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Qiang R, Liu XZ, Xu JC. The Immune Pathogenesis of Acute-On-Chronic Liver Failure and the Danger Hypothesis. Front Immunol 2022; 13:935160. [PMID: 35911735 PMCID: PMC9329538 DOI: 10.3389/fimmu.2022.935160] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 06/20/2022] [Indexed: 11/21/2022] Open
Abstract
Acute-on-chronic liver failure (ACLF) is a group of clinical syndromes related to severe acute liver function impairment and multiple-organ failure caused by various acute triggering factors on the basis of chronic liver disease. Due to its severe condition, rapid progression, and high mortality, it has received increasing attention. Recent studies have shown that the pathogenesis of ACLF mainly includes direct injury and immune injury. In immune injury, cytotoxic T lymphocytes (CTLs), dendritic cells (DCs), and CD4+ T cells accumulate in the liver tissue, secrete a variety of proinflammatory cytokines and chemokines, and recruit more immune cells to the liver, resulting in immune damage to the liver tissue, massive hepatocyte necrosis, and liver failure, but the key molecules and signaling pathways remain unclear. The “danger hypothesis” holds that in addition to the need for antigens, damage-associated molecular patterns (DAMPs) also play a very important role in the occurrence of the immune response, and this hypothesis is related to the pathogenesis of ACLF. Here, the research status and development trend of ACLF, as well as the mechanism of action and research progress on various DAMPs in ACLF, are summarized to identify biomarkers that can predict the occurrence and development of diseases or the prognosis of patients at an early stage.
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Affiliation(s)
- Rui Qiang
- The Affiliated Infectious Diseases Hospital, Suzhou Medical College of Soochow University, Suzhou, China
| | - Xing-Zi Liu
- Key Laboratory of Oral Diseases Research of Anhui Province, College and Hospital of Stomatology, Anhui Medical University, Hefei, China
| | - Jun-Chi Xu
- The Affiliated Infectious Diseases Hospital, Suzhou Medical College of Soochow University, Suzhou, China
- Key Laboratory of Infection and Immunity of Suzhou City, The Fifth People’s Hospital of Suzhou, Suzhou, China
- *Correspondence: Jun-Chi Xu,
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Hypotension and Hypocapnia During General Anesthesia in Piglets: Study of S100b as an Acute Biomarker for Cerebral Tissue Injury. J Neurosurg Anesthesiol 2019; 32:273-278. [DOI: 10.1097/ana.0000000000000601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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3
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Olivecrona Z, Bobinski L, Koskinen LOD. Association of ICP, CPP, CT findings and S-100B and NSE in severe traumatic head injury. Prognostic value of the biomarkers. Brain Inj 2014; 29:446-54. [PMID: 25518864 DOI: 10.3109/02699052.2014.989403] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The association was studied of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) on S-100B and neuron-specific enolase (NSE) in severe traumatic brain injury (sTBI). The relationship was explored between biomarkers, ICP, CPP, CT-scan classifications and the clinical outcome. MATERIALS AND METHODS Data were collected prospectively and consecutively in 48 patients with Glasgow Coma Scale score ≤ 8, age 15-70 years. NSE and S-100B were analysed during 5 consecutive days. The initial and follow-up CT-scans were classified according to the Marshall, Rotterdam and Morris-Marshall classifications. Outcome was evaluated with extended Glasgow outcome scale at 3 months. RESULTS Maximal ICP and minimal CPP correlated with S-100B and NSE levels. Complex relations between biomarkers and CT classifications were observed. S-100B bulk release (AUC = 0.8333, p = 0.0009), and NSE at 72 hours (AUC = 0.8476, p = 0.0045) had the highest prediction power of mortality. Combining Morris-Marshall score and S-100B bulk release improved the prediction of clinical outcome (AUC = 0.8929, p = 0.0008). CONCLUSION Biomarker levels are associated with ICP and CPP and reflect different aspects of brain injury as evaluated by CT-scan. The biomarkers might predict mortality. There are several pitfalls influencing the interpretation of biomarker data in respect to ICP, CPP, CT-findings and clinical outcome.
