Leukocyte arylsulfatase A activity in patients with alcohol‐related cirrhosis

Arylsulfatase (ASA) enzyme deficiency is associated with metachromatic leukodystrophy (MLD), which is a hereditary myelin metabolic disease. It has been proposed that in alcoholic subjects with abnormal ASA, the accumulation of sulfatides may lead to demyelinization and generalized cerebral atrophy. ASA may be diminished in subjects with alcoholic cirrhosis having encephalopathic manifestations. This idea has not been previously proposed. Leukocyte arylsulfatase A (ASA) activity was measured in 30 healthy male volunteers and 28 patients with alcohol‐related cirrhosis. The patients were divided into two groups: patients with alcohol‐related cirrhosis with hepatic encephalopathy history and patients with alcoholic cirrhosis without history of hepatic encephalopathy. Alcoholic cirrhotic patients with history of encephalopathy showed 58.21% (40.95 nmol/mg protein/h) less enzymatic activity than a control group (98.00 nmol/mg protein/h), whereas the group without history of encephalopathy showed an ASA value which was 38.2% (60.55 nmol/mg protein/h) less than the control group. The results suggest that the low ASA activity is a factor associated to the appearance of encephalopathy in patients with alcohol‐related cirrhosis. Am. J. Hum. Biol. 13:297–300, 2001. © 2001 Wiley‐Liss, Inc.     

Activation of soluble guanylate cyclase by nitric oxide in lymphocytes correlates with minimal hepatic encephalopathy in cirrhotic patients

Patients with liver cirrhosis with normal neurological and mental status examination may present minimal forms of hepatic encephalopathy, showing intellectual function impairment that cannot be detected through general clinical examination but can be unveiled using specific neuropsychological or neurophysiological examination. Evaluation of minimal hepatic encephalopathy (MHE) in cirrhotic patients would have prognostic value. The psychometric hepatic encephalopathy score (PHES) has been recommended as the "gold standard" in the diagnosis of MHE. Altered modulation of cyclic GMP (cGMP) levels in the brain seems to be responsible for the impairment of some types of cognitive function in liver disease. In animal models of liver disease, some of the alterations in modulation of cGMP levels in the brain are reproduced in lymphocytes. The aim of the present work was to assess whether there is a correlation between the alterations in different parameters involved in modulation of cGMP levels and the presence of MHE in patients with liver disease. We studied in 46 patients with liver cirrhosis and 26 controls the performance in the PHES battery of psychometric tests and the critical flicker frequency (CFF), the concentration of cGMP in plasma and lymphocytes, activation of guanylate cyclase by nitric oxide (NO) in lymphocytes, and several parameters likely involved in altered cGMP homeostasis in liver disease such as ammonia, NO metabolites, and atrial natriuretic peptide (ANP). Activation of guanylate cyclase by NO in lymphocytes and cGMP in plasma were higher and CFF lower in patients with MHE than in patients without MHE. Ammonia, ANP, and metabolites of NO were higher in patients than in controls but were no different in patients with or without MHE. Alteration in activation of guanylate cyclase by NO in lymphocytes correlates with PHES performance, CFF, and ammonia levels. This suggests that altered modulation of guanylate cyclase by NO in lymphocytes would reflect a parallel alteration in the brain occurring in patients with MHE that would be involved in their cognitive impairment.     

Working memory impairment and reduced hippocampal and prefrontal cortex c-Fos expression in a rat model of cirrhosis

Hepatic encephalopathy (HE) is a frequent neurological complication observed in patients with liver malfunction. Previous studies have shown memory impairment in these patients. In order to investigate brain substrates of spatial working memory impairment in chronic HE, neuronal expression of c-Fos protein was studied in an experimental model of cirrhosis. Control and cirrhotic rats were trained on a spatial working memory task in the Morris water maze (MWM). Differences between groups were found in the working memory task. Cirrhotic rats were unable to locate the platform in the retention trial. Neuronal activation, measured by c-Fos protein, was compared between groups. No differences were found in c-Fos expression of control and cirrhotic rats that were not tested in the MWM. Working memory task produced increase in c-Fos positive cells in dorsal hippocampus, CA1 and CA3, and prefrontal cortex in control group compared to thioacetamide group or naïve, which only swam in the maze during a similar time. These findings suggest that cirrhotic rats show spatial working memory impairment that could be linked to dysfunction in neuronal activity in prefrontal cortex and hippocampus.     

