performed by allergists who are trained in this procedure.

UDP-glucose:glycoprotein glucosyltransferase associates with endoplasmic reticulum chaperones and its activity is decreased in vivo by the inhalation anesthetic halothane

Halothane causes an idiosyncratic hepatitis that is thought to result, in part, from immune reactions against one or more lumenal endoplasmic reticulum (ER) proteins that have been covalently modified by the trifluoroacetyl chloride metabolite of halothane. In this study, we have identified a 170 kDa protein target of halothane in the liver of rats. The 170 kDa protein was first detected when proteins in lysates of hepatocytes from halothane-treated rats were immunoprecipitated with antisera against several resident ER proteins. This 170 kDa protein was found to be associated with other protein targets of halothane, including protein disulfide isomerase, a protein disulfide isomerase isoform, a 59 kDa carboxylesterase, and 78 kDa glucose-regulated protein. Immunoblotting with antiserum directed against the trifluoroacetylated hapten indicated that the 170 kDa protein was trifluoroacetylated. Based upon its subcellular localization, molecular mass, N-terminal amino acid sequence, and antigenicity, the trifluoroacetylated 170 kDa protein was identified as UDP-glucose:glycoprotein glucosyltransferase (UGGT), a lumenal ER protein that is thought to have a role in the folding of N-linked glycoproteins. Moreover, treatment of rats with halothane caused a 44% decrease in the activity of liver microsomal UGGT, and at least 36% of the change in the activity of the enzyme could be due to a decrease in the level of the protein. The results suggest that the function of UGGT in folding of N-linked glycoproteins may be affected by other resident ER proteins or xenobiotics such as halothane.

Human cytochrome P450 2E1 is a major autoantigen associated with halothane hepatitis

Autoantibodies against specific human cytochrome P450s have been found in the sera of patients suffering from a variety of diseases, including those caused by drugs. In the cases of tienilic acid- and dihydralazine-induced hepatitis, patients have serum autoantibodies directed against cytochromes P450 2C9 and P450 1A2, respectively. In the present study, we have found that 25 of 56 (45%) patients diagnosed with halothane hepatitis have autoantibodies that react with human cytochrome P450 2E1 that was purified from a baculovirus expression system. The autoantibodies inhibited the activity of cytochrome P450 2E1 and appeared to be directed against mainly conformational epitopes. In addition, because cytochrome P450 2E1 became trifluoroacetylated when it oxidatively metabolized halothane, it is possible that the covalently altered form of cytochrome P450 2E1 may be able to bypass the immunologic tolerance that normally exists against cytochrome P450 2E1. A similar mechanism may explain the formation of autoantibodies that have been found against other cellular targets of the reactive trifluoroacetyl chloride metabolite of halothane.

Cytotoxic activity of T cells and non-T cells from diclofenac-immunized mice against cultured syngeneic hepatocytes exposed to diclofenac

To evaluate whether hepatocellular protein adducts of the nonsteroidal antiinflammatory drug diclofenac could elicit a specific cell-mediated or antibody-dependent immune response that eventually results in liver cell destruction, we developed a murine ex vivo/in vitro mixed lymphocyte hepatocyte culture (MLHC) model. C57BL/6 mice were immunized either with diclofenac conjugated to keyhole limpet hemocyanin (KLH) or with KLH alone. Splenocytes from mice exhibiting hgih antidiclofenac antibody titers were isolated and co-cultured at an effector/target cell ratio of 100:1 with syngeneic murine hepatocytes preexposed to diclofenac. By 48 and 72 hours, extracellular alanine transaminase (ALT) activity had increased 6.4- and 7.6-fold, respectively, versus the 24-hour value. In contrast, there was no significant cytotoxic response after either drug treatment alone or immunization alone. Furthermore, those cellular populations capable of inducing ALT release also showed lymphocyte stimulation as determined by interleukin-2 (IL-2) receptor expression and lymphocyte proliferation analysis. The extent of cell injury was highest in the presence of lymphocytes highly enriched in T cells and was reduced by 40% in the presence of anti-MHC I antibodies. Similarly, albeit to a lesser extent, non-T cell-enriched lymphocyte fractions also induced hepatocyte injury. The addition of co-culture supernatants to hepatocytes had no effect, thus ruling out the possibility that soluble factors alone mediated the cell injury. However, supernatants from diclofenac-stimulated lymphocytes, combined with nonstimulated splenocytes, triggered an immediate (< 1 hour) cytotoxic response, suggesting antibody-dependent cell-mediated mechanisms of target cell injury. These results indicate that diclofenac-treated hepatocytes carried antigenic determinants that were recognized by T cells and non-T cells derived from diclofenac/KLH-immunized mice, resulting in cell-mediated destruction of the target hepatocytes.

Formation of trifluoroacetylated protein antigens in cultured rat hepatocytes exposed to halothane in vitro

Immune responses to novel, halothane metabolite-modified protein antigens (tri-fluoroacetylated proteins; TFA-proteins) have been implicated in the pathogenesis of halothane hepatitis. The aim of the present study was to investigate and characterize expression of TFA-proteins in cultures of rat hepatocytes which were exposed to halothane in vitro. Following exposure to halothane, the hepatocytes were harvested, then subcellular fractions were prepared and were analysed by immunoblotting for expression of antigens recognized by a rabbit anti-TFA antiserum, and by antibodies in sera from two patients with halothane hepatitis. Hepatocytes exposed to halothane in vitro were shown to express novel microsomal protein antigens, which exhibited molecular masses that were identical to the molecular masses of the major TFA-protein antigens expressed in vivo, in livers of halothane-treated rats (100, 80 and 60 kDa). Experiments in which hepatocytes were exposed to halothane in the presence of SKF-525A, or were exposed to deuterated halothane in place of halothane, confirmed that these novel antigens were TFA-modified proteins whose generation required cytochrome P450-mediated metabolism of halothane. The maximal levels of TFA-antigens expressed in vitro were about 30% of the levels expressed in halothane-treated rats in vivo. Maximal expression of the TFA-antigens in vitro occurred when hepatocytes were exposed to halothane at doses which yielded concentrations of the drug in culture medium of about 13 microM. Expression of the antigens in vitro occurred slowly, with an apparent half-time of about 8 hr. Overall, these results demonstrate that the properties of the TFA-antigens expressed in cultured hepatocytes in vitro closely resemble the properties exhibited by the antigens expressed in vivo, in livers of halothane-treated rats.

Mechanisms of halothane toxicity: novel insights

Exposure of individuals to halothane causes, in 20% of patients, a mild form of hepatotoxicity. In contrast, a very small subset of individuals only develops halothane hepatitis, which is thought to have an immunological basis. Sera of halothane hepatitis patients contain antibodies directed against some discrete liver trifluoroacetyl (TFA)-protein adducts, which arise upon oxidative biotransformation of halothane and include protein disulfide isomerase, microsomal carboxylesterase, calreticulin, ERp72, GRP 78 and ERp99. No immune response occurs in the majority of human individuals, although evidence suggests that TFA-protein adducts arise in all halothane-exposed individuals. The lack of immunological responsiveness of individuals might be due to tolerance, induced by a presumed repertoire of self-peptides that molecularly mimic TFA-protein adducts. Thus, constitutively expressed proteins of 52 and 64 kDa have been identified that confer molecular mimicry of TFA-protein adducts. The 64 kDa protein corresponds to the E2 subunit of the mitochondrial pyruvate dehydrogenase complex. Lipoic acid, the prosthetic group of the E2 subunit, is involved in the molecular mimicry process. A fraction of halothane hepatitis patients exhibit irregularities in the expression levels of the 52 kDa protein and the E2 subunit protein. Molecular mimicry of TFA-protein adducts by the 52 kDa protein and the E2 subunit protein might play a role in the susceptibility of individuals to development of halothane hepatitis.

Molecular mimicry of trifluoroacetylated human liver protein adducts by constitutive proteins and immunochemical evidence for its impairment in halothane hepatitis

A monospecific antibody (anti-CF3CO antibody) was obtained by affinity chromatography on a N epsilon-trifluoroacetyl-L-lysine (CF3CO-Lys) matrix of a rabbit polyclonal antiserum, directed against trifluoroacetylated protein adducts (CF3CO-proteins). The anti-CF3CO antibody recognized distinct CF3CO-proteins on immunoblots of a liver biopsy obtained from a human individual 10 h after halothane anaesthesia. Cross-reactive proteins of 52 kDa and 64 kDa were recognized on immunoblots of livers obtained from human individuals not exposed to halothane. Recognition of both CF3CO-proteins and the 52-kDa and 64-kDa cross-reactive proteins was abolished in the presence of 1 mM CF3CO-Lys. Anti-CF3CO antibody, affinity-adsorbed to the 52-kDa or the 64-kDa cross-reactive proteins of human liver, recognized the majority of target CF3CO-proteins on immunoblots of the human liver biopsy of an individual exposed to halothane. Liver biopsies of 5 out of 7 (71%) patients with halothane hepatitis exhibited an absence or low amounts of immunorecognizable 52-kDa and/or 64-kDa cross-reactive proteins. In contrast, of 22 control human individuals tested, all liver tissue samples were positive for the 52-kDa and/or the 64-kDa cross-reactive proteins. These data indicate that epitopes on the cross-reactive proteins of 52 kDa and 64 kDa of human liver bear strong immunochemical resemblance to epitopes on human liver CF3CO-proteins. Low-level expression of the cross-reactive proteins of 52 kDa and 64 kDa is discussed as one possible factor in human susceptibility to halothane hepatitis.

The topography of trifluoroacetylated protein antigens in liver microsomal fractions from halothane treated rats

Sera from patients with halothane hepatitis contain immunoglobulin G (IgG) antibodies to trifluoroacetylated liver microsomal proteins of 100, 76, 59, 57 and 54 kDa, which are produced as a consequence of metabolism of halothane to trifluoroacetyl halide by cytochrome(s) P450. In the present study, the membrane topographies of the various antigens in rat liver microsomal fractions were investigated. Liver microsomal fractions from rats treated with halothane in vivo, and rat liver microsomal fractions which had been incubated with halothane in vitro, were used as the source of trifluoroacetyl antigens. The antigens were detected by immunoblotting. Whereas the 100, 76, 59 and 57 kDa antigens were solubilized from the microsomal membrane by either 0.1 M sodium carbonate or 0.1% (w/v) sodium deoxycholate, the 54 kDa antigen was not solubilized by 0.1% (w/v) sodium deoxycholate. In intact microsomal fractions, the 100, 76, 59 and 57 kDa antigens were not degraded appreciably by trypsin unless detergent was added to permeabilize the microsomal membrane. These results indicate that the 54 kDa antigen is an integral membrane protein, whereas the 100, 76, 59 and 57 kDa antigens are peripheral membrane proteins situated within the lumen of microsomal vesicles, and hence presumably located within the lumen of the endoplasmic reticulum in vivo.

Postoperative elevation of serum transaminases following isoflurane anesthesia

Halogenated inhalational anesthetics have been implicated in hepatotoxicity. Halothane hepatitis results from the biotransformation of the drug to a metabolite that binds to liver proteins, which creates a hapten, which, in turn, causes an immunologic response in the liver. Case reports of hepatic injury resulting from isoflurane, which has a decreased biotransformation compared with that of halothane, have received much criticism. We describe a patient who had elevated liver enzymes and a positive trifluoroacetyl antibody titer following an anesthetic regimen that included isoflurane.

The kidney as a novel target tissue for protein adduct formation associated with metabolism of halothane and the candidate chlorofluorocarbon replacement 2,2-dichloro-1,1,1-trifluoroethane

Hydrochlorofluorocarbons (HCFCs) have been identified as chemical replacements of the widely used chlorofluorocarbons (CFCs) that are implicated in stratospheric ozone depletion. Many HCFCs are structural analogues of the anesthetic agent halothane and may follow a common pathway of biotransformation and formation of adducts to protein-centered and other cellular nucleophiles. Exposure of rats to a single dose of halothane (2-bromo-2-chloro-1,1,1-trifluoroethane) or of the candidate CFC substitute HCFC 123 (2,2-dichloro-1,1,1-trifluoroethane) led to the formation of trifluoroacetylated protein adducts (CF3CO-proteins) not only in the liver, but also in the kidney as a novel target tissue for protein trifluoroacetylation. CF3CO-proteins in the kidney amounted to about 5% of those formed in the liver of the same animal. The amount of CF3CO-proteins formed within the kidney was roughly reflected by the capacity of metabolism of halothane or HCFC 123 by rat kidney microsomes in vitro which amounted to about 10% of that observed with liver microsomes. By immunohistochemistry, CF3CO-proteins in the kidney were mainly localized in the tubular segments of the cortex. In the liver, the density of CF3CO-proteins decreased from the central vein towards the portal triad. In vitro incubation of rat liver microsomes with halothane or HCFC 123 resulted in extensive formation of CF3CO-proteins and reproduced faithfully the pattern of liver CF3CO-proteins obtained in vivo. CF3CO-proteins generated in vitro were immunochemically not discernible from those generated in vivo. Glutathione (5 mM) and cysteine (5 mM) virtually abolished CF3CO-protein formation; the release of Br- from halothane and Cl- from HCFC 123 was reduced to much lesser a degree. S-Methyl-glutathione, N-acetyl-cysteine, methionine, and N-acetyl-methionine only slightly affected the formation of CF3CO-proteins or metabolism of either substrate. The data suggest that metabolism and concomitant CF3CO-protein formation of halothane or of candidate CFC replacements like HCFC 123 is not restricted to the liver but also takes place in the kidney. Furthermore, an in vitro system for CF3CO-protein formation has been developed and used to show that protein-centered and glutathione-centered nucleophilic sites compete for intermediates of metabolism of halothane or of HCFC 123.

Halothane metabolism. Impairment of hepatic omega-oxidation of leukotrienes in vivo and in vitro

Omega-oxidation of leukotrienes is the initial step of hepatic degradation and thus inactivation of these proinflammatory mediators. Omega-oxidation is followed by beta-oxidation of leukotrienes from the omega-end. After exposure of rats to a single dose of the anesthetic agent halothane, a transient decrease in leukotriene omega-oxidation was induced both in vivo and in vitro. In untreated rats, 44.1 +/- 6.0% of N-[3H]acetylleukotriene E4 injected intravenously was recovered unchanged in bile collected for 60 min in vivo; 46.5 +/- 3.0% was recovered as omega-/beta-oxidation products, of which 24.7 +/- 4.5% were associated with beta-oxidation products only (mean +/- SEM; n = 5). In rats receiving a single dose of halothane 18 h before the experiment, recovery of unchanged N-[3H]acetylleukotriene E4 was significantly increased to 79.8 +/- 4.8%, while the fraction of omega-/beta-oxidation products decreased to 9.0 +/- 1.7% (n = 5); 90 h after exposure to halothane, N-[3H]acetylleukotriene E4 recovery decreased to 30.0 +/- 3.0% and omega-/beta-oxidation products amounted to 49.1 +/- 3.8%; the fraction of beta-oxidation products was significantly increased to 43.1 +/- 3.4% (n = 5). Ten days after exposure of rats to halothane, the recoveries of N-[3H]acetylleukotriene E4, of omega-/beta-oxidation products, and of beta-oxidation products alone, returned to almost normal values. Microsomal fractions obtained from rat hepatocytes catalyzed the NADPH- and O2-dependent leukotriene omega-oxidation in vitro. The formation of omega-hydroxy-metabolites of leukotriene B4, leukotriene E4, and N-acetylleukotriene E4 was decreased by 50% in microsomal fractions obtained from rats 18 h and 90 h after halothane treatment, and returned back to control levels in microsomal fractions obtained 10 days after halothane treatment. The Km value of leukotriene B4 omega-oxidation revealed no significant change in enzyme affinity towards leukotriene B4; in contrast, as reflected by the reduction of the Vmax value by 65%, a decrease in the amount of the active enzyme in microsomes obtained from rats 18 h after halothane treatment was observed. Halothane-metabolism-dependent trifluoroacetylation of hepatic proteins may mediate this process. Thus, the time course of the density on immunoblots of trifluoroacetylated protein adducts paralleled that of the transient decrease in leukotriene omega-oxidation. In contrast to its omega-oxidation, leukotriene B4 synthesis from 5-hydroperoxyeicosatetraenoate was not inhibited in hepatocyte homogenates obtained from rats pretreated with halothane. The data suggest that metabolism of halothane causes a transient derangement of hepatic leukotriene homeostasis in vivo.