Copper-associated liver disease in North Ronaldsay sheep: a possible animal model for non-Wilsonian hepatic copper toxicosis of infancy and childhood

Indian childhood cirrhosis (ICC), endemic Tyrolean infantile cirrhosis (ETIC) and idiopathic copper toxicosis (ICT), are clinically and pathologically indistinguishable liver disorders of infants and young children linked with exogenous copper and with increasing evidence for a genetic predisposition. North Ronaldsay sheep are a primitive breed which have adapted to a copper impoverished environment (<5 ppm) and display an abnormal sensitivity to copper poisoning when transferred to a copper replete (11 ppm) habitat. The aetiological parallels prompted a study of copper-associated liver disease in North Ronaldsay sheep (RCT) to see if the pathology could contribute to the understanding of the childhood disorder. A retrospective study was performed in which the livers of 22 mainland-bred North Ronaldsay sheep were compared with three island-bred sheep and categorized for liver copper content and pathomorphology. It was found that all the mainland sheep had accumulated liver copper (>300 microg/g), in contrast to the island sheep, although 10 sheep with increased liver copper (mean 600 SD 270 microg/g) showed no evidence of liver damage. A further 10 sheep with liver copper (mean 1276 SD 508 microg/g) exhibited periportal to panlobular histochemical copper retention, a periportal and/or panlobular pericellular fibrosis, a mixed inflammatory infiltrate and cholangioplasia. Steatosis was absent and regeneration was in abeyance. Finally, two sheep (liver copper >2000 microg/g) had a more active hepatitis with a florid pericellular, panlobular fibrosis and cirrhosis. Electron microscopy identified large numbers of collagen-producing hepatic stellate (Ito) cells in periportal regions. The pathological findings were sufficiently reminiscent of ICC, ETIC and ICT to warrant further exploration of RCT as a putative animal model. The North Ronaldsay sheep liver may be a useful tool for the investigation of copper-induced fibrogenesis.     

Copper toxicosis and tolerance in the rat. I--Changes in copper content of the liver and kidney

Rats can tolerate toxic copper diets; the extent of this adaptation and the changes that take place in the liver and kidney with respect to copper are studied. Rats were fed diets containing 3000-6000 mg/kg copper for 15 weeks and groups were killed at regular intervals. Their livers and kidneys were examined for pathological changes and for their copper content. Liver copper rose rapidly in the 3000 mg/kg trial to 4780 +/- 636 micrograms/g copper between 4 and 5 weeks with marked liver damage. Stainable copper protein was present at 2 weeks in the hepatocytes but had disappeared by 5 weeks. Liver copper subsequently fell with recovery by 15 weeks. Kidney copper rose to plateau from 4 weeks. Stainable copper protein was present from 2 weeks in the cells of the proximal tubules and was apparently excreted. Tubular necrosis occurred at 4-5 weeks followed by regeneration. In the 6000 mg/kg trial the toxicosis was prolonged. Copper toxicosis in the rat can be a temporary phenomenon during the transformation of copper protein synthesis in the liver from a stainable to a non stainable form. Adaptation occurs after the removal of excess liver copper, facilitated probably by renal excretion, and the animals become tolerant.     

The greater susceptibility of North Ronaldsay sheep compared with Cambridge sheep to copper-induced oxidative stress, mitochondrial damage and hepatic stellate cell activation

Sheep of the semi-feral North Ronaldsay (copper-sensitive) and domesticated Cambridge (copper-tolerant) breeds were compared in respect of pathological changes and protein expression in the liver as a result of excessive dietary copper. Acute mitochondrial damage and hepatic stellate cell (HSC) activation with collagen synthesis occurred in response to moderate copper overload in North Ronaldsay but not in Cambridge sheep. Mitochondrial degradative changes occurred either as ballooning degeneration and rupture with subsequent autophagic degradation or as mitochondrial matrical condensation (pyknosis). In North Ronaldsay sheep prolonged exposure to copper produced mitochondrial hyperplasia and hypertrophy, and nuclear damage with necrosis. Cytosolic isocitrate dehydrogenase (IDH), an enzyme responsive to oxidative stress, was induced in the liver of Cambridge sheep receiving a Cu-supplemented diet but was undetectable in the non-supplemented control sheep. Conversely, IDH was detected at similar levels in both control and copper-supplemented North Ronaldsay sheep, indicating a lower threshold response, and an enhanced susceptibility, to oxidative stress. "Upregulation" of mitochondrial thioredoxin-dependent peroxidase reductase (antioxidant protein-1) in the hepatic cytosol of the North Ronaldsay (but not Cambridge) sheep affirmed the increased susceptibility of the mitochondria to Cu-induced oxidative stress in this breed. Likewise the upregulation of cathepsin-D indicated increased lysosomal activity and HSC activation. The findings may be relevant to copper toxicosis in human infants.     