Metronidazole-induced encephalopathy in a patient with liver cirrhosis

Encephalopathy is a disorder characterized by altered brain function, which can be attributed to various causes. Encephalopathy associated with metronidazole administration occurs rarely and depends on the cumulative metronidazole dose, and most patients with this condition recover rapidly after discontinuation of therapy. Because metronidazole is metabolized in the liver and can be transported by the cerebrospinal fluid and cross the blood-brain barrier, it may induce encephalopathy even at a low cumulative dose in patients with hepatic dysfunction. We experienced a patient who showed ataxic gait and dysarthric speech after receiving metronidazole for the treatment of hepatic encephalopathy that was not controlled by the administration of lactulose. The patient was diagnosed as metronidazole-induced encephalopathy, and stopping drug administration resulted in a complete recovery from encephalopathy. This case shows that caution should be exercised when administering metronidazole because even a low dose can induce encephalopathy in patients with liver cirrhosis.     

暴发性肝损伤肝性脑病大鼠脑糖胺多糖含量的变化

本文应用硫代乙酰胺灌胃复制暴发性肝损伤肝性脑病大鼠模型,检测了实验大鼠大脑、脑干、小脑糖胺多糖含量的变化。结果表明肝性脑病发生时大脑、脑干糖胺多糖含量较正常大鼠显著降低,而小脑糖胺多糖含量并无变化。说明肝性脑病发生时大脑及脑干部位伴有糖胺多糖的变化,提示肝性脑病的发生与脑内神经细胞外基质成份糖胺多糖等的变化有关。     

左旋肉碱治疗肝硬化并显性肝性脑病的效果观察

目的 探讨左旋肉碱治疗肝硬化并显性肝性脑病患者的临床疗效。方法 选择2011年3月~2018年6月天津市宝坻区人民医院收治的84例肝硬化并发肝性脑病显性症状,且住院治疗＞1周的患者作为研究对象,随机分为左旋肉碱组和对照组,每组42例。对照组接受常规治疗,左旋肉碱组在常规治疗基础上联合应用左旋肉碱。比较治疗7 天时两组患者肝性脑病West-Haven分级、NCT-A时间、血氨情况,以及两组住院天数、随访6周时肝性脑病复发情况。结果 治疗7天时左旋肉碱组NCT-A时间为（52.31±17.92）s ,低于对照组的（61.32±18.24）s（P＜0.05）;空腹静脉血氨水平为（45.23±27.42）μmol/L,低于对照组的 （60.44±25.43）μmol/L（P＜0.05）;左旋肉碱组HE分级为（1.47±0.51）,与对照组的（1.43±0.54）比较,差异无统计学意义（P＞0.05）。两组患者平均住院日［（8.32±3.60）d vs（9.12±5.81）d］及随访6周肝性脑病早期复发率（35.71% vs 28.57%）分别比较,差异均无统计学意义（P＞0.05）。结论 左旋肉碱虽能降低肝硬化并显性肝性脑病患者血氨水平、改善NCT-A时间,但不能改善肝性脑病严重程度分级、降低住院日及肝性脑病复发率,其在肝硬化并显性肝性脑病中的应用价值有待进一步证实。     

What the clinician can learn from MR glutamine/glutamate assays.

At present in vivo NMR spectroscopic studies of brain glutamate and glutamine concentrations relative to encephalopathy have mainly been performed in hepatic encephalopathy (HE). In vivo proton NMR studies were performed in rats with hyperammonemia and acute HE due to acute liver ischemia as well as in rats with hyperammonemia due to either repeated urease i.p. injection or i.p. administration of methionine sulfoximine, a well known inhibitor of glutamine synthetase. In man, in vivo proton NMR is described in patients with chronic liver disease: cirrhosis of different etiology and associated with different degrees of HE. In the experimental models proton NMR spectroscopy of the cerebral cortex revealed an increase in glutamine concentration, a decrease in glutamate concentration and a decrease in phosphocholine compounds. In humans no clear distinction between cerebral cortex glutamate and glutamine concentration could be made by in vivo 1H NMR spectroscopy. However, the combined glutamate/glutamine peak increased in a way compatible with an increased cerebral cortex glutamine concentration during chronic HE. In the cirrhotic patients too a decrease in cerebral cortex phosphocholine compounds was observed, the explanation of which is unclear. Both the experimental work and the clinical observations support the hypothesis that impairment of the glutamate/glutamine cycle between astrocytes and neurons plays a role in the pathogenesis of hepatic encephalopathy.     

Synbiotic formulation of probiotic and lactulose combination for hepatic encephalopathy treatment: A realistic hope?

Gut-produced ammonia plays a vital role in the pathogenesis of hepatic encephalopathy because cirrhotic liver fails to clear toxic metabolites. Small intestinal bacterial overgrowth and delayed gastrointestinal transit time in cirrhosis add to the pathogenesis. Lactulose is a mainstay in the treatment of hepatic encephalopathy. Another benefit of lactulose is its prebiotic effect on probiotics that reduce the activity of bacterial urease, resulting in decreased hyperammoneamia and increased elimination of ammonia and other nitrogenous waste through enteric toxin reduction technology. Synbiotic formulation of probiotic and lactulose can synergistically/additively reduce ammonia production, increase utilization and excretion of ammonia and other nitrogenous wastes, thereby improving the well-being of patients with hepatic encephalopathy. We hypothesize that oral administration of a synbiotic formulation prepared from a combination of selected microbial strains of probiotics and lactulose will offer additional protection against hepatic encephalopathy via intra-intestinal extraction of toxic solutes in patients with cirrhosis.     

暴发性肝损伤肝性脑病大鼠血浆及脑游离氨基酸变化的相关分析

本文测定了D-氨基半乳糖所致暴发性肝损伤肝性脑病大鼠血浆及脑勺浆游离氨基酸含量的变化,并作相应的相关分析。结果表明,正常大鼠血浆及脑内各种氨基酸含量间均无相关。肝性脑病大鼠血浆及脑勺浆多种氨基酸水平均有增高,脑内大多数氨基酸含量与血浆相应氨基酸的变化无相关关系,但一些与肝性脑病发生相关的氨基酸水平与其相应的血浆含量呈显著相关。提示肝性脑病的发生与血脑屏障氨基酸转运功能选择性改变有关。     

HBV抗原在乙型肝炎肝硬化患者脑组织中的表达及意义

目的 探讨惭型肝炎肝硬化患者脑组织中乙型肝炎病毒（HBV）感染的状况及意义。方法 应用免疫组织化学链霉菌亲生物素蛋白-过氧化物酶连接法（S-P法）对70例乙型肝炎肝硬化死亡患者脑组织进行了HBsAg、HBcAg检测，分析HBV抗原的表达与临床、病理的关系。结果 HBV抗原患者30例（42.89%)，其中HBsAg阳性24例（34.29%)，HBcAg阳性18例（25.71%)。抗原主要定位于细胞质，分布于神经元、神经胶质细胞及血管内皮细胞内，阳性细胞呈单个霰 在或灶性、小片状分布。HBV抗原的表达与血清HBV水平无关，而与肝性脑病（HE）的有无及HE患者脑组织病理损害的程度相关。结论 乙型肝炎肝硬化患者脑组织中存在HBV感染。并可能存在复制，脑组织中HBV感染，可能对乙型肝炎肝硬化患者HE的发生发展具有重要作用。     

Tryptophan-Metabolismus bei Lebererkrankungen: Eine pharmakokinetische und enzymatische Untersuchung

Summary Tryptophan is considered to be one of the agents involved in the pathogenesis of hepatic encephalopathy. In our study, we evaluated tryptophan metabolism in liver disease. A bolus of 1.5 g ofl-tryptophan was administered intravenously to 14 patients with noncirrhotic liver disease, 40 patients with liver cirrhosis, and 8 healthy volunteers. As pharmacokinetic parameters, the half life, clearance, and volume of distribution of free and total tryptophan were determined using a biexponential formula. In addition, the activity of liver tryptophan pyrrolase, the key enzyme of tryptophan metabolism, was measured in liver biopsy specimens of 15 patients with noncirrhotic liver disease, 8 patients with cirrhosis of the liver, and 4 patients with histologically normal livers.Healthy subjects and patients with noncirrhotic liver disease both showed similar results in measured and calculated data. In contrast, patients with cirrhosis revealed significant alterations of the pharmacokinetic parameters of free and total tryptophan: the half-life was increased by 195% and 176%, the clearance was decreased by 73% and 34%, respectively, and the activity of tryptophan pyrrolase was decreased by 22%. The tryptophan transfer in cirrhosis amounted to only 0.75±0.03 g per 24 h compared with 2.6±0.34 g per 24 h in healthy individuals. The findings demonstrate that patients with cirrhosis show a marked reduction in their ability to metabolize tryptophan. This should be taken into account in the oral and parenteral nutrition of those patients.

     

Brain carbonic anhydrase activity in rats in experimental hepatogenic encephalopathy

Carbonic anhydrase (CA) activity was measured in the brains of rats subjected to repeated administration of thioacetamide (TAA), known to produce symptoms of hepatogenic encephalopathy (HE). In the early phase of the experiment, an increase of the enzyme activity was observed, which correlated well with elevated blood ammonia, while the brain ammonia remained unchanged. Prolonged TAA treatment resulted in the cessation of the activation of CA coinciding with the increase of brain ammonia above control levels. The results, in addition to supporting the idea that CA participates in ammonia detoxication in brain, may also indicate that the enhancement of the enzyme activity represents an adaptation mechanism to the increased ammonia load during HE.     

肝性脑病大鼠海马齿状回神经元形态及一氧化氮合酶表达的变化

目的:观察肝性脑病模型组大鼠海马齿状回内神经元的变化及一氧化氮合酶(NOS)的表达,探讨海马神经元的形态学改变及一氧化氮(NO)在肝硬化和肝性脑病发病机制中的作用。方法:先对50只雄性大鼠进行Morris水迷宫测试,之后将动物分为正常对照组和实验模型组。9周后建立CCL4肝性脑病模型,分别取两组大鼠肝、海马组织进行HE染色、Nissl染色及NADPH-d染色。结果:(1)肉眼下可见模型组肝脏普遍呈坏死性肝硬化;(2)HE模型组血氨浓度明显高于正常对照组(P<0.05);(3)Nissl染色结果显示实验组大鼠海马神经元数目减少、染色较浅,胞浆内Nissl体减少或消失;(4)NADPH-d染色结果显示实验组可见粗大轴突着色,树突联系广泛;对照组则少有粗大轴突着色,树突间联系不如实验组广泛。实验组一氧化氮合酶(NOS)阳性神经元染色较对照组深,为紫蓝或深蓝色,且阳性神经元的数目较多。结论:(1)血氨增高是肝性脑病发病机制之一;(2)肝性脑病时海马受到损伤,并且一氧化氮(NO)可能介导了神经元的损伤。     

Increased Reissner's fiber material in the subcommissural organ and ventricular area in bile duct ligated rats

Hepatic encephalopathy is a common neuropsychiatric complication of acute and chronic liver failure. Whether brain structures with strategic positions in the interface of blood-brain barriers such as the circumventricular organs are involved in hepatic encephalopathy is not yet established. Among the circumventricular organs, the subcommissural organ secretes a glycoprotein known as Reissner's fiber, which condenses and forms an ever-growing thread-like structure into the cerebrospinal fluid. In the present work we describe the Reissner's fiber material within the subcommissural organ and its serotoninergic innervation in an animal model of chronic hepatic encephalopathy following bile duct ligation in experimental rats. The study involved immunohistochemical techniques with antibodies against Reissner's fiber and 5-hydroxytryptamine (5-HT). Four weeks after surgical bile duct ligation, a significant rise of Reissner's fiber immunoreactivity was observed in all subcommissural organ areas compared with controls. Moreover, significant Reissner's fiber immunoreactive materials within the ependyma and inside the parenchyma close to the ventricular borders were also seen in bile duct ligated rats, but not in control rats. Increased Reissner's fiber material in bile duct ligated rats seems to be related to a reduction of 5-HT innervation of the subcommissural organ, the ventricular borders and the nucleus of origin, the dorsal raphe nucleus. Our data describe alterations of the subcommissural organ/Reissner's fiber material and the subcommissural organ 5-HT innervation probably due to a general 5-HT deficit in bile duct ligated rats.     

肝硬化患者的神经心理功能障碍研究

目的：探讨肝硬化患者的神经心理功能障碍及其特征,为诊断亚临床肝性脑病提供科学依据和检测手段。方法：采用几种神经心理检测对６９例肝硬化患者、６５例脑肿瘤患者及６２名正常人进行测试。结果：三组被试各测验组间比较均有显著性差异（Ｐ〈０．００１）;组间两两比较显示,绝大多数测验成绩正常组优于其它两组（Ｐ〈０．０５０;而肝病组和脑病组的成绩相比,只有少数几个变量（相似性测验、第四例外的全误、木图测验）肝病组优于脑病组（Ｐ〈０．０５）,其余测验成绩两组比较无显著性差异（Ｐ〉０．０５）。结论：亚临床肝性脑病存在分析综合、抽象概括、概念化思维、心理灵活性、心理运动速度、知觉－运动协调和视觉空间等神经心理功能障碍,其严重程度的许多方面和脑肿瘤患者无明显差异。     

结肠净化对肝性脑病干预的临床研究

目的 观察结肠净化治疗肝性脑病的临床疗效.方法 将我院收治的肝硬化合并肝性脑病患者117例随机分为两组,治疗组59例,对照组58例,在积极去除诱因基础上,两组患者均给予常规的抗肝性脑病治疗,治疗组在上述治疗的基础上加用结肠净化治疗.比较两组患者治疗前后症状、体征、肝功能、血氨及治疗后恢复清醒时间的变化,总有效率及死亡率.观察治疗前后的肝性脑病分期计分情况.结果 治疗组与对照组比较,治疗组可明显改善患者的症状体征,缩短患者的清醒时间,降低患者的血清转氨酶、胆红素及血氨水平,提高总有效率,降低死亡率,改善肝性脑病的计分值.结论 结肠净化是较为有效的治疗肝硬化合并肝性脑病的疗法.     

AFP联合CA19—9检查对良恶性肝病鉴别诊断的临床研究

目的探讨AFP（甲胎蛋白）联合CA19—9（糖链抗原）检查对原发性肝癌、转移性肝癌、肝硬化、病毒性肝炎的鉴别诊断价值。方法采用全自动电化学发光系统对300例各类肝病患者及50例健康对照者进行血清AFP和CA19—9检查。结果原发性肝癌患者AFP值（838．5±175．4）μg／L较其他患者明显增高,而肝硬化患者AFP中度升高,病毒性肝炎和转移性肝癌患者AFP仅轻度升高。当以AFP〉500μg／L作为原发性肝癌诊断界值时,其灵敏度为70.3％．特异性为98．8％。转移性肝癌患者CA19—9值（1265．8±113．4）U／ml较原发性肝癌、肝硬化、病毒性肝炎患者明显增高。结论AFP联合CA19—9检测在原发性肝癌和转移性肝癌,以及对其他良恶性肝病的鉴别诊断具有良好的价值。     

Peripheral inflammation induces neuroinflammation that alters neurotransmission and cognitive and motor function in hepatic encephalopathy: Underlying mechanisms and therapeutic implications

Several million patients with liver cirrhosis suffer minimal hepatic encephalopathy (MHE), with mild cognitive and coordination impairments that reduce their quality of life and life span. Hyperammonaemia and peripheral inflammation act synergistically to induce these neurological alterations. We propose that MHE appearance is because of the changes in peripheral immune system, which are transmitted to brain, leading to neuroinflammation that alters neurotransmission leading to cognitive and motor alterations. We summarize studies showing that MHE in cirrhotic patients is associated with alterations in the immune system and that patients died with HE show neuroinflammation in cerebellum, with microglial and astrocytic activation and Purkinje cell loss. We also summarize studies in animal models of MHE on the role of peripheral inflammation in neuroinflammation induction, how neuroinflammation alters neurotransmission and how this leads to cognitive and motor alterations. These studies identify therapeutic targets and treatments that improve cognitive and motor function. Rats with MHE show neuroinflammation in hippocampus and altered NMDA and AMPA receptor membrane expression, which impairs spatial learning and memory. Neuroinflammation in cerebellum is associated with altered GABA transporters and extracellular GABA, which impair motor coordination and learning in a Y maze. These alterations are reversed by treatments that reduce peripheral inflammation (anti‐TNFα, ibuprofen), neuroinflammation (sulphoraphane, p38 inhibitors), GABAergic tone (bicuculline, pregnenolone sulphate) or increase extracellular cGMP (sildenafil or cGMP). The mechanisms identified would also occur in other chronic diseases associated with inflammation, aging and some mental and neurodegenerative diseases. Treatments that improve MHE may also be beneficial to treat these pathologies.     

Fractal and Fourier analysis of the hepatic sinusoidal network in normal and cirrhotic rat liver

The organization of the hepatic microvascular network has been widely studied in recent years, especially with regard to cirrhosis. This research has enabled us to recognize the distinctive vascular patterns in the cirrhotic liver, compared with the normal liver, which may explain the cause of liver dysfunction and failure. The aim of this study was to compare normal and cirrhotic rat livers by means of a quantitative mathematical approach based on fractal and Fourier analyses performed on photomicrographs and therefore on discriminant analysis. Vascular corrosion casts of livers belonging to the following three experimental groups were studied by scanning electron microscopy: normal rats, CCl(4)-induced cirrhotic rats and cirrhotic rats after ligation of the bile duct. Photomicrographs were taken at a standard magnification; these images were used for the mathematical analysis. Our experimental design found that use of these different analyses reaches an efficiency of over 94%. Our analyses demonstrated a higher complexity of the normal hepatic sinusoidal network in comparison with the cirrhotic network. In particular, the morphological changes were more marked in the animals with bile duct-ligation cirrhosis compared with animals with CCl(4)-induced cirrhosis. The present findings based on fractal and Fourier analysis could increase our understanding of the pathophysiological alterations of the liver, and may have a diagnostic value in future clinical research.     

Post-ischemic synaptic plasticity in the rat hippocampus after long-term survival: histochemical and autoradiographic study.

The hippocampus provides a suitable area in the brain for the analysis of neuronal plasticity after application of a selective lesioning technique. Using histochemistry and autoradiography, we studied synaptic reorganization in the rat hippocampus with selective CA1 pyramidal cell lesioning caused by transient forebrain ischemia after long-term survival. An autoradiographic study was performed on second messenger systems ([3H]inositol 1,4,5-trisphosphate, [3H]forskolin and [3H]phorbol 12,13-dibutyrate binding). One-hundred days after ischemia, depletion of CA1 pyramidal cells and marked shrinkage of the CA1 subfield was noted in spite of unaltered thickness of the CA3 band and of the dentate molecular layers. Although neuronal density in the CA3 region of animals killed seven days after ischemia was not different from the normal group, 78% of animals showed neuronal loss of 30-50% in the stratum pyramidale of the CA3b 100 days after recirculation. Sixty-seven per cent of animals exhibited supragranular mossy fiber sprouting in the dentate gyrus. However, CA3 neuronal loss did not correlate with mossy fiber sprouting. Succinic dehydrogenase was depleted in the CA1 100 days after ischemia, and animals with CA3 damage showed a reduction of succinic dehydrogenase activity in the CA3. In contrast to the unaltered acetylcholinesterase in the animals killed seven days after ischemia, high density bands of acetylcholinesterase activity in the stratum pyramidale of the CA1 were found to be broadened 100 days after ischemia. In the CA1 subfield, subnormal activity of [3H]phorbol 12,13-dibutyrate and [3H]forskolin binding were observed in spite of the depleted [3H]inositol 1,4,5-triphosphate binding. [3H]Forskolin binding in the hilus had increased by 62% 100 days after ischemia, although binding in the stratum lucidum of the CA3 and in the stratum moleculare of the dentate gyrus was unaltered. However, no visible supragranular increase in [3H]forskolin binding was observed. These results indicate that long-term survival after CA1 pyramidal cell depletion caused by transient forebrain ischemia induced the modulation of neuronal activity and synaptic rearrangements in the whole hippocampal formation.