1
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Ryu DK, Park M, Woo S, Cho HS, Min JJ. Postoperative liver injury after sevoflurane or propofol anesthesia in patients undergoing non-cardiac surgery: a retrospective cohort study. Sci Rep 2024; 14:11178. [PMID: 38750181 PMCID: PMC11096158 DOI: 10.1038/s41598-024-61799-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/09/2024] [Indexed: 05/18/2024] Open
Abstract
Although sevoflurane is generally considered safe, reports suggest that sevoflurane may cause postoperative liver injury more frequently than previously believed. Therefore, we aimed to compare the incidence of clinically significant postoperative liver injury following non-cardiac surgery between patients who underwent sevoflurane anesthesia and propofol-based total intravenous anesthesia. We retrospectively reviewed adult surgical patients from January 2010 to September 2022 who underwent general anesthesia in our center using sevoflurane or propofol over 3 h. After 1:1 propensity score matching, the incidence of postoperative liver injury was compared between the two groups. Out of 58,300 patients reviewed, 44,345 patients were included in the analysis. After propensity score matching, 7767 patients were included in each group. The incidence of postoperative liver injury was 1.4% in the sevoflurane group, which was similar to that in the propofol group (1.6%; p = 0.432). Comparison of the severity of postoperative alanine aminotransferase elevation showed that the incidence of borderline and mild elevation was higher in the sevoflurane group, but there was no difference in the incidence of moderate and severe elevation. In conclusion, sevoflurane anesthesia over 3 h was not associated with a higher incidence of clinically significant postoperative liver injury compared to propofol anesthesia.
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Affiliation(s)
- Dae Kyun Ryu
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - MiHye Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seunghyeon Woo
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyun Seong Cho
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeong-Jin Min
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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2
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Hu M, Scott C. Toward the development of a molecular toolkit for the microbial remediation of per-and polyfluoroalkyl substances. Appl Environ Microbiol 2024; 90:e0015724. [PMID: 38477530 PMCID: PMC11022551 DOI: 10.1128/aem.00157-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024] Open
Abstract
Per- and polyfluoroalkyl substances (PFAS) are highly fluorinated synthetic organic compounds that have been used extensively in various industries owing to their unique properties. The PFAS family encompasses diverse classes, with only a fraction being commercially relevant. These substances are found in the environment, including in water sources, soil, and wildlife, leading to human exposure and fueling concerns about potential human health impacts. Although PFAS degradation is challenging, biodegradation offers a promising, eco-friendly solution. Biodegradation has been effective for a variety of organic contaminants but is yet to be successful for PFAS due to a paucity of identified microbial species capable of transforming these compounds. Recent studies have investigated PFAS biotransformation and fluoride release; however, the number of specific microorganisms and enzymes with demonstrable activity with PFAS remains limited. This review discusses enzymes that could be used in PFAS metabolism, including haloacid dehalogenases, reductive dehalogenases, cytochromes P450, alkane and butane monooxygenases, peroxidases, laccases, desulfonases, and the mechanisms of microbial resistance to intracellular fluoride. Finally, we emphasize the potential of enzyme and microbial engineering to advance PFAS degradation strategies and provide insights for future research in this field.
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Affiliation(s)
- Miao Hu
- CSIRO Environment, Black Mountain Science and Innovation Park, Canberra, ACT, Australia
| | - Colin Scott
- CSIRO Environment, Black Mountain Science and Innovation Park, Canberra, ACT, Australia
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3
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El Aidouni G, Merbouh M, Lazreg M, Kachmar S, Laaribi I, Bouchlarhem A, Chatar MCE, Lamzouri O, Bkiyar H, Housni B. Severe hepatic impairment after sevoflurane anesthesia in a 10-month-old child: Case report. Ann Med Surg (Lond) 2021; 70:102915. [PMID: 34691439 PMCID: PMC8519796 DOI: 10.1016/j.amsu.2021.102915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/01/2021] [Accepted: 10/03/2021] [Indexed: 10/29/2022] Open
Abstract
Introduction Like other halogenated agents, sevoflurane can potentially cause a toxic reaction including severe hepatic failure which can lead to the death of the patient. However, Halogen immuno-allergic hepatitis is a very rare complication of anesthesia. We reported a 10 months' child who presented a severe hepatic injury after sevoflurane exposure. Case management A 10-month-old child was scheduled for acute intussusception anesthesia, induction was done with sevoflurane and propofol while maintenance of anesthesia was provided by sevoflurane alone. Three days after the operation, he was developed jaundice and altered general condition. A dramatic increase in liver enzymes was observed. The evolution was marked by an alteration of his consciousness and his hemodynamic state, he was intubated. Without improvement, the patient died on the 4th postoperative day. The autopsy was refused by the family. Conclusion These results underscore the need findings for a global and comprehensive understanding of the potential hepatotoxicity of exposure to volatile anesthetics including sevoflurane in infants and its long-term side effects which can be fatal.
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Affiliation(s)
- Ghizlane El Aidouni
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Manal Merbouh
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Moussa Lazreg
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Safae Kachmar
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Ilyass Laaribi
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Amine Bouchlarhem
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Mohammed Charaf-Eddine Chatar
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Oussama Lamzouri
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Houssam Bkiyar
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Brahim Housni
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Mohammed First University Oujda, Faculty of Medicine and Pharmacy, Oujda, Morocco.,Mohammed First University Oujda, FMP Oujda, LAMCESM, Oujda, Morocco
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4
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Schwier E, Kirchner C, Eickmeyer C, Winde G, Henzler D, Köhler T. Profound decrease of liver maximum function capacity test of isoflurane sedated patients: A report of three cases. Clin Case Rep 2021; 9:e04862. [PMID: 34594555 PMCID: PMC8462060 DOI: 10.1002/ccr3.4862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/15/2021] [Accepted: 07/17/2021] [Indexed: 12/18/2022] Open
Abstract
LiMAx 13C-methacetin breath test results should be interpreted with caution in patients sedated with isoflurane.
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Affiliation(s)
- Elke Schwier
- Department of AnesthesiologySurgical Intensive Care, Emergency and Pain MedicineRuhr University BochumKlinikum HerfordHerfordGermany
| | - Carmen Kirchner
- Department of General and Visceral SurgeryThoracic Surgery and ProctologyRuhr University BochumKlinikum HerfordHerfordGermany
| | - Claas Eickmeyer
- Department of AnesthesiologySurgical Intensive Care, Emergency and Pain MedicineRuhr University BochumKlinikum HerfordHerfordGermany
| | - Günther Winde
- Department of General and Visceral SurgeryThoracic Surgery and ProctologyRuhr University BochumKlinikum HerfordHerfordGermany
| | - Dietrich Henzler
- Department of AnesthesiologySurgical Intensive Care, Emergency and Pain MedicineRuhr University BochumKlinikum HerfordHerfordGermany
| | - Thomas Köhler
- Department of AnesthesiologySurgical Intensive Care, Emergency and Pain MedicineRuhr University BochumKlinikum HerfordHerfordGermany
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5
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Wu Y, Zhu J, Fu P, Tong W, Hong H, Chen M. Machine Learning for Predicting Risk of Drug-Induced Autoimmune Diseases by Structural Alerts and Daily Dose. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18137139. [PMID: 34281077 PMCID: PMC8296890 DOI: 10.3390/ijerph18137139] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/20/2021] [Accepted: 06/25/2021] [Indexed: 12/28/2022]
Abstract
An effective approach for assessing a drug’s potential to induce autoimmune diseases (ADs) is needed in drug development. Here, we aim to develop a workflow to examine the association between structural alerts and drugs-induced ADs to improve toxicological prescreening tools. Considering reactive metabolite (RM) formation as a well-documented mechanism for drug-induced ADs, we investigated whether the presence of certain RM-related structural alerts was predictive for the risk of drug-induced AD. We constructed a database containing 171 RM-related structural alerts, generated a dataset of 407 AD- and non-AD-associated drugs, and performed statistical analysis. The nitrogen-containing benzene substituent alerts were found to be significantly associated with the risk of drug-induced ADs (odds ratio = 2.95, p = 0.0036). Furthermore, we developed a machine-learning-based predictive model by using daily dose and nitrogen-containing benzene substituent alerts as the top inputs and achieved the predictive performance of area under curve (AUC) of 70%. Additionally, we confirmed the reactivity of the nitrogen-containing benzene substituent aniline and related metabolites using quantum chemistry analysis and explored the underlying mechanisms. These identified structural alerts could be helpful in identifying drug candidates that carry a potential risk of drug-induced ADs to improve their safety profiles.
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Affiliation(s)
- Yue Wu
- National Center for Toxicological Research, Division of Bioinformatics and Biostatistics, U.S. Food and Drug Administration, Jefferson, AR 72079, USA; (Y.W.); (J.Z.); (W.T.); (H.H.)
| | - Jieqiang Zhu
- National Center for Toxicological Research, Division of Bioinformatics and Biostatistics, U.S. Food and Drug Administration, Jefferson, AR 72079, USA; (Y.W.); (J.Z.); (W.T.); (H.H.)
| | - Peter Fu
- National Center for Toxicological Research, Division of Biochemical Toxicology, U.S. Food and Drug Administration, Jefferson, AR 72079, USA;
| | - Weida Tong
- National Center for Toxicological Research, Division of Bioinformatics and Biostatistics, U.S. Food and Drug Administration, Jefferson, AR 72079, USA; (Y.W.); (J.Z.); (W.T.); (H.H.)
| | - Huixiao Hong
- National Center for Toxicological Research, Division of Bioinformatics and Biostatistics, U.S. Food and Drug Administration, Jefferson, AR 72079, USA; (Y.W.); (J.Z.); (W.T.); (H.H.)
| | - Minjun Chen
- National Center for Toxicological Research, Division of Bioinformatics and Biostatistics, U.S. Food and Drug Administration, Jefferson, AR 72079, USA; (Y.W.); (J.Z.); (W.T.); (H.H.)
- Correspondence: ; Fax: +1-870-543-7865
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6
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Abstract
Fluorochemicals are a widely distributed class of compounds and have been utilized across a wide range of industries for decades. Given the environmental toxicity and adverse health threats of some fluorochemicals, the development of new methods for their decomposition is significant to public health. However, the carbon-fluorine (C-F) bond is among the most chemically robust bonds; consequently, the degradation of fluorinated hydrocarbons is exceptionally difficult. Here, metalloenzymes that catalyze the cleavage of this chemically challenging bond are reviewed. These enzymes include histidine-ligated heme-dependent dehaloperoxidase and tyrosine hydroxylase, thiolate-ligated heme-dependent cytochrome P450, and four nonheme oxygenases, namely, tetrahydrobiopterin-dependent aromatic amino acid hydroxylase, 2-oxoglutarate-dependent hydroxylase, Rieske dioxygenase, and thiol dioxygenase. While much of the literature regarding the aforementioned enzymes highlights their ability to catalyze C-H bond activation and functionalization, in many cases, the C-F bond cleavage has been shown to occur on fluorinated substrates. A copper-dependent laccase-mediated system representing an unnatural radical defluorination approach is also described. Detailed discussions on the structure-function relationships and catalytic mechanisms provide insights into biocatalytic defluorination, which may inspire drug design considerations and environmental remediation of halogenated contaminants.
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Affiliation(s)
- Yifan Wang
- Department of Chemistry, University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX 78249, USA.
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7
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Oh SK, Lim BG, Kim YS, Kim SS. Comparison of the Postoperative Liver Function Between Total Intravenous Anesthesia and Inhalation Anesthesia in Patients with Preoperatively Elevated Liver Transaminase Levels: A Retrospective Cohort Study. Ther Clin Risk Manag 2020; 16:223-232. [PMID: 32308400 PMCID: PMC7147612 DOI: 10.2147/tcrm.s248441] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/23/2020] [Indexed: 12/22/2022] Open
Abstract
Background Anesthesia and surgery may deteriorate liver function in patients with elevated liver enzyme levels; therefore, in these patients, choosing anesthetics with less hepatotoxicity is important. Methods This retrospective study investigated the effect of total intravenous anesthesia (TIVA) versus inhalation anesthesia (INHA) on the postoperative liver function in patients with preoperatively elevated liver enzyme levels (aspartate transaminase [AST] or alanine transaminase [ALT] >40 U/L) who underwent non-hepatic surgery under general anesthesia. We compared the changes in enzyme levels within 24 hrs before and after surgery. Results In 730 patients (TIVA: n=138; INHA: n=592), the baseline characteristics were comparable, except for higher comorbidity rates in the TIVA group. The median anesthesia and operation times were significantly longer in the TIVA group because approximately 50% of the TIVA group (vs 19.7% of the INHA group) underwent neurosurgery, which had a relatively longer operation time than other surgeries. Intraoperative hypotensive events and vasopressor use were more frequent in the TIVA group. After 1:4 propensity score matching (TIVA: n=94; INHA: n=376), the baseline characteristics and surgical variables were comparable, except for longer anesthesia time. Before matching, postoperative AST and ALT changes were significantly lower in the TIVA group than in the INHA group. After matching, only the ALT change was significantly lower after TIVA than after INHA [median (interquartile range), -16.7 (-32 to -4) % vs -12.0 (-28.6-6.5) %, P=0.025]. Conclusion TIVA may be safer for patients with preoperatively elevated liver transaminase levels.
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Affiliation(s)
- Seok Kyeong Oh
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Byung Gun Lim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young Sung Kim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Seong Shin Kim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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8
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Lee J, Kim MS, Lee HM, Lee JR, Park JH. The comparison of desflurane and sevoflurane on postoperative hepatic function of infant with biliary atresia undergoing Kasai operation. Anesth Pain Med (Seoul) 2019. [DOI: 10.17085/apm.2019.14.3.272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Jimin Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Min-Soo Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hye-Mi Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong-Rim Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ji-Hoon Park
- Department of Anesthesiology and Pain Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
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9
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Colquhoun JM, Ha L, Beckley A, Meyers B, Flaherty DP, Dunman PM. Identification of Small Molecule Inhibitors of Staphylococcus aureus RnpA. Antibiotics (Basel) 2019; 8:antibiotics8020048. [PMID: 31035380 PMCID: PMC6627331 DOI: 10.3390/antibiotics8020048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 04/23/2019] [Accepted: 04/25/2019] [Indexed: 12/17/2022] Open
Abstract
Staphylococcus aureus RnpA is thought to be a unique dual functional antimicrobial target that is required for two essential cellular processes, precursor tRNA processing and messenger RNA degradation. Herein, we used a previously described whole cell-based mupirocin synergy assay to screen members of a 53,000 compound small molecule diversity library and simultaneously enrich for agents with cellular RnpA inhibitory activity. A medicinal chemistry-based campaign was launched to generate a preliminary structure activity relationship and guide early optimization of two novel chemical classes of RnpA inhibitors identified, phenylcarbamoyl cyclic thiophene and piperidinecarboxamide. Representatives of each chemical class displayed potent anti-staphylococcal activity, limited the protein’s in vitro ptRNA processing and mRNA degradation activities, and exhibited favorable therapeutic indexes. The most potent piperidinecarboxamide RnpA inhibitor, JC2, displayed inhibition of cellular RnpA mRNA turnover, RnpA-depletion strain hypersusceptibility, and exhibited antimicrobial efficacy in a wax worm model of S. aureus infection. Taken together, these results establish that the whole cell screening assay used is amenable to identifying small molecule RnpA inhibitors within large chemical libraries and that the chemical classes identified here may represent progenitors of new classes of antimicrobials that target RnpA.
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Affiliation(s)
- Jennifer M Colquhoun
- Department of Microbiology and Immunology, University of Rochester School of Medicine, Rochester, NY 14642, USA.
| | - Lisha Ha
- Department of Medicinal Chemistry and Molecular Pharmacology, College of Pharmacy, Purdue University, West Lafayette, IN 47906, USA.
| | - Andrew Beckley
- Department of Microbiology and Immunology, University of Rochester School of Medicine, Rochester, NY 14642, USA.
| | - Brinkley Meyers
- Department of Microbiology and Immunology, University of Rochester School of Medicine, Rochester, NY 14642, USA.
| | - Daniel P Flaherty
- Department of Medicinal Chemistry and Molecular Pharmacology, College of Pharmacy, Purdue University, West Lafayette, IN 47906, USA.
- Purdue Institute of Inflammation, Immunology and Infectious Disease, Purdue University, West Lafayette, IN 47906, USA.
- Purdue Institute for Drug Discovery, Purdue University, West Lafayette, IN 47906, USA.
| | - Paul M Dunman
- Department of Microbiology and Immunology, University of Rochester School of Medicine, Rochester, NY 14642, USA.
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10
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Hepatotoxicity after sevoflurane anaesthesia: a new twist to an old story. Br J Anaesth 2019; 122:e63-e64. [PMID: 30857610 DOI: 10.1016/j.bja.2019.01.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/05/2019] [Accepted: 01/05/2019] [Indexed: 11/23/2022] Open
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11
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Limban C, Nuţă DC, Chiriţă C, Negreș S, Arsene AL, Goumenou M, Karakitsios SP, Tsatsakis AM, Sarigiannis DA. The use of structural alerts to avoid the toxicity of pharmaceuticals. Toxicol Rep 2018; 5:943-953. [PMID: 30258789 PMCID: PMC6151358 DOI: 10.1016/j.toxrep.2018.08.017] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 08/12/2018] [Accepted: 08/29/2018] [Indexed: 01/18/2023] Open
Abstract
In order to identify compounds with potential toxicity problems, particular attention is paid to structural alerts, which are high chemical reactivity molecular fragments or fragments that can be transformed via bioactivation by human enzymes into fragments with high chemical reactivity. The concept has been introduced in order to reduce the likelihood that future candidate substances as pharmaceuticals will have undesirable toxic effects. A significant proportion (∼78–86%) of drugs characterized by residual toxicity contain structural alerts; there is also evidence indicating the formation of active metabolites as a causal factor for the toxicity of 62–69% of these molecules. On the other hand, the pharmacological action of certain drugs depends on the formation of reactive metabolites. Detailed assessment of the potential for the formation of active metabolites is recommended to characterize a biologically active compound. Although many prescribed drugs frequently contain structural alerts and form reactive metabolites, the vast majority of these drugs are administered in low daily doses. Avoiding structural alerts has become almost a norm in new drug design. An in-depth review of the biochemical reactivity of these structural alerts for new drug candidates is critical from a safety point of view and is currently being monitored in the discovery of drugs. The chemical strategies applied to structural alerts in molecules to limit the toxicity are: partial replacement or full replacement of the structural alert; reduction of electronic density; introduction of a structural element of metabolic interest (metabolic switching); multiple approaches.
Therefore, chemical intervention strategies to eliminate bioactivation are often interactive processes; their success depends largely on a close working relationship between drug chemists, pharmacologists and researchers in metabolic science.
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Affiliation(s)
- Carmen Limban
- "Carol Davila" University of Medicine and Pharmacy, Department of Pharmaceutical Chemistry, Traian Vuia 6, Bucharest, 020956, Romania
| | - Diana C Nuţă
- "Carol Davila" University of Medicine and Pharmacy, Department of Pharmaceutical Chemistry, Traian Vuia 6, Bucharest, 020956, Romania
| | - Cornel Chiriţă
- "Carol Davila" University of Medicine and Pharmacy, Department of Pharmacology and Clinical Pharmacy, Traian Vuia 6, Bucharest, 020956, Romania
| | - Simona Negreș
- "Carol Davila" University of Medicine and Pharmacy, Department of Pharmacology and Clinical Pharmacy, Traian Vuia 6, Bucharest, 020956, Romania
| | - Andreea L Arsene
- "Carol Davila" University of Medicine and Pharmacy, Department of Pharmaceutical Microbiology, Traian Vuia 6, Bucharest, 020956, Romania
| | - Marina Goumenou
- Laboratory of Toxicology, Medical School, University of Crete, Voutes, Heraklion, 71409, Crete, Greece
| | - Spyros P Karakitsios
- Aristotle University of Thessaloniki, Department of Chemical Engineering, Environmental Engineering Laboratory, University Campus, Thessaloniki 54124, Greece.,HERACLES Research Center on the Exposome and Health, Center for Interdisciplinary Research and Innovation, Balkan Center, Bldg. B, 10th km Thessaloniki-Thermi Road, 57001, Greece
| | - Aristidis M Tsatsakis
- Laboratory of Toxicology, Medical School, University of Crete, Voutes, Heraklion, 71409, Crete, Greece
| | - Dimosthenis A Sarigiannis
- Aristotle University of Thessaloniki, Department of Chemical Engineering, Environmental Engineering Laboratory, University Campus, Thessaloniki 54124, Greece.,HERACLES Research Center on the Exposome and Health, Center for Interdisciplinary Research and Innovation, Balkan Center, Bldg. B, 10th km Thessaloniki-Thermi Road, 57001, Greece.,University School for Advanced Study (IUSS), Piazza della Vittoria 15, Pavia 27100, Italy
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12
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Herzog-Niescery J, Seipp HM, Weber TP, Bellgardt M. Inhaled anesthetic agent sedation in the ICU and trace gas concentrations: a review. J Clin Monit Comput 2017; 32:667-675. [PMID: 28861655 DOI: 10.1007/s10877-017-0055-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 08/15/2017] [Indexed: 12/12/2022]
Abstract
There is a growing interest in the use of volatile anesthetics for inhalational sedation of adult critically ill patients in the ICU. Its safety and efficacy has been demonstrated in various studies and technical equipment such as the anaesthetic conserving device (AnaConDa™; Sedana Medical, Uppsala, Sweden) or the MIRUS™ system (Pall Medical, Dreieich, Germany) have significantly simplified the application of volatile anesthetics in the ICU. However, the personnel's exposure to waste anesthetic gas during daily work is possibly disadvantageous, because there is still uncertainty about potential health risks. The fact that average threshold limit concentrations for isoflurane, sevoflurane and desflurane either differ significantly between countries or are not even defined at all, leads to raising concerns among ICU staff. In this review, benefits, risks, and technical aspects of inhalational sedation in the ICU are discussed. Further, the potential health effects of occupational long-term low-concentration agent exposure, the staffs' exposure levels in clinical practice, and strategies to minimize the individual gas exposure are reviewed.
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Affiliation(s)
- Jennifer Herzog-Niescery
- Department of Anesthesiology, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany.
| | - Hans-Martin Seipp
- Department of Life Science Engineering, University of Applied Sciences, Wiesenstr. 14, 35390, Giessen, Germany
| | - Thomas Peter Weber
- Department of Anesthesiology, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany
| | - Martin Bellgardt
- Department of Anesthesiology, Ruhr-University Bochum, St. Josef Hospital, Gudrunstraße 56, 44791, Bochum, Germany
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13
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Zhu Y, Xiao X, Li G, Bu J, Zhou W, Zhou S. Isoflurane anesthesia induces liver injury by regulating the expression of insulin-like growth factor 1. Exp Ther Med 2017; 13:1608-1613. [PMID: 28413517 DOI: 10.3892/etm.2017.4157] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 12/09/2016] [Indexed: 12/20/2022] Open
Abstract
It has been suggested that isoflurane may cause perioperative liver injury. However, the mechanism of its action remains unknown. The purpose of the present study was to determine this possible mechanism. Sprague-Dawley rats were randomly assigned into one of three groups (all n=12): Control group (exposed to mock anesthesia), isoflurane group (exposed to 2% isoflurane for 90 min), and isoflurane + insulin-like growth factor 1 (IGF-1) group (exposed to 2% isoflurane for 90 min and then treated with IGF-1). Reverse transcription-quantitative polymerase chain reaction (RT-qPCR) and western blotting were conducted to determine the levels of expression of IGF-1 and its receptor IGF-R. Liver necrosis was assessed by histological examination. TUNEL assay was performed to determine the apoptosis of hepatic cells. In addition, the levels of the proteins caspase-3 and B-cell lymphoma-extra large (Bcl-xL) were measured. Compared with the control group, levels of IGF-1 and IGF-1R mRNA and protein were significantly decreased following exposure to isoflurane (all P<0.05). The necrosis rate and liver apoptosis were significantly increased in the group treated with isoflurane alone compared with the control group (P<0.05), but were significantly decreased compared with the isoflurane group following application of IGF-1 (P<0.05). Additionally, isoflurane exposure significantly increased levels of caspase-3 compared with the control group (P<0.05), but decreased levels of Bcl-xL (P<0.05). By contrast, application of IGF-1 reversed these changes. The present study therefore suggests that isoflurane induces liver injury in part by regulating the expression of IGF-1 and that application of IGF-1 may protect against liver injury induced by isoflurane exposure.
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Affiliation(s)
- Yingxian Zhu
- Department of Anesthesiology, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong 519000, P.R. China
| | - Xiaoyu Xiao
- Department of Anesthesiology, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong 519000, P.R. China
| | - Guowei Li
- Department of Orthopaedics II, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong 519000, P.R. China
| | - Juyuan Bu
- Department of General Surgery I, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong 519000, P.R. China
| | - Wenying Zhou
- Department of Center Laboratory, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong 519000, P.R. China
| | - Shaopeng Zhou
- Department of Anesthesiology, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong 519000, P.R. China
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14
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Safari S, Motavaf M, Seyed Siamdoust SA, Alavian SM. Hepatotoxicity of halogenated inhalational anesthetics. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e20153. [PMID: 25593732 PMCID: PMC4270648 DOI: 10.5812/ircmj.20153] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Revised: 08/18/2014] [Accepted: 07/31/2014] [Indexed: 12/17/2022]
Abstract
Context: Halogenated inhalational anesthetics are currently the most common drugs used for the induction and maintenance of general anesthesia. Postoperative hepatic injury has been reported after exposure to these agents. Based on much evidence, mechanism of liver toxicity is more likely to be immunoallergic. The objective of this review study was to assess available studies on hepatotoxicity of these anesthetics. Evidence Acquisition: We searched PubMed, Google Scholar, Scopus, Index Copernicus, EBSCO and the Cochrane Database using the following keywords: “inhalational Anesthetics” and “liver injury”; “inhalational anesthetics” and “hepatotoxicity”; “volatile anesthetics” and “liver injury”; “volatile anesthetics” and hepatotoxicity for the period of 1966 to 2013. Fifty two studies were included in this work. Results: All halogenated inhalational anesthetics are associated with liver injury. Halothane, enflurane, isoflurane and desflurane are metabolized through the metabolic pathway involving cytochrome P-450 2E1 (CYP2E1) and produce trifluoroacetylated components; some of which may be immunogenic. The severity of hepatotoxicity is associated with the degree by which they undergo hepatic metabolism by this cytochrome. However, liver toxicity is highly unlikely from sevoflurane as is not metabolized to trifluoroacetyl compounds. Conclusions: Hepatotoxicity of halogenated inhalational anesthetics has been well documented in available literature. Halothane-induced liver injury was extensively acknowledged; however, the next generation halogenated anesthetics have different molecular structures and associated with less hepatotoxicity. Although anesthesia-induced hepatitis is not a common occurrence, we must consider the association between this disorder and the use of halogenated anesthetics.
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Affiliation(s)
- Saeid Safari
- Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, IR Iran
| | - Mahsa Motavaf
- Department of Genetics, Faculty of Biological Sciences, Tarbiat Modares University, Tehran, IR Iran
- Department of Molecular Hepatology, Middle East Liver Disease Center, Tehran, IR Iran
| | | | - Seyed Moayed Alavian
- Department of Molecular Hepatology, Middle East Liver Disease Center, Tehran, IR Iran
- Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
- Corresponding Author: Seyed Moayed Alavian, Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences and Tehran Hepatitis Center, Tehran, IR Iran. Tel: +98-2188945186, Fax: +98-2188945188, E-mail:
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15
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Cho J, Kim L, Li Z, Rose NR, Talor MV, Njoku DB. Sex bias in experimental immune-mediated, drug-induced liver injury in BALB/c mice: suggested roles for Tregs, estrogen, and IL-6. PLoS One 2013; 8:e61186. [PMID: 23577207 PMCID: PMC3618451 DOI: 10.1371/journal.pone.0061186] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 03/07/2013] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND AND AIMS Immune-mediated, drug-induced liver injury (DILI) triggered by drug haptens is more prevalent in women than in men. However, mechanisms responsible for this sex bias are not clear. Immune regulation by CD4+CD25+FoxP3+ regulatory T-cells (Tregs) and 17β-estradiol is crucial in the pathogenesis of sex bias in cancer and autoimmunity. Therefore, we investigated their role in a mouse model of immune-mediated DILI. METHODS To model DILI, we immunized BALB/c, BALB/cBy, IL-6-deficient, and castrated BALB/c mice with trifluoroacetyl chloride-haptenated liver proteins. We then measured degree of hepatitis, cytokines, antibodies, and Treg and splenocyte function. RESULTS BALB/c females developed more severe hepatitis (p<0.01) and produced more pro-inflammatory hepatic cytokines and antibodies (p<0.05) than did males. Castrated males developed more severe hepatitis than did intact males (p<0.001) and females (p<0.05). Splenocytes cultured from female mice exhibited fewer Tregs (p<0.01) and higher IL-1β (p<0.01) and IL-6 (p<0.05) than did those from males. However, Treg function did not differ by sex, as evidenced by absence of sex bias in programmed death receptor-1 and responses to IL-6, anti-IL-10, anti-CD3, and anti-CD28. Diminished hepatitis in IL-6-deficient, anti-IL-6 receptor α-treated, ovariectomized, or male mice; undetectable IL-6 levels in splenocyte supernatants from ovariectomized and male mice; elevated splenic IL-6 and serum estrogen levels in castrated male mice, and IL-6 induction by 17β-estradiol in splenocytes from naïve female mice (p<0.05) suggested that 17β-estradiol may enhance sex bias through IL-6 induction, which subsequently discourages Treg survival. Treg transfer from naïve female mice to those with DILI reduced hepatitis severity and hepatic IL-6. CONCLUSIONS 17β-estradiol and IL-6 may act synergistically to promote sex bias in experimental DILI by reducing Tregs. Modulating Treg numbers may provide a therapeutic approach to DILI.
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Affiliation(s)
- Joonhee Cho
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Lina Kim
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Zhaoxia Li
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Noel R. Rose
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, United States of America
- The W. Harvey Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Monica Vladut Talor
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Dolores B. Njoku
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
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16
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Nicoll A, Moore D, Njoku D, Hockey B. Repeated exposure to modern volatile anaesthetics may cause chronic hepatitis as well as acute liver injury. BMJ Case Rep 2012; 2012:bcr-2012-006543. [PMID: 23131606 DOI: 10.1136/bcr-2012-006543] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Volatile anaesthetic agents are known to cause acute hepatitis and fulminant hepatic failure in susceptible individuals. Four patients were identified with prolonged liver injury due to volatile anaesthetic-induced hepatitis. Three had liver biopsy confirmation and all gave blood for specific diagnostic tests (TFA and CYP 2E1 IgG4 antibodies). The Roussel Uclaf Causality Assessment Method (RUCAM) drug causality scale was used to determine the likelihood of volatile anaesthetics causing the chronic liver injury. We describe four cases of volatile anaesthetic hepatitis in which three evolved into chronic hepatitis. The fourth followed a more typical pattern of acute hepatitis; however, resolution took a few months. These cases all occurred with modern volatile anaesthetics, predominantly sevoflurane, and all cases were proven with specific antibody tests, liver histology and a drug causality scale. This is the first report of chronic liver injury due to volatile anaesthetic exposure.
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Affiliation(s)
- Amanda Nicoll
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.
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17
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Kusuma HR, Venkataramana NK, Rao SA, Naik AL, Gangadhara D, Venkatesh KH. Fulminant hepatic failure after repeated exposure to isoflurane. Indian J Anaesth 2011; 55:290-2. [PMID: 21808406 PMCID: PMC3141158 DOI: 10.4103/0019-5049.82696] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Inhalational agents are used routinely for maintenance of anaesthesia. Post anaesthesia hepatic failure has been documented following exposure to halothane. However, there are very few reports of such complications following isoflurane anaesthesia. A 6-year-old child developed fulminant hepatic failure 2 days following craniotomy under general anaesthesia. There was no evidence of viral, autoimmune, or metabolic causes of hepatitis. No other medications known to cause hepatitis, except low dose paracetamol, were administered. The clinical and histological picture of our case is similar to that of halothane hepatitis, which has a significant mortality rate. We report this as a possible fulminant hepatic failure resulting from exposure to isoflurane anaesthesia.
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Affiliation(s)
- Halemani R Kusuma
- Department of Anaesthesiology & Critical Care, BGS Global Hospitals, Bangalore, Karnataka, India
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18
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Herz S, Puhl G, Spies C, Jörres D, Neuhaus P, von Heymann C. [Perioperative anesthesia management of extended partial liver resection. Pathophysiology of hepatic diseases and functional signs of hepatic failure]. Anaesthesist 2011; 60:103-17. [PMID: 21293838 DOI: 10.1007/s00101-011-1852-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The importance of partial liver resection as a therapeutic option to cure hepatic tumors has increased over the last decades. This has been influenced on the one hand by advances in surgical and anesthetic management resulting in a reduced mortality after surgery and on the other hand by an increased incidence of hepatocellular carcinoma. Nowadays, partial resection of the liver is performed safely and as a routine operation in specialized centers. This article describes the pathophysiological changes secondary to liver failure and assesses the perioperative management of patients undergoing partial or extended liver resection. It looks in detail at the preoperative assessment, the intraoperative anesthetic management including fluid management and techniques to reduce blood loss as well as postoperative analgesia and intensive care therapy.
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Affiliation(s)
- S Herz
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité-Universitätsmedizin Berlin,Campus Virchow-Klinikum und Charité Mitte, Augustenburger Platz 1, Berlin, Germany
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19
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Raufman JP, Xu S, Cheng K, Khurana S, Johnson D, Shao C, Kane MA, Shi D, Gullapalli R, Polli J. In vivo magnetic resonance imaging to detect biliary excretion of 19F-labeled drug in mice. Drug Metab Dispos 2011; 39:736-9. [PMID: 21270105 DOI: 10.1124/dmd.110.037358] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Isoflurane is an inhaled halogenated hydrocarbon anesthetic commonly used for animal research. In our quest to develop a method for measuring bile acid transport in live animals using (19)F magnetic resonance (MR) imaging, it occurred to us that isoflurane, which contains five fluorines per molecule and is probably widely distributed, would provide an excellent test drug to evaluate the merits of this approach. Experiments in 20- to 28-g male C57BL/6 mice were performed using a horizontal bore scanner with a 30-mm (19)F/(1)H dual-tuned surface coil used to transmit and receive radiofrequency signals at 300.28 MHz for (1)H and 282.55 MHz for (19)F nuclei. Proton MR imaging was used to identify the mouse gallbladder in vivo, which was verified by anatomical dissection. Subsequent experiments in mice inhaling 1.5% isoflurane for 1 to 2 h revealed robust (19)F signals from the gallbladder, verified by overlying (1)H and (19)F signals. No (19)F signal was detected in mice anesthetized with nonhalogenated anesthetics. The presence of isoflurane in gallbladder bile of isoflurane-treated mice was verified using liquid chromatography-mass spectrometry. Gallbladder bile isoflurane content ranged from 3.2 to 4.7 μg. The data presented here provide proof of concept that this novel approach can be used for in vivo measurement of biliary excretion of both existing and novel (19)F-labeled drugs.
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Affiliation(s)
- Jean-Pierre Raufman
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, 22 South Greene St., N3W62, Baltimore, MD 21201, USA.
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20
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Yagi H, Tafaleng E, Nagaya M, Hansel MC, Strom SC, Fox IJ, Soto-Gutierrez A. Embryonic and induced pluripotent stem cells as a model for liver disease. Crit Rev Biomed Eng 2010; 37:377-98. [PMID: 20528732 DOI: 10.1615/critrevbiomedeng.v37.i4-5.40] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Induced pluripotent stem (iPS) cells are human somatic cells that have been reprogrammed to a pluripotent state. Through several elegant technologies, we are now able to generate human iPS cells with disease genotypes that could serve as invaluable tools for human disease modeling. This could lead to an understanding of the root causes of a disease and to the development of effective prophylactic and therapeutic strategies for it. However, we are still far from generating fully functional liver cells from stem cells, including iPS cells, on in vitro culture systems. Tissue-engineering techniques have opened the window to inducing a functional fate for differentiated cells by providing a microenvironment that allows the maintenance of signals similar to those found in the natural microenvironment. Here we review the current technology to establish iPS cells and discuss strategies to generate human liver disease modeling using iPS cell technology in concert with bioengineering approaches.
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Affiliation(s)
- Hiroshi Yagi
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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21
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Teng WC, Oh JW, New LS, Wahlin MD, Nelson SD, Ho HK, Chan ECY. Mechanism-Based Inactivation of Cytochrome P450 3A4 by Lapatinib. Mol Pharmacol 2010; 78:693-703. [DOI: 10.1124/mol.110.065839] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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22
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Njoku DB. Suppressive and pro-inflammatory roles for IL-4 in the pathogenesis of experimental drug-induced liver injury: a review. Expert Opin Drug Metab Toxicol 2010; 6:519-31. [PMID: 20166853 DOI: 10.1517/17425251003601979] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE OF THE FIELD Idiosyncratic drug reactions resulting in drug-induced liver injury (DILI) account for approximately 13% of acute liver failure cases in the US. Idiosyncratic drug reactions are the third most common cause of liver transplantation, exceeded only by acetaminophen and indeterminate causes. Clinical evidence suggests that idiosyncratic DILI is triggered by drug hapten-altered self proteins resulting in hepatocellular injury. An example of this type of DILI is hepatitis that develops in susceptible individuals following administration of halogenated volatile anesthetics, dihydralazine, carbamazepine or diclofenac. AREAS COVERED IN THIS REVIEW In this review, we describe research in animal models that supports a critical role for suppressive and pro-inflammatory roles for IL-4 in the pathogenesis of immune-mediated DILI. WHAT THE READER WILL GAIN The reader will gain insights into the roles of IL-4 in the development of experimental DILI. The reader will gain tools to assist in the translation of these findings to those in patients with immune-mediated DILI, as well as other inflammatory diseases of the liver. The reader will then be made aware of gaps in knowledge in the pathogenesis of DILI where research could result in significant advances in the care of these complicated patients. TAKE HOME MESSAGE In experimental immune-mediated DILI, IL-4 suppresses regulatory responses to CYP2E1 autoantigens but induces pro-inflammatory responses to drug haptens.
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Affiliation(s)
- Dolores B Njoku
- Johns Hopkins University, Department of Anesthesiology and Critical Care Medicine, 600 North Wolfe Street, Baltimore 21287, USA.
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23
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Murata H, Inoue H, Sumikawa K. Anesthetic management of a patient undergoing liver transplantation who had previous coronary artery bypass grafting using an in situ right gastroepiploic artery. J Anesth 2010; 24:264-7. [PMID: 20191293 DOI: 10.1007/s00540-010-0892-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2009] [Accepted: 12/20/2009] [Indexed: 01/30/2023]
Abstract
We describe successful anesthetic management during living-donor liver transplantation in a 63-year-old man with previous coronary artery bypass grafting (CABG) that employed an in situ right gastroepiploic artery (RGEA). Anesthesia was maintained with 1.5% isoflurane in air/oxygen and fentanyl. A five-lead electrocardiogram, transesophageal echocardiogram, and pacing pulmonary artery catheter evaluated cardiac function. A pacing wire was inserted through the catheter to prepare for intraoperative severe bradyarrhythmia. Olprinone and nicorandil were continuously infused to prevent decrease in coronary arterial blood flow and the collapse of cardiac function. Avoiding disruption of circulation to coronary arteries through injury or spasm of the RGEA graft and preparing for cardiac insufficiency during liver transplantation of a patient with previous CABG using an in situ RGEA is critical.
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Affiliation(s)
- Hiroaki Murata
- Department of Anesthesiology, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
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24
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Russmann S, Kullak-Ublick GA, Grattagliano I. Current concepts of mechanisms in drug-induced hepatotoxicity. Curr Med Chem 2009; 16:3041-53. [PMID: 19689281 PMCID: PMC2765083 DOI: 10.2174/092986709788803097] [Citation(s) in RCA: 247] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Drug-induced liver injury (DILI) has become a leading cause of severe liver disease in Western countries and therefore poses a major clinical and regulatory challenge. Whereas previously drug-specific pathways leading to initial injury of liver cells were the main focus of mechanistic research and classifications, current concepts see these as initial upstream events and appreciate that subsequent common downstream pathways and their attenuation by drugs and other environmental and genetic factors also have a profound impact on the risk of an individual patient to develop overt liver disease. This review summarizes current mechanistic concepts of DILI in a 3-step model that limits its principle mechanisms to three main ways of initial injury, i.e. direct cell stress, direct mitochondrial impairment, and specific immune reactions. Subsequently, initial injury initiates further downstream events, i.e. direct and death receptor-mediated pathways leading to mitochondrial permeability transition, which then results in apoptotic or necrotic cell death. For all mechanisms, mitochondria play a central role in events leading to apoptotic vs. necrotic cell death. New treatment targets consequently focus on interference with downstream pathways that mediate injury and therefore determine the ultimate outcome of DILI. Genome wide and targeted pharmacogenetic as well as metabonomic approaches are now used in order to reach the key goals of a better understanding of mechanisms in hepatotoxicity, and to develop new strategies for its prediction and treatment. However, the complexity of interactions between genetic and environmental risk factors is considerable, and DILI therefore currently remains unpredictable for most hepatotoxins.
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Affiliation(s)
- Stefan Russmann
- Division of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland.
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25
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Njoku DB, Li Z, Washington ND, Mellerson JL, Talor MV, Sharma R, Rose NR. Suppressive and pro-inflammatory roles for IL-4 in the pathogenesis of experimental drug-induced liver injury. Eur J Immunol 2009; 39:1652-63. [PMID: 19499520 DOI: 10.1002/eji.200838135] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The pathogenesis of immune-mediated drug-induced liver injury (DILI) following halogenated anesthetics, carbamazepine or alcohol has not been fully elucidated. Detecting cytochrome P450 2E1 (CYP2E1) IgG4 auto-antibodies in anesthetic DILI patients suggests a role for IL-4 in this hapten-mediated process. We investigated IL-4-mediated mechanisms using our model of experimental DILI induced by immunizing BALB/c (WT) and IL-4(-/-) (KO) mice with S100 liver proteins covalently modified by a trifluoroacetyl chloride (TFA) hapten formed following halogenated anesthetic metabolism by CYP2E1. WT mice developed more hepatitis, TFA and S100 antibodies (p<0.01), as well as T-cell proliferation to CYP2E1 and TFA (p<0.01) than KO mice. Additionally, WT CD4(+) T cells adoptively transferred hepatitis to naïve Rag(-/-) mice (p<0.01). Pro-inflammatory cytokines were expectedly decreased in TFA hapten-stimulated KO splenocyte supernatants (p<0.001); however, IL-2 and IFN-gamma (p<0.05), as well as IL-6 and IL-10 (p<0.001) levels were elevated in CYP2E1-stimulated KO splenocyte supernatants, suggesting dual IL-4-mediated pro-inflammatory and regulatory responses. Anti-IL-10 administered to KO mice increased hepatitis, TFA and CYP2E1 antibodies in KO mice confirming a critical role for IL-4. This is the first demonstration of dual roles for IL-4 in the pathogenesis of immune-mediated DILI by suppressing auto-antigen-induced regulatory responses while promoting hapten-induced pro-inflammatory responses.
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Affiliation(s)
- Dolores B Njoku
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA.
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26
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Njoku DB, Li Z, Mellerson JL, Sharma R, Talor MV, Barat N, Rose NR. IP-10 protects while MIP-2 promotes experimental anesthetic hapten - induced hepatitis. J Autoimmun 2009; 32:52-9. [PMID: 19131211 DOI: 10.1016/j.jaut.2008.11.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2008] [Revised: 11/06/2008] [Accepted: 11/07/2008] [Indexed: 01/01/2023]
Abstract
MIP-2 and IFN-gamma inducible protein-10 (IP-10) and their respective receptors, CXCR2 and CXCR3, modulate tissue inflammation by recruiting neutrophils or T cells from the spleen or bone marrow. Yet, how these chemokines modulate diseases such as immune-mediated drug-induced liver injury (DILI) is essentially unknown. To investigate how chemokines modulate experimental DILI in our model we used susceptible BALB/c (WT) and IL-4-/- (KO) mice that develop significantly reduced hepatitis and splenic T cell priming to anesthetic haptens and self proteins following TFA-S100 immunizations. We detected CXCR2+ splenic granulocytes in all mice two weeks following immunizations; by three weeks, MIP-2 levels (p<0.001) and GR1+ cells were elevated in WT livers, suggesting MIP-2-recruited granulocytes. Elevated splenic CXCR3+CD4+T cells were identified after two weeks in KO mice indicating elevated IP-10 levels which were confirmed during T cell priming. This result suggested that IP-10 reduced T cell priming to critical DILI antigens. Increased T cell proliferation following co-culture of TFA-S100-primed WT splenocytes with anti-IP-10 (p<0.05) confirmed that IP-10 reduced T cell priming to CYP2E1 and TFA. We propose that MIP-2 promotes and IP-10 protects against the development of hepatitis and T cell priming in this murine model.
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Affiliation(s)
- Dolores B Njoku
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD 21287, USA.
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27
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Anderson JS, Rose NR, Martin JL, Eger EI, Njoku DB. Desflurane hepatitis associated with hapten and autoantigen-specific IgG4 antibodies. Anesth Analg 2007; 104:1452-3, table of contents. [PMID: 17513640 PMCID: PMC3650136 DOI: 10.1213/01.ane.0000263275.10081.47] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Three cases of drug-induced liver injury (DILI) have been reported after desflurane anesthesia. However, no previous reports have detected serum autoantibodies such as that reported with DILI from halothane or isoflurane. METHODS AND RESULTS We describe the first documentation of cytochrome P450 2E1 IgG4 autoantibodies, as well as 58 kDa endoplasmic reticulum protein and trifluoroacetyl chloride hapten-specific IgG4 antibodies, in a patient who developed DILI after desflurane anesthesia. CONCLUSIONS These findings suggest that allergic and autoimmune mechanisms have critical roles in the development of desflurane DILI.
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28
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Njoku DB, Mellerson JL, Talor MV, Kerr DR, Faraday NR, Outschoorn I, Rose NR. Role of CYP2E1 immunoglobulin G4 subclass antibodies and complement in pathogenesis of idiosyncratic drug-induced hepatitis. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2006; 13:258-65. [PMID: 16467335 PMCID: PMC1391926 DOI: 10.1128/cvi.13.2.258-265.2006] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Idiosyncratic drug-induced hepatitis (IDDIH) is the third most common cause for acute liver failure in the United States. Previous studies have attempted to identify susceptible patients or early stages of disease with various degrees of success. To determine if total serum immunoglobulin subclasses, CYP2E1-specific subclass autoantibodies, complement components, or immune complexes could distinguish persons with IDDIH from others exposed to drugs, we studied persons exposed to halogenated volatile anesthetics, which have been associated with IDDIH and CYP2E1 autoantibodies. We found that patients with anesthetic-induced IDDIH had significantly elevated levels of CYP2E1-specific immunoglobulin G4 (IgG4) autoantibodies, while anesthetic-exposed healthy persons had significantly elevated levels of CYP2E1-specific IgG1 autoantibodies. Anesthetic IDDIH patients had significantly lower levels of C4a, C3a, and C5a compared to anesthetic-exposed healthy persons. C1q- and C3d-containing immune complexes were significantly elevated in anesthetic-exposed persons. In conclusion, our data suggest that anesthetic-exposed persons develop CYP2E1-specific IgG1 autoantibodies which may form detectable circulating immune complexes subsequently cleared by classical pathway activation of the complement system. Persons susceptible to anesthetic-induced IDDIH develop CYP2E1-specific IgG4 autoantibodies which form small, nonprecipitating immune complexes that escape clearance because of their size or by direct inhibition of complement activation.
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Affiliation(s)
- Dolores B Njoku
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, 600 North Wolfe St. Blalock 906A, Baltimore, MD 21287, USA.
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Abstract
Recent breakthroughs in molecular biology have enabled a reclassification of drug metabolising enzymes based on their amino acid sequence. This has led to a better understanding of drug metabolism and drug interactions. The majority of these drug metabolising enzymes may be either induced or inhibited by drugs or by extraneous substances including foodstuffs, cigarette smoke and environmental pollutants. Virtually all drugs used in anaesthesia are metabolised by either hepatic phase 1 or phase II enzymes. This review considers the classification of drug metabolising enzymes, explains the mechanisms of enzyme induction and inhibition, and also considers how the action of drugs commonly used by anaesthetists, including opioids and neuromuscular blocking drugs, may be altered by this mechanism.
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Affiliation(s)
- B P Sweeney
- Department of Anaesthesia, Poole and Royal Bournemouth Hospitals, Bournemouth BH7 7DW, UK.
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Sanderson JP, Naisbitt DJ, Park BK. Role of bioactivation in drug-induced hypersensitivity reactions. AAPS JOURNAL 2006; 8:E55-64. [PMID: 16584134 PMCID: PMC2751424 DOI: 10.1208/aapsj080107] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Drug-induced hypersensitivity reactions are a major problem in both clinical treatment and drug development. This review covers recent developments in our understanding of the pathogenic mechanisms involved, with special focus on the potential role of metabolism and bioactivation in generating a chemical signal for activation of the immune system. The possible role of haptenation and neoantigen formation is discussed, alongside recent findings that challenge this paradigm. Additionally, the essential role of costimulation is examined, as are the potential points whereby costimulation may be driven by reactive metabolites. The relevance of local generation of metabolites in determining the location and character of a reaction is also covered.
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Affiliation(s)
- Joseph P. Sanderson
- Department of Pharmacology and Therapeutics, University of Liverpool, Sherrington Buildings, Ashton Street, L69 3GE Liverpool, England
| | - Dean J. Naisbitt
- Department of Pharmacology and Therapeutics, University of Liverpool, Sherrington Buildings, Ashton Street, L69 3GE Liverpool, England
| | - B. Kevin Park
- Department of Pharmacology and Therapeutics, University of Liverpool, Sherrington Buildings, Ashton Street, L69 3GE Liverpool, England
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Naisbitt DJ, Pirmohamed M, Park BK. Immunopharmacology of hypersensitivity reactions to drugs. Curr Allergy Asthma Rep 2003; 3:22-9. [PMID: 12542989 DOI: 10.1007/s11882-003-0006-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Drug hypersensitivity reactions are characterized by their unpredictability, lack of simple dose-dependency, host sensitivity, and potentially serious clinical outcome. They occur in a small proportion of patients, and usually the predisposing factors are unknown, although there is increasing evidence for genetic predisposition and disease being significant risk factors. The current understanding of the chemical basis of immune-mediated reactions is based on the hapten hypothesis, which requires drug bioactivation, covalent binding to proteins, followed by uptake, antigen processing, and a polyclonal immune response. The recently proposed "danger hypothesis" can be considered to be an essential addition to the hapten hypothesis. According to the danger hypothesis, the immune response to a drug-derived antigen requires the presence of co-stimulatory signals and cytokines, which propagate and determine the type of immune response. The "danger signal" might result from chemical, physical, or viral stress.