Various copper and iron overload patterns in the livers of patients with Wilson disease and idiopathic copper toxicosis

Wilson disease (WD) is a major type of primary copper toxicosis associated with hypoceruloplasminemia, while idiopathic copper toxicosis (ICT) is a minor type characterized by normoceruloplasminemia. Because ceruloplasmin is the major circulating ferroxidase, iron metabolism may be affected in patients with WD. Biopsied liver specimens obtained from patients with primary copper toxicosis were fixed with glutaraldehyde solution and embedded in epoxy resin. Ultrathin sections that had or had not been stained with uranyl acetate solution were examined under an electron microscope equipped with an energy dispersive X-ray analyzer. A 7-year-old boy with WD was free from any metal overloading at the pre-treatment stage. Pre-treatment liver specimens of another 16 patients showed a variety of copper and iron overload patterns, from isolated copper to evenly distributed combined overloading. A 19-year-old female patient was free from any metal overloading after 7 years of treatment. Post-treatment overloading in another 6 patients ranged between evenly distributed combined patterns and isolated iron patterns. All patients had hypoceruloplasminemia throughout treatment periods. A patient with normoceruloplasminemic ICT continued to display isolated copper overloading after 2.5 years of treatment. In conclusion, these observations support the hypothesis that iron accumulates in patients with hypoceruloplasminemia.     

The significance of variations in the distribution of copper in liver disease.

Biopsy and autopsy specimens of liver from patients with Wilson's disease in various stages, chronic cholestatic conditions (including primary biliary cirrhosis, extrahepatic biliary obstruction, sclerosing cholangitis, and biliary atresia), chronic active hepatitis, and Indian childhood cirrhosis, as well as normal neonates, were examined by means of histochemical techniques for copper and copper-associated protein. The intracellular localization of copper and the lobular distribution of the metal and its associated protein differed in these conditions. Periportal hepatocytes containing granules (lysosomes) that were reactive for copper and for copper-associated protein were characteristic of cholestasis and neonatal liver. However, in cholestasis extralysosomal copper was often present in the hepatocellular cytoplasm. In contrast, in Wilson's disease, despite very high concentrations of copper in the early stages, the metal was diffuse in the cytoplasm, and the histochemical reactions for granular copper and its associated protein were usually negative. Therefore, a failure to stain for copper does not exclude the diagnosis of Wilson's disease. In the late stages of Wilson's disease staining varied in different nodules. In Indian childhood cirrhosis copper was present throughout the parenchyma, with periportal predominance. Differences in the distribution of copper and the cellular changes associated with its deposition suggest that different pathogenetic mechanisms and possibly different intracellular targets are susceptible to the toxic effects of the metal. For diagnosis, staining for copper and for copper-associated protein may assist in the differentiation of primary biliary cirrhosis from chronic active hepatitis.     

Cirrhosis of the liver induced by cupric nitrilotriacetate in Wistar rats. An experimental model of copper toxicosis.

Rats intraperitoneally injected with a daily dose of cupric nitrilotriacetate (Cu-NTA), which contained 4 to 7 mg of copper/kg body weight, showed submassive liver necrosis, hemolytic anemia, and acute renal tubular necrosis at the beginning of the experiment and intermittently after 4 weeks of injections. All rats that survived over 8 weeks exhibited liver fibrosis with portal-portal, portal-central, and central-central bridging. In all rats that survived over 16 weeks, micronodular cirrhosis of the liver or extensive liver fibrosis was observed. The copper content of the cirrhotic/fibrotic liver was above 250 micrograms/g dry weight. Electron-microscopic x-ray analysis at day 93 revealed that copper stored in secondary lysosomes was always accompanied by a proportional amount of sulfur (correlation coefficient, 0.98; P less than 0.005). An experimental model of copper toxicosis in terms of copper-induced cirrhosis of the liver was established with exogenous copper chelated by nitrilotriacetate.     