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Affiliation(s)
- Zandra Olivecrona
- Institution of Pharmacology and Clinical Neuroscience, Department of Neurosurgery, Umeå University , Umeå , Sweden
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4
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Kristiansen RG, Rose CF, Fuskevåg OM, Mæhre H, Revhaug A, Jalan R, Ytrebø LM. L-Ornithine phenylacetate reduces ammonia in pigs with acute liver failure through phenylacetylglycine formation: a novel ammonia-lowering pathway. Am J Physiol Gastrointest Liver Physiol 2014; 307:G1024-31. [PMID: 25258408 DOI: 10.1152/ajpgi.00244.2014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Glycine is an important ammoniagenic amino acid, which is increased in acute liver failure (ALF). We have previously shown that L-ornithine phenylacetate (OP) attenuates ammonia rise and intracranial pressure in pigs suffering from ALF but failed to demonstrate a stoichiometric relationship between change in plasma ammonia levels and excretion of phenylacetylglutamine in urine. The aim was to investigate the impact of OP treatment on the phenylacetylglycine pathway as an alternative and additional ammonia-lowering pathway. A well-validated and -characterized large porcine model of ALF (portacaval anastomosis, followed by hepatic artery ligation), which recapitulates the cardinal features of human ALF, was used. Twenty-four female pigs were randomized into three groups: (1) sham operated + vehicle, (2) ALF + vehicle, and (3) ALF + OP. There was a significant increase in arterial glycine concentration in ALF (P < 0.001 compared with sham), with a three-fold increase in glycine release into the systemic circulation from the kidney compared with the sham group. This increase was attenuated in both the blood and brain of the OP-treated animals (P < 0.001 and P < 0.05, respectively), and the attenuation was associated with renal removal of glycine through excretion of the conjugation product phenylacetylglycine in urine (ALF + vehicle: 1,060 ± 106 μmol/l; ALF + OP: 27,625 ± 2,670 μmol/l; P < 0.003). Data from this study provide solid evidence for the existence of a novel, additional pathway for ammonia removal in ALF, involving glycine production and removal, which is targeted by OP.
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Affiliation(s)
- Rune Gangsøy Kristiansen
- Department of Anesthesiology, University Hospital of North Norway and UiT The Arctic University of Norway, Tromsø, Norway;
| | - Christopher F Rose
- Hepato-Neuro Laboratory, The University of Montreal Hospital Research Centre, Université de Montréal, Québec, Canada
| | - Ole-Martin Fuskevåg
- Department of Clinical Pharmacology, University Hospital of North Norway and UiT The Arctic University of Norway, Tromsø, Norway
| | - Hanne Mæhre
- Norwegian College of Fishery Science, UiT The Arctic University of Norway, Tromsø, Norway
| | - Arthur Revhaug
- Department of Digestive Surgery, University Hospital of North Norway and UiT The Arctic University of Norway, Tromsø, Norway; and
| | - Rajiv Jalan
- Liver Failure Group, University College London Institute for Liver and Digestive Health, Medical School, Royal Free Hospital, London, United Kingdom
| | - Lars Marius Ytrebø
- Department of Anesthesiology, University Hospital of North Norway and UiT The Arctic University of Norway, Tromsø, Norway
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5
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Sharma V, Ten Have GAM, Ytrebo L, Sen S, Rose CF, Dalton RN, Turner C, Revhaug A, van-Eijk HMH, Deutz NEP, Jalan R, Mookerjee RP, Davies NA. Nitric oxide and L-arginine metabolism in a devascularized porcine model of acute liver failure. Am J Physiol Gastrointest Liver Physiol 2012; 303:G435-41. [PMID: 22421619 PMCID: PMC3774247 DOI: 10.1152/ajpgi.00268.2011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In acute liver failure (ALF), the hyperdynamic circulation is believed to be the result of overproduction of nitric oxide (NO) in the splanchnic circulation. However, it has been suggested that arginine concentrations (the substrate for NO) are believed to be decreased, limiting substrate availability for NO production. To characterize the metabolic fate of arginine in early-phase ALF, we systematically assessed its interorgan transport and metabolism and measured the endogenous NO synthase inhibitor asymmetric dimethylarginine (ADMA) in a porcine model of ALF. Female adult pigs (23-30 kg) were randomized to sham (N = 8) or hepatic devascularization ALF (N = 8) procedure for 6 h. We measured plasma arginine, citrulline, ornithine levels; arginase activity, NO, and ADMA. Whole body metabolic rates and interorgan flux measurements were calculated using stable isotope-labeled amino acids. Plasma arginine decreased >85% of the basal level at t = 6 h (P < 0.001), whereas citrulline and ornithine progressively increased in ALF (P < 0.001 and P < 0.001, vs. sham respectively). No difference was found between the groups in the whole body rate of appearance of arginine or NO. However, ALF showed a significant increase in de novo arginine synthesis (P < 0.05). Interorgan data showed citrulline net intestinal production and renal consumption that was related to net renal production of arginine and ornithine. Both plasma arginase activity and plasma ADMA levels significantly increased in ALF (P < 0.001). In this model of early-phase ALF, arginine deficiency or higher ADMA levels do not limit whole body NO production. Arginine deficiency is caused by arginase-related arginine clearance in which arginine production is stimulated de novo.
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Affiliation(s)
- Vikram Sharma
- 1UCL Institute of Hepatology, Royal Free Campus, University College London;
| | - Gabriella A. M. Ten Have
- 2Center for Translational Research in Aging & Longevity, Donald W. Reynolds Institute on Aging, University of Arkansas Medical Sciences, Little Rock, Arkansas; ,3Department of Surgery, University Maastricht, Maastricht, The Netherlands;
| | - Lars Ytrebo
- 5Department of Anesthesiology, University Hospital of North Norway and University of Tromsø, Norway;
| | - Sambit Sen
- 1UCL Institute of Hepatology, Royal Free Campus, University College London;
| | - Christopher F. Rose
- 6Neuroscience Research Unit, Ho^pital Saint-Luc (CRCHUM), Universite' de Montre'al, Que'bec, Canada
| | - R. Neil Dalton
- 4WellChild Laboratory, Evelina Children's Hospital, London, United Kingdom;
| | - Charles Turner
- 4WellChild Laboratory, Evelina Children's Hospital, London, United Kingdom;
| | - Arthur Revhaug
- 5Department of Anesthesiology, University Hospital of North Norway and University of Tromsø, Norway;
| | | | - Nicolaas E. P. Deutz
- 2Center for Translational Research in Aging & Longevity, Donald W. Reynolds Institute on Aging, University of Arkansas Medical Sciences, Little Rock, Arkansas; ,3Department of Surgery, University Maastricht, Maastricht, The Netherlands;
| | - Rajiv Jalan
- 1UCL Institute of Hepatology, Royal Free Campus, University College London;
| | | | - Nathan A. Davies
- 1UCL Institute of Hepatology, Royal Free Campus, University College London;
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The release of S-100B and NSE in severe traumatic head injury is associated with APOE ε4. Acta Neurochir (Wien) 2012; 154:675-80; discussion 680. [PMID: 22322856 DOI: 10.1007/s00701-012-1292-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 01/24/2012] [Indexed: 10/14/2022]
Abstract
OBJECT In this article we tested the hypothesis that the level of two biochemical markers of brain injury may be associated with the apolipoprotein E (APOE) ε4 allele. METHODS In this prospective consecutive study patients with sTBI were included (n = 48). Inclusion criteria were Glasgow Coma Scale (GCS) score ≤ 8 at the time of intubation and sedation, patient age between 15 and 70 years, an initial cerebral perfusion pressure > 10 mmHg, and arrival to our level-one trauma university hospital within 24 h after trauma. Blood samples for neuron-specific enolase (NSE) and S-100B were collected as soon as possibly after arrival, and then twice daily (12-h intervals) for 5 consecutive days. Venous blood was used for APOE genotype determination. Clinical outcome at 3 months after injury was assessed with the Extended Glasgow Outcome Scale (GOSE). RESULTS Significantly higher levels of the maximal S-100B (S-100B(max)) and area under the curve (S-100B(AUC)) were found in subjects with the APOE ε4 allele compared to those with non-ε4. A similar tendency was observed for NSE(max) and NSE(AUC), though not statistically significant. CONCLUSION Our data indicate that there might be a gene-induced susceptibility to severe traumatic brain injury and that patients with the APOE ε4 allele may be more predisposed to brain cellular damage measured as S-100B and NSE. Thus, it seems to be of importance to consider the APOE genotype in interpreting the levels of the biomarkers.
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7
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Kristiansen RG, Lindal S, Myreng K, Revhaug A, Ytrebø LM, Rose CF. Neuropathological changes in the brain of pigs with acute liver failure. Scand J Gastroenterol 2010; 45:935-43. [PMID: 20443756 DOI: 10.3109/00365521003675047] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Cerebral edema is a serious complication of acute liver failure (ALF), which may lead to intracranial hypertension and death. An accepted tenet has been that the blood-brain barrier is intact and that brain edema is primarily caused by a cytotoxic etiology due to hyperammonemia. However, the neuropathological changes in ALF have been poorly studied. Using a well characterized porcine model we aimed to investigate ultrastructural changes in the brain from pigs suffering from ALF. MATERIALS AND METHODS Sixteen female Norwegian Landrace pigs weighing 27-35 kg were randomised into two groups: ALF (n = 8) and sham operated controls (n = 8). ALF was induced with an end-to-side portacaval shunt followed by ligation of the hepatic arteries. Biopsies were harvested from three different areas of the brain (frontal lobe, cerebellum, and brain stem) following eight hours of ALF and analyzed using electron microscopy. RESULTS Profound perivascular and interstitial edema were found in all three areas. Disruption of pericytic and astrocytic processes were seen, reflecting breakdown/lesion of the blood-brain barrier in animals suffering from ALF. Furthermore, neurons and axons were edematous and surrounded by vesicles. Severe damage to Purkinje neuron (necrosis) and damaged myelin were seen in the cerebellum and brain stem, respectively. Biopsies from sham operated animals were normal. CONCLUSIONS Our data support the concept that vasogenic brain edema plays an important role in the development of intracranial hypertension in pigs with ALF.
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Affiliation(s)
- Rune Gangsøy Kristiansen
- Department of Anesthesiology, University Hospital of North Norway and University of Tromsø, Sykehusveien, Tromsø, Norway.
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Lipcsey M, Olovsson M, Larsson E, Einarsson R, Qadhr GA, Sjölin J, Larsson A. The Brain Is a Source of S100B Increase During Endotoxemia in the Pig. Anesth Analg 2010; 110:174-80. [DOI: 10.1213/ane.0b013e3181c0724a] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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9
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Ytrebø LM, Kristiansen RG, Maehre H, Fuskevåg OM, Kalstad T, Revhaug A, Cobos MJ, Jalan R, Rose CF, Deutz NEP, Jalan R, Revhaug A. L-ornithine phenylacetate attenuates increased arterial and extracellular brain ammonia and prevents intracranial hypertension in pigs with acute liver failure. Hepatology 2009; 50:165-74. [PMID: 19554542 DOI: 10.1002/hep.22917] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
UNLABELLED Hyperammonemia is a feature of acute liver failure (ALF), which is associated with increased intracranial pressure (ICP) and brain herniation. We hypothesized that a combination of L-ornithine and phenylacetate (OP) would synergistically reduce toxic levels of ammonia by (1) L-ornithine increasing glutamine production (ammonia removal) through muscle glutamine synthetase and (2) phenylacetate conjugating with the ornithine-derived glutamine to form phenylacetylglutamine, which is excreted into the urine. The aims of this study were to determine the effect of OP on arterial and extracellular brain ammonia concentrations as well as ICP in pigs with ALF (induced by liver devascularization). ALF pigs were treated with OP (L-ornithine 0.07 g/kg/hour intravenously; phenylbutyrate, prodrug for phenylacetate; 0.05 g/kg/hour intraduodenally) for 8 hours following ALF induction. ICP was monitored throughout, and arterial and extracellular brain ammonia were measured along with phenylacetylglutamine in the urine. Compared with ALF + saline pigs, treatment with OP significantly attenuated concentrations of arterial ammonia (589.6 +/- 56.7 versus 365.2 +/- 60.4 mumol/L [mean +/- SEM], P= 0.002) and extracellular brain ammonia (P= 0.01). The ALF-induced increase in ICP was prevented in ALF + OP-treated pigs (18.3 +/- 1.3 mmHg in ALF + saline versus 10.3 +/- 1.1 mmHg in ALF + OP-treated pigs;P= 0.001). The value of ICP significantly correlated with the concentration of extracellular brain ammonia (r(2) = 0.36,P< 0.001). Urine phenylacetylglutamine levels increased to 4.9 +/- 0.6 micromol/L in ALF + OP-treated pigs versus 0.5 +/- 0.04 micromol/L in ALF + saline-treated pigs (P< 0.001). CONCLUSION L-Ornithine and phenylacetate act synergistically to successfully attenuate increases in arterial ammonia, which is accompanied by a significant decrease in extracellular brain ammonia and prevention of intracranial hypertension in pigs with ALF.
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Affiliation(s)
- Lars Marius Ytrebø
- Department of Anesthesiology, University Hospital of North Norway and University of Tromsø, Norway.
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Rose C, Ytrebø LM, Davies NA, Sen S, Nedredal GI, Belanger M, Revhaug A, Jalan R. Association of reduced extracellular brain ammonia, lactate, and intracranial pressure in pigs with acute liver failure. Hepatology 2007; 46:1883-92. [PMID: 17705298 DOI: 10.1002/hep.21877] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
UNLABELLED We previously demonstrated in pigs with acute liver failure (ALF) that albumin dialysis using the molecular adsorbents recirculating system (MARS) attenuated a rise in intracranial pressure (ICP). This was independent of changes in arterial ammonia, cerebral blood flow and inflammation, allowing alternative hypotheses to be tested. The aims of the present study were to determine whether changes in cerebral extracellular ammonia, lactate, glutamine, glutamate, and energy metabolites were associated with the beneficial effects of MARS on ICP. Three randomized groups [sham, ALF (induced by portacaval anastomosis and hepatic artery ligation), and ALF+MARS] were studied over a 6-hour period with a 4-hour MARS treatment given beginning 2 hours after devascularization. Using cerebral microdialysis, the ALF-induced increase in extracellular brain ammonia, lactate, and glutamate was significantly attenuated in the ALF+MARS group as well as the increases in extracellular lactate/pyruvate and lactate/glucose ratios. The percent change in extracellular brain ammonia correlated with the percent change in ICP (r(2) = 0.511). Increases in brain lactate dehydrogenase activity and mitochondrial complex activity for complex IV were found in ALF compared with those in the sham, which was unaffected by MARS treatment. Brain oxygen consumption did not differ among the study groups. CONCLUSION The observation that brain oxygen consumption and mitochondrial complex enzyme activity changed in parallel in both ALF- and MARS-treated animals indicates that the attenuation of increased extracellular brain ammonia (and extracellular brain glutamate) in the MARS-treated animals reduces energy demand and increases supply, resulting in attenuation of increased extracellular brain lactate. The mechanism of how MARS reduces extracellular brain ammonia requires further investigation.
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Affiliation(s)
- Christopher Rose
- Department of Cellular Neuroscience, Max-Delbrück Center for Molecular Medicine, Berlin, Germany
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11
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Ekse S, Clapp LH, Revhaug A, Ytrebø LM. Endothelium-derived hyperpolarization factor (EDHF) is up-regulated in a pig model of acute liver failure. Scand J Gastroenterol 2007; 42:356-65. [PMID: 17354116 DOI: 10.1080/00365520600930636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Acute liver failure (ALF) is hemodynamically characterized by hyperdynamic circulation, but the pathophysiologic mechanisms underlying these disturbances are not known. The purposes of the present experiments were: to study systemic and peripheral hemodynamics in vivo, to measure changes in vascular reactivity in vitro, and to determine the role of endothelium-dependent vasodilator pathways in a well-validated porcine model of ALF. METHODS Landrace pigs (24-29 kg) were allocated to sham operation (n=8) or ALF induced by hepatic devascularization (n=9). Systemic and regional hemodynamics were monitored. Femoral artery rings were prepared for isometric tension recordings 8 h after ALF induction. Contractile responses to phenylephrine were assessed in ring segments of endothelium-intact femoral arteries in the absence or presence of inhibitors of endothelium-derived hyperpolarizing factor, nitric oxide synthase, cyclooxygenase and heme oxygenase pathways. RESULTS Pigs with ALF developed a hyperdynamic circulation. Cardiac index increased (PGT<0.001), while mean arterial pressure (PGT=0.012) and systemic vascular resistance decreased (PGT<0.001) in this group. Femoral artery blood flow decreased in controls, while it remained unchanged in ALF (PGT=0.010). Accordingly, vascular resistance across the hind leg was significantly decreased (PGT<0.001) in ALF. The combination of Ca2+-activated potassium channel inhibitors charybdotoxin and apamin, which block the release of endothelium-derived hyperpolarizing factor, increased the contraction force (ANOVA, PGT=0.05) and Emax (P=0.01) to phenylephrine in ALF. In contrast, inhibitors of nitric oxide synthase, cyclooxygenase and heme oxygenase pathways did not increase isometric contraction force. CONCLUSIONS Endothelium dependent hyperpolarization of vascular smooth muscle contributes to the development of hyperdynamic circulation in ALF.
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MESH Headings
- Analysis of Variance
- Animals
- Apamin/pharmacology
- Biological Factors/metabolism
- Blood Pressure/drug effects
- Cardiac Output/drug effects
- Charybdotoxin/pharmacology
- Disease Models, Animal
- Dose-Response Relationship, Drug
- Endothelium, Vascular/drug effects
- Endothelium, Vascular/metabolism
- Endothelium, Vascular/physiopathology
- Enzyme Inhibitors/pharmacology
- Female
- Femoral Artery/drug effects
- Femoral Artery/metabolism
- Femoral Artery/physiopathology
- Heme Oxygenase (Decyclizing)/drug effects
- Heme Oxygenase (Decyclizing)/metabolism
- Isometric Contraction/drug effects
- Liver Circulation/drug effects
- Liver Failure, Acute/metabolism
- Liver Failure, Acute/physiopathology
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/physiopathology
- Nitric Oxide Synthase/drug effects
- Nitric Oxide Synthase/metabolism
- Phenylephrine/pharmacology
- Potassium Channel Blockers/pharmacology
- Potassium Channels, Calcium-Activated/drug effects
- Potassium Channels, Calcium-Activated/metabolism
- Prostaglandin-Endoperoxide Synthases/drug effects
- Prostaglandin-Endoperoxide Synthases/metabolism
- Swine
- Up-Regulation/drug effects
- Vascular Resistance/drug effects
- Vasoconstriction/drug effects
- Vasoconstrictor Agents/pharmacology
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Affiliation(s)
- Sveinung Ekse
- Department of Anesthesiology and Intensive Care, University of Tromsø, University Hospital Northern Norway, Tromsø, Norway
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12
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Ytrebø LM, Sen S, Rose C, Davies NA, Nedredal GI, Fuskevaag OM, Ten Have GAM, Prinzen FW, Williams R, Deutz NEP, Jalan R, Revhaug A. Systemic and regional hemodynamics in pigs with acute liver failure and the effect of albumin dialysis. Scand J Gastroenterol 2006; 41:1350-60. [PMID: 17060130 DOI: 10.1080/00365520600714527] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Acute liver failure (ALF) is haemodynamically characterized by a hyperdynamic circulation. The aims of this study were to investigate the systemic and regional haemodynamics in ALF, to measure changes in nitric oxide metabolites (NOx) and to evaluate whether these haemodynamic disturbances could be attenuated with albumin dialysis. MATERIAL AND METHODS Norwegian Landrace pigs (23-30 kg) were randomly allocated to groups as controls (sham-operation, n = 8), ALF (hepatic devascularization, n = 8) and ALF + albumin dialysis (n = 8). Albumin dialysis was started 2 h after ALF induction and continued for 4 h. Systemic and regional haemodynamics were monitored. Creatinine clearance, nitrite/nitrate and catecholamines were measured. A repeated measures ANOVA was used to analyse the data. RESULTS In the ALF group, the cardiac index increased (PGT < 0.0001), while mean arterial pressure (PG = 0.02) and systemic vascular resistance decreased (PGT < 0.0001). Renal resistance (PG = 0.04) and hind-leg resistance (PGT = 0.003) decreased in ALF. There was no difference in jejunal blood flow between the groups. ALF pigs developed renal dysfunction with increased serum creatinine (PGT = 0.002) and decreased creatinine clearance (P = 0.02). Catecholamines were significantly higher in ALF, but NOx levels were not different. Albumin dialysis did not attenuate these haemodynamic or renal disturbances. CONCLUSIONS The haemodynamic disturbances during the early phase of ALF are characterized by progressive systemic vasodilatation with no associated changes in metabolites of NO. Renal vascular resistance decreased and renal dysfunction developed independently of changes in renal blood flow. After 4 h of albumin dialysis there was no attenuation of the haemodynamic or renal disturbances.
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Affiliation(s)
- Lars M Ytrebø
- Department of Digestive Surgery, University Hospital Northern Norway, Tromsø, Norway
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13
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Ytrebø LM, Sen S, Rose C, Ten Have GAM, Davies NA, Hodges S, Nedredal GI, Romero-Gomez M, Williams R, Revhaug A, Jalan R, Deutz NEP. Interorgan ammonia, glutamate, and glutamine trafficking in pigs with acute liver failure. Am J Physiol Gastrointest Liver Physiol 2006; 291:G373-81. [PMID: 16782695 DOI: 10.1152/ajpgi.00440.2005] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Ammonia reduction is the target for therapy of hepatic encephalopathy, but lack of quantitative data about how the individual organs handle ammonia limits our ability to develop novel therapeutic strategies. The study aims were to evaluate interorgan ammonia metabolism quantitatively in a devascularized pig model of acute liver failure (ALF). Ammonia and amino acid fluxes were measured across the portal drained viscera (PDV), kidneys, hind leg, and lungs in ALF pigs. ALF pigs developed hyperammonemia and increased glutamine levels, whereas glutamate levels were decreased. PDV contributed to the hyperammonemic state mainly through increased shunting and not as a result of increased glutamine breakdown. The kidneys were quantitatively as important as PDV in systemic ammonia release, whereas muscle took up ammonia. Data suggest that the lungs are able to remove ammonia from the circulation during the initial stage of ALF. Our study provides new data supporting the concept of glutamate deficiency in a pig model of ALF. Furthermore, the kidneys are quantitatively as important as PDV in ammonia production, and the muscles play an important role in ammonia removal.
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Affiliation(s)
- Lars M Ytrebø
- Liver Failure Group, Institute of Hepatology, Univ. College London, 69-75 Chenies Mews, London WC1E 6HX, UK
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14
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Sen S, Rose C, Ytrebø LM, Davies NA, Nedredal GI, Drevland SS, Kjønnø M, Prinzen FW, Hodges SJ, Deutz NEP, Williams R, Butterworth RF, Revhaug A, Jalan R. Effect of albumin dialysis on intracranial pressure increase in pigs with acute liver failure: a randomized study. Crit Care Med 2006; 34:158-64. [PMID: 16374170 DOI: 10.1097/01.ccm.0000196203.39832.3c] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Increased intracranial pressure (ICP) worsens the outcome of acute liver failure (ALF). This study investigates the underlying pathophysiological mechanisms and evaluates the therapeutic effect of albumin dialysis in ALF with use of the Molecular Adsorbents Recirculating System without hemofiltration/dialysis (modified, M-MARS). METHODS Pigs were randomized into three groups: sham, ALF, and ALF + M-MARS. ALF was induced by hepatic devascularization (time = 0). M-MARS began at time = 2 and ended with the experiment at time = 6. ICP, arterial ammonia, brain water, cerebral blood flow (CBF), and plasma inflammatory markers were measured. RESULTS ICP and arterial ammonia increased significantly over 6 hrs in the ALF group, in comparison with the sham group. M-MARS attenuated (did not normalize) the increased ICP in the ALF group, whereas arterial ammonia was unaltered by M-MARS. Brain water in the frontal cortex (grey matter) and in the subcortical white matter at 6 hrs was significantly higher in the ALF group than in the sham group. M-MARS prevented a rise in water content, but only in white matter. CBF and inflammatory mediators remained unchanged in all groups. CONCLUSION The initial development of cerebral edema and increased ICP occurs independently of CBF changes in this noninflammatory model of ALF. Factor(s) other than or in addition to hyperammonemia are important, however, and may be more amenable to alteration by albumin dialysis.
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Affiliation(s)
- Sambit Sen
- Liver Failure Group, The UCL Institute of Hepatology, Division of Medicine, Royal Free and University College Medical School, London
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Larsson A, Lipcsey M, Sjölin J, Hansson LO, Eriksson MB. Slight increase of serum S-100B during porcine endotoxemic shock may indicate blood-brain barrier damage. Anesth Analg 2005; 101:1465-1469. [PMID: 16244012 DOI: 10.1213/01.ane.0000180193.29655.6a] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Septic shock is a condition that affects many organs, but little is known about the effects on the central nervous system. S-100B, an acidic low molecular weight protein, has attracted considerable interest as a marker for brain damage and disintegration of the blood-brain barrier. It is released into the cerebrospinal fluid and blood from brain tissue after brain damage. We studied S-100B in a porcine model of endotoxemic shock that resembles human Gram-negative septic shock. Ten piglets received IV endotoxin, and plasma samples were collected before the endotoxin infusion and each hour (1-6 h) during the endotoxin infusion. S-100B was measured by sandwich enzyme-linked immunosorbent assay. Low levels of plasma S-100B were detected, but there was a significant increase in S-100B during Hours 1-5 in comparison with the 0 values. We determined that endotoxemia causes a very small but significant increase in the levels of the widely used brain damage marker serum S-100B. However, it cannot be excluded that the increase in S-100B could be caused by release from organs other than the brain.
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Affiliation(s)
- Anders Larsson
- Departments of *Medical Sciences and †Surgical Sciences, Uppsala University Hospital, Sweden
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Gottlieb A, DeBoer KR. Brain preservation during orthotopic liver transplantation in a patient with acute liver failure and severe elevation of intracranial pressure. J Gastrointest Surg 2005; 9:888-90. [PMID: 16137579 DOI: 10.1016/j.gassur.2005.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2005] [Accepted: 06/05/2005] [Indexed: 01/31/2023]
Affiliation(s)
- Alexandru Gottlieb
- Department of General Anesthesiology, Section of Liver Transplantation, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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Schmidt M, Marx T, Armbruster S, Reinelt H, Schirmer U. Effect of Xenon on elevated intracranial pressure as compared with nitrous oxide and total intravenous anesthesia in pigs. Acta Anaesthesiol Scand 2005; 49:494-501. [PMID: 15777297 DOI: 10.1111/j.1399-6576.2005.00609.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Xenon in low concentrations has been investigated in neuroradiology to measure cerebral blood flow (CBF). Several reports have suggested that inhalation of Xenon might increase intracranial pressure (ICP) by increasing the cerebral blood flow and blood volume, raising concerns about using Xenon as an anesthetic in higher concentrations for head-injured patients. A porcine study is presented in which the effects of inhaled 75% Xenon on elevated ICP, cerebral perfusion pressure and the efficacy of hyperventilation for ICP treatment were compared with nitrous oxide anesthesia and total intravenous anesthesia (TIVA). METHODS Twenty-one pentobarbital-anesthetized pigs (age: 12-16 weeks) were randomly assigned to three groups to receive either 4 h of Xenon-oxygen ventilation, nitrous oxide-oxygen ventilation or air-oxygen (75%/25%) ventilation, respectively. After instrumentation for parenchymal ICP measurement and ICP manipulation, an epidurally placed 6-F balloon catheter was inflated until a target ICP of 20 mmHg was achieved. After 4 h of anesthesia hyper- and hypoventilation maneuvers were performed and consecutive ICP and CBF changes were investigated. RESULTS Intracranial pressure and CBF increased significantly in the nitrous oxide group as compared with the controls. There was no increase of ICP or CBF in the Xenon or control group. Intracranial pressure changed in all three groups corresponding to hyper- and hypoventilation. CONCLUSIONS During Xenon anesthesia, elevated ICP is not increased further and is partially reversible by hyperventilation. Our study suggests that inhalation of 75% Xenon seems not to be contraindicated in patients with elevated ICP.
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Affiliation(s)
- M Schmidt
- Department Cardiac Anesthesia, University of Ulm, Ulm, Germany.
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Ytrebø LM, Ekse S, Sen S, Rose C, Nedredal GI, Fuskevåg OM, Jalan R, Revhaug A. Contractile response of femoral arteries in pigs with acute liver failure. Scand J Gastroenterol 2004; 39:1000-4. [PMID: 15513341 DOI: 10.1080/00365520410003254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Acute liver failure (ALF) is characterized haemodynamically by a progressive hyperdynamic circulation. The pathophysiological mechanism is unknown, but impaired contractility of vascular smooth muscle may play an important role. The aim of this study was to evaluate the vascular response to stimulation with norepinephrine and angiotensin II in endothelium-denuded femoral artery rings. METHODS Norwegian Landrace pigs weighing 27.1 +/- 0.5 kg (mean +/- sx (standard error of the mean)) were used. ALF was induced by performing a portacaval shunt followed by ligation of the hepatic arteries (n = 6). Sham-operated animals served as controls (n = 5). Cumulative isometric concentration contraction curves were obtained after in vitro stimulation of the femoral artery rings with either angiotensin II (10(-13) - 10(-5) mol/L) or norepinephrine (10(-13) - 10(-3) mol/L). RESULTS Pigs suffering from ALF developed a hyperdynamic circulation with an increased cardiac index (P = 0.017) and decreased systemic vascular resistance index (P = 0.015). Studies of the hind leg revealed a decreased vascular resistance index and increased blood flow compared to sham-operated controls (P = 0.003 and P = 0.01, respectively). Angiotensin II caused a concentration-dependent contraction of the arterial segments, with no significant differences in vascular responses between the two groups. Maximum force generated did not differ (55 +/- 7 versus 56 +/- 7 mN, P = 0.95). Furthermore, there were no differences for norepinephrine in the cumulative concentration-response curves and the maximum contractile force was not significantly different (87 +/- 8 versus 93 +/- 16 mN, P = 0.55). CONCLUSIONS This study documents for the first time that there are no signs of endothelium-independent peripheral vascular hyporesponsiveness to angiotensin II and norepinephrine in pigs with ALF.
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Affiliation(s)
- L M Ytrebø
- Department of Digestive Surgery, University Hospital Northern Norway, Tromsø.
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Brvar M, Mozina H, Osredkar J, Mozina M, Brucan A, Bunc M. The potential value of the protein S-100B level as a criterion for hyperbaric oxygen treatment and prognostic marker in carbon monoxide poisoned patients. Resuscitation 2003; 56:105-9. [PMID: 12505746 DOI: 10.1016/s0300-9572(02)00289-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Carbon monoxide (CO) poisoning resulting in diffuse tissue hypoxia. Cerebral hypoxia is a major cause of morbidity and mortality after CO poisoning. There are some clinical criteria that could help a physician to make a decision concerning the application of hyperbaric oxygenation therapy. However, it would be convenient to discover an objective biochemical serum marker that could help in the grade evaluation of CO poisoning and indication of therapy in CO-poisoned patients. We present two case reports where the established criteria for the CO poisoning were not optimum for the decision regarding therapy. It seems that the S-100B protein could be used as a biochemical marker of CO induced brain injury. S-100B values could perhaps help us to select patients for hyperbaric oxygen therapy and to predict the short and long term outcome.
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Affiliation(s)
- Miran Brvar
- Poison Control Center, Ljubljana Medical Center, Zaloska cesta 7, 1000 Ljubljana, Slovenia
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Jordano Q, Córdoba J, Pena M. Valor de la determinación sérica de S-100β en la encefalopatía hepática. Med Clin (Barc) 2003; 121:718. [PMID: 14651823 DOI: 10.1016/s0025-7753(03)74072-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Ytrebø LM, Korvald C, Nedredal GI, Elvenes OP, Nielsen Grymyr OJ, Revhaug A. N-acetylcysteine increases cerebral perfusion pressure in pigs with fulminant hepatic failure. Crit Care Med 2001; 29:1989-95. [PMID: 11588469 DOI: 10.1097/00003246-200110000-00023] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Intravenous administration of N-acetylcysteine beyond 15 hrs reduces mortality rates in patients suffering from paracetamol-induced fulminant hepatic failure, although the mechanism of the therapeutic benefit remains unclear. We hypothesized increased survival to be caused by improved hemodynamic performance. The main objective for the study was to explore the effect of N-acetylcysteine on hemodynamics, oxygen transport, and regional blood flow in pigs with fulminant hepatic failure. DESIGN Prospective, randomized, controlled trial. SETTING Surgical research laboratory in a university hospital. SUBJECTS Female Norwegian Landrace pigs. INTERVENTIONS Fulminant hepatic failure was induced by a total liver devascularization procedure. Five hours later, the pigs were allocated to N-acetylcysteine treatment (150 mg.kg-1 in 100 mL of 0.9% saline over 15 mins, followed by 50 mg.kg-1 in 500 mL of 0.9% saline over a period of 4 hrs) or placebo. MEASUREMENTS AND MAIN RESULTS Mean arterial pressure stabilized in the N-acetylcysteine group and increased slightly during the last 2 hrs (pGT =.009). Thus, mean arterial pressure was significantly higher compared with placebo after 3 hrs (p =.01). Cerebral perfusion pressure was significantly higher during the last 2 hrs in the N-acetylcysteine group (pGT =.033). Common carotid artery flow also increased and was maintained at a higher level compared with placebo (pG =.027). Systemic vascular resistance index initially decreased but then gradually increased (pGT <.001). Cardiac index increased after 15 mins of N-acetylcysteine infusion, causing a significant interaction (pGT =.038), but did not differ after 3 hrs. No significant differences in hindleg and mesentery hemodynamics were found. A short-lived increase in oxygen delivery caused by a temporary increase in cardiac index was observed but without any corresponding increase in oxygen consumption. CONCLUSIONS Intravenous N-acetylcysteine infusion increases cerebral perfusion pressure in pigs with fulminant hepatic failure. Earlier reported effects on oxygen transport and uptake could not be confirmed.
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Affiliation(s)
- L M Ytrebø
- Department of Digestive Surgery, Tromsø University Hospital, N-9038 Tromsø, Norway
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