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Affiliation(s)
- Dean J Naisbitt
- Department of Pharmacology and Therapeutics, The University of Liverpool, Ashton Street, Liverpool, L69 3GE, UK.
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32
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Njoku DB, Greenberg RS, Bourdi M, Borkowf CB, Dake EM, Martin JL, Pohl LR. Autoantibodies associated with volatile anesthetic hepatitis found in the sera of a large cohort of pediatric anesthesiologists. Anesth Analg 2002. [PMID: 11812677 DOI: 10.1213/00000539-200202000-00003] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED Anesthetic-induced hepatitis is thought to have an immune-mediated basis, in part because many patients who develop hepatitis have serum autoantibodies that react with specific hepatic proteins. The present study shows that pediatric anesthesiologists also have these serum autoantibodies. Moreover, levels of these autoantibodies are higher than those of general anesthesiologists. We collected sera from 105 pediatric and 53 general anesthesiologists (including 3 nurse anesthetists), 20 halothane hepatitis patients, and 20 control individuals who were never exposed to inhaled anesthetics. Serum cytochrome P450 2E1 (P450 2E1) and 58-kd hepatic endoplasmic reticulum protein (ERp58) autoantibodies were measured by enzyme-linked immunosorbent assays. Positive values were 2 SD above median control values. Two multiple regression models were constructed. Pediatric anesthesiologists, like halothane hepatitis patients, had higher serum autoantibody levels of ERp58 and P450 2E1 than general anesthesiologists and controls, which was possibly because of their increased occupational exposures to anesthetics. Female anesthesiologists had higher levels of ERp58 autoantibodies than male anesthesiologists, whereas female pediatric anesthesiologists had higher levels of P450 2E1 autoantibodies than all other anesthesiologists. One female pediatric anesthesiologist had symptoms of hepatic injury. Because most anesthesiologists do not develop volatile anesthetic-induced hepatic injury, the findings suggest that pathogenic ERp58 and P450 2E1 autoantibodies may not directly cause volatile anesthetic hepatitis. Female anesthesiologists have high levels of these autoantibodies; however, the majority of these individuals do not develop hepatitis, suggesting that autoantibodies may not have a pathological role in volatile anesthetic-induced hepatitis. IMPLICATIONS Environmental exposure of anesthesiology personnel to certain inhaled anesthetics can induce the formation of autoantibodies that have been associated with anesthetic hepatitis. Female anesthesiologists have high levels of these autoantibodies; however, the majority of these individuals do not develop hepatitis, suggesting that autoantibodies may not have a pathological role in volatile anesthetic-induced hepatitis.
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Affiliation(s)
- Dolores B Njoku
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287,
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Long SA, Quan C, Van de Water J, Nantz MH, Kurth MJ, Barsky D, Colvin ME, Lam KS, Coppel RL, Ansari A, Gershwin ME. Immunoreactivity of organic mimeotopes of the E2 component of pyruvate dehydrogenase: connecting xenobiotics with primary biliary cirrhosis. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2001; 167:2956-63. [PMID: 11509645 DOI: 10.4049/jimmunol.167.5.2956] [Citation(s) in RCA: 132] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
In primary biliary cirrhosis (PBC), the major autoepitope recognized by both T and B cells is the inner lipoyl domain of the E2 component of pyruvate dehydrogenase. To address the hypothesis that PBC is induced by xenobiotic exposure, we took advantage of ab initio quantum chemistry and synthesized the inner lipoyl domain of E2 component of pyruvate dehydrogenase, replacing the lipoic acid moiety with synthetic structures designed to mimic a xenobiotically modified lipoyl hapten, and we quantitated the reactivity of these structures with sera from PBC patients. Interestingly, antimitochondrial Abs from all seropositive patients with PBC, but no controls, reacted against 3 of the 18 organic modified autoepitopes significantly better than to the native domain. By structural analysis, the features that correlated with autoantibody binding included synthetic domain peptides with a halide or methyl halide in the meta or para position containing no strong hydrogen bond accepting groups on the phenyl ring of the lysine substituents, and synthetic domain peptides with a relatively low rotation barrier about the linkage bond. Many chemicals including pharmaceuticals and household detergents have the potential to form such halogenated derivatives as metabolites. These data reflect the first time that an organic compound has been shown to serve as a mimeotope for an autoantigen and further provide evidence for a potential mechanism by which environmental organic compounds may cause PBC.
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Affiliation(s)
- S A Long
- Division of Rheumatology, University of California School of Medicine, Davis, CA 95616, USA
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34
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Park BK, Kitteringham NR, Kenny JR, Pirmohamed M. Drug metabolism and drug toxicity. Inflammopharmacology 2001. [DOI: 10.1163/156856001300248461] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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35
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Abstract
The three anesthetic drugs introduced most recently to the market are sevoflurane, desflurane, and ropivacaine. Sevoflurane and desflurane are both inhalational anesthetic agents and ropivacaine is a local anesthetic agent. Sevoflurane provides a rapid onset and offset of action; it is well tolerated with little airway irritation. It is hemodynamically stable, with low potential for toxicity. Concerns about its interaction with soda lime during low-flow anesthesia with the production of Compound A have not proved to be a clinical problem. While desflurane also provides rapid onset and recovery from anesthesia, it is not as hemodynamically stable as sevoflurane, and also causes airway irritation. Ropivacaine is a unique local anesthetic in that it is supplied as the pure S-enantiomer. It is at least as effective as bupivacaine, with lower toxicity and less motor block for the same degree of sensory block.
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Affiliation(s)
- N J O'Keeffe
- Department of Anesthesia, Manchester Royal Infirmary, Manchester, UK.
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36
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Uetrecht JP. New concepts in immunology relevant to idiosyncratic drug reactions: the "danger hypothesis" and innate immune system. Chem Res Toxicol 1999; 12:387-95. [PMID: 10328748 DOI: 10.1021/tx980249i] [Citation(s) in RCA: 237] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J P Uetrecht
- Faculties of Pharmacy and Medicine, University of Toronto, Toronto, Ontario, Canada M5S 2S2.
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37
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Nelson PD, Ferguson CN, Jones RM. Anaesthetic organ toxicity: is it really a problem? Curr Opin Anaesthesiol 1998; 11:399-401. [PMID: 17013248 DOI: 10.1097/00001503-199808000-00004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The hepatotoxicity of halothane is now well known, but only became apparent after several years of use. The nephrotoxicity of methoxyflurane was not realized immediately, but once identified, led to its withdrawal from use. Therefore, when new agents that appear to offer significant advantages over established drugs become available, exhaustive testing and monitoring is necessary to ensure their safety. Sevoflurane, recently available in the UK and the USA but used for some time in Japan, has been subjected to considerable scrutiny.
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Affiliation(s)
- P D Nelson
- Department of Anaesthesia, St Mary's Hospital, London W2 1NY, UK
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