Effect of intravenously administered tetrathiomolybdate on plasma copper concentrations of copper-loaded sheep

Chronic copper toxicity was induced in 14 ewes in two groups by oral dosing with CuSO4. Copper dosing was stopped in sheep of groups 1 and 2 at the first rise of serum acid phosphatase activity and on the first day of haemolysis, respectively. Thiomolybdate was administered intravenously (i.v.) to sheep of group 2 at the rate of 100 mg on the first day of haemolysis and at 24-h intervals, with a maximum of 3 doses during haemolysis. Thiomolybdate was also given intravenously at a dose of 50 mg twice weekly for 11 weeks to four sheep of group 1 after the cessation of copper dosing (group 1B) and to five sheep of group 2 at the end of haemolysis. Plasma copper concentration was determined before and 24 h after each injection of 50 mg thiomolybdate and "elevations" of plasma copper concentration were seen after each injection of thiomolybdate. The differences between plasma copper concentrations observed before and after each thiomolybdate injection for doses 1 to 11 were significantly higher than those seen for doses 12 to 22. Following thiomolybdate administration, the copper content of the liver of sheep in groups 1B and 2 was reduced much more than in sheep of group 1A, in which copper dosing also ceased but which did not receive thiomolybdate. It was concluded that the high plasma copper response to thiomolybdate doses 1 to 11 was due to an influx of copper into the bloodstream from the heavily copper-loaded liver cells. The lower plasma copper response during the latter part of thiomolybdate administration was due to a gradual reduction in the amount of copper entering the bloodstream from the liver cells, as these cells became depleted of copper. Some of this copper may become part of the glomerular filtrate and be taken up by the cells of the proximal convoluted tubules of the kidney or may be excreted in the urine.     

Copper toxicosis and tolerance in the rat. III. Intracellular localization of copper in the liver and kidney

Male rats fed a 3 g/kg copper diet were killed sequentially up to 14 weeks. Copper in liver and kidney cortex was identified histochemically and assayed in homogenates and gradient fractions following analytical subcellular fractionation on reorientating sucrose density gradients. Copper accumulated fastest in the liver postnuclear (PNS) supernatant fraction which became saturated at 2 weeks; there was a distinct localization of copper in hepatic lysosomes which displayed progressively enhanced fragility. Rapid accumulation of copper then occurred in liver and kidney nuclear (N) fractions, peak copper concentrations coinciding with hepatic and renal tubular necrosis. Copper accumulated slowly up to 4 weeks and was maintained to 14 weeks in the cytosol of the proximal renal tubules from which it appeared to be excreted. Subsequently liver copper declined in both liver fractions and kidney (N) fractions; hepatic lysosomes regained stability, regeneration of liver and kidney occurred, and the rats were tolerant to continued copper administration. These findings do not support a primary role for copper-loaded lysosomes in the genesis of cell injury, but suggest that nuclear saturation may be the destabilizing event. Recovery is associated with changes in the subcellular distribution of copper within liver and kidney and renal excretion of excess.     

Identification of a new copper metabolism gene by positional cloning in a purebred dog population.

Domesticated animal species such as dogs and cats, with their many different characteristics and breed-specific diseases, and their close relationship and shared environment with humans, are a potentially rich source for the identification of the genetic contribution to human biology and disease. Copper toxicosis in Bedlington terriers is a genetic disease occurring with a high prevalence worldwide and is unique to this breed. Copper homeostasis appears to be well regulated in mammals. Two copper carrier proteins have been identified in man and rodents which, when dysfunctional, cause either copper deficiency (Menkes disease) or copper accumulation in various tissues (Wilson disease). However, these proteins are not primarily involved in the biliary excretion of copper. Bedlington terriers have a high prevalence of copper toxicosis and it is well documented that their biliary excretion of copper is impaired. This disease is of direct relevance for the understanding of copper metabolism in mammals. Previously, we mapped the copper toxicosis gene to dog chromosome region 10q26. Based on DNA samples obtained from privately owned dogs, we were able to confine the localization of the copper toxicosis gene to a region of <500 kb by linkage disequilibrium mapping. While screening genes and expressed sequence tags in this region for mutations we found that exon 2 of the MURR1 gene is deleted in both alleles of all affected Bedlington terriers and in single alleles in obligate carriers. Although the function of the MURR1 gene is still unknown, the discovery of a mutated MURR1 gene in Bedlington terriers with copper toxicosis provides a new lead to disentangling the complexities of copper metabolism in mammals.     

Liver structures of a patient with idiopathic copper toxicosis

This is the first report describing the liver structures of a Japanese patient with idiopathic copper toxicosis, which should be differentiated from hepatolenticular degeneration of Wilson disease. An 11-year-old Japanese boy presented with ascites associated with biochemical liver damage. Involvement of hepatitis virus was ruled out by laboratory tests. Because urinary copper excretion was increased, Wilson disease was highly suspected, but the serum level of ceruloplasmin was normal, and Kayser-Fleischer rings were not detected by slit lamp examination. Brain images were within normal limits. ATP7B analysis was negative for mutations. Liver specimen showed cirrhosis associated with chronic active hepatitis. Almost all hepatocytes were positive for orcein-stained granules. Mallory bodies were found in some hepatocytes. Fatty change was minimal, and there were no glycogenated nuclei in the parenchyma. Combined regimens of trientine and zinc for 6 months improved the decompensated state of liver function. After 2.5 years of treatment, a second liver biopsy was performed. The post-treatment liver showed complete disappearance of portal inflammation and remarkable decrease in cuprothionein granules. Mallory bodies disappeared from the parenchyma. An abundance of hepatocellular Mallory bodies and heavy copper loading limited to the liver may be specific to idiopathic copper toxicosis.     

Hepatic copper distribution in primary biliary cirrhosis shown by the scanning proton microprobe.

A number of conditions are associated with abnormalities of trace metal handling by the liver. We report the application of the Oxford scanning proton microprobe to the analysis of hepatic copper in one such condition, primary biliary cirrhosis. The scanning proton microprobe analyses conventional tissue sections (5-10 micron thickness) and produces simultaneous elemental distribution maps of biologically relevant elements with a spatial resolution of 1 micron and a detection limit better than 1 ppm. We have confirmed the localisation of excess copper to periportal areas and suggest that such accumulation is confined to a proportion of periportal hepatocytes. We have also shown a close spatial correlation between regions of copper accumulation and areas of high sulphur concentration. The copper to sulphur ratio in these areas is consistent with their identity as aggregates of copper loaded metallothionein, and the scanning proton microprobe was further able to show that the aggregates contain less than 30 ppm zinc.     

Experimental copper and heliotrope intoxication in sheep: morphological changes

Young Merino wethers were used to determine the effects of copper and heliotrope, fed together or separately, on the development of toxicity and the concentration of trace elements in the liver and kidney. In one experiment copper and heliotrope were given concurrently, in a second experiment heliotrope was fed for 12 weeks and copper administration commenced 8 weeks later. The 10 sheep fed heliotrope alone did not show signs of clinical illness but one died and was found to have severe liver damage. Eleven sheep were given copper alone and three developed the clinical signs and lesions of haemolysis. Fourteen sheep were given copper and heliotrope and 13 became ill. Of these, three developed haemolysis, eight became jaundiced and two became weak without developing jaundice. The concentrations of copper in the livers of control and heliotrope-treated sheep, were comparable. In the animals given copper alone, the concentration of copper in the liver was twice as high as that in controls and in those given heliotrope and copper, it was three times as high as in the liver of control sheep. Feeding heliotrope alone induced the histological changes of pyrrolizidine alkaloid toxicity in the liver, but this was not associated with an excessive accumulation of copper or the development of clinical illness. However, it did predispose the animals to the effects of a second toxin since giving heliotrope and copper concurrently, or giving copper subsequent to feeding heliotrope, markedly enhanced the toxicity of the two substances and caused an excessive accumulation of copper in the liver.     

Plasma and total blood cell copper in rheumatoid arthritis

Conclusions The results summarized above confirm that copper increases in the plasma and in the cell fraction of blood of RA patients, as reported in a previously published work [3]. In RA patients, the plasma copper concentration values may barely discriminate patients in remission, whereas total blood cell copper concentration seems to be more strictly correlated with the severity of the disease. Similar data were obtained studying the copper concentration in plasma and total blood cells in complete-adjuvant tail-injected female rats during the symptomatic phase of the disease [1]. In fact plasma copper concentration was found unable to discriminate severe (high score) from moderate (low score) arthritic rats, whereas the concentration of the metal in the cell fraction of blood of high score rats was found significantly higher not only when compared with control animals but also when compared with the low score group. This statistically significant increase of total blood cell copper may be the expression of an increase of the intra-cellular enzyme superoxide dismutase (SOD) although some authors have actually found a decrease of erythrocyte SOD activity in this disease [5]. Alternatively it may indicate an increase of the non-SOD-bound fraction of red cell copper, which may, in turn, suggest an increase in the non-cerulo-plasmin-bound fraction of plasma copper, which is possibly in equilibrium with the former [6].     

Lysosomes in the pathogenesis of liver injury in chronic copper poisoned sheep: an ultrastructural and morphometric study

Chronic copper poisoning was induced in sheep by oral dosing with CuSO4. The distribution of copper between hepatocytes was unequal and, with increasing liver copper concentration, isolated hepatocytes packed with electron-dense lysosomes were seen. These cells underwent degeneration and necrosis. During the pre-haemolytic period, the concentration of Cu in the liver increased and the volume density, numerical density and mean volume of hepatocyte lysosomes increased in a linear fashion, indicating that there was proliferation as well as increase in the size of lysosomes. However, in animals killed during haemolysis, the numerical density had decreased but the volume density was little changed which indicates that lysosomal production may have diminished. It is postulated that the necrosis of hepatocytes packed with electron-dense lysosomes may be due to the accumulation of toxic amounts of copper in the cytosol, resulting from a reduced uptake of copper into the lysosomal system of these cells, and that the susceptibility of liver cells to Cu-induced damage may be increased if lysosome production is diminished.     

Verifying copper toxicosis in Bedlington terriers by analytical electron microscopy of needle biopsies of liver

Diagnosis of copper toxicosis in Bedlington terriers was performed by analytical electron microscopy of needle biopsy of the liver. The animals were four Bedlington terriers clinically suspected of hereditary copper toxicosis, and four healthy control animals of the same breed. Light microscopy of the livers of the diseased animals revealed dense bodies in the hepatocytes which stained histochemically for copper. Analytical electron microscopy showed that the intrahepatocytic bodies consisted almost entirely of copper.     

Novel assessment of hepatic iron distribution by synchrotron radiation X-ray fluorescence microscopy

Excess iron deposition in the liver is known to be hepatotoxic and may exacerbate liver injury. However, little is known about iron distribution in the lobule because of the lack of a highly sensitive detection method. The aim of this study is to determine iron distribution in the lobule of human liver by means of synchrotron radiation X-ray fluorescence (SRXRF) microscopy. Mapping of the trace elements was done with use of SRXRF microscopy and compared with the results of staining by Berlin blue and oxidative stress markers. Iron deposits were distributed predominantly in periportal hepatocytes in the normal liver in a decreasing gradient from the periportal area to the perivenous area. This distribution was consistent with the formation of oxidative stress markers, suggesting that hepatocytes in the periportal area may be predominantly primed by iron-induced free radical damage even in normal liver. On the other hand, iron deposits in the periportal area were more intense than those in the centrilobular area in both the liver with chronic hepatitis C and the cirrhotic liver. In conclusion, elemental mapping by SRXRF microscopy was a highly sensitive method for the detection and mapping of elements such as iron and copper in liver sections.     

Genetic mapping of the copper toxicosis locus in Bedlington terriers to dog chromosome 10, in a region syntenic to human chromosome region 2p13- p16

Abnormal hepatic copper accumulation is recognized as an inherited disorder in man, mouse, rat and dog. The major cause of hepatic copper accumulation in man is a dysfunctional ATP7B gene, causing Wilson disease (WD). Mutations in the ATP7B genes have also been demonstrated in mouse and rat. The ATP7B gene has been excluded in the much rarer human copper overload disease non-Indian childhood cirrhosis, indicating genetic heterogeneity. By investigating the common autosomal recessive copper toxicosis (CT) in Bedlington terriers, we have identified a new locus involved in progressive liver disease. We examined whether the WD gene ATP7B was also causative for CT by investigating the chromosomal co-localization of ATP7B and C04107, using fluorescence in situ hybridization (FISH). C04107 is an anonymous microsatellite marker closely linked to CT. However, BAC clones containing ATP7B and C04107 mapped to the canine chromosome regions CFA22q11 and CFA10q26, respectively, demonstrating that WD cannot be homologous to CT. The copper transport genes CTR1 and CTR2 were also excluded as candidate genes for CT since they both mapped to canine chromosome region CFA11q22. 2-22.5. A transcribed sequence identified from the C04107-containing BAC was found to be homologous to a gene expressed from human chromosome 2p13-p16, a region devoid of any positional candidate genes.      

Interaction of nutrition and infection: effect of copper deficiency on resistance to Trypanosoma lewisi.

The copper-deficient rat-trypanosome system was used to study copper deficiency in Sprague Dawley rats infected with Trypanosoma lewisi. Throughout the observational period, animals on the deficient diet had lower plasma and liver copper concentrations compared with complete and pair-fed animals. In all dietary groups, the food intake and body weight changes of rats inoculated with T lewisi showed significant increases over the noninoculated controls. The rate of these indices were significantly less in the copper-deficient animals compared with the animals fed complete diets. Copper-deficient and pair-fed control rats showed greater numbers of parasites than controls throughout the infection. The duration of the trypanosomal infection was longer in copper-deficient rats compared with other groups. In all of the dietary groups, severe depression in the primary and secondary antibody responses (IgM and IgG) to in vivo immunization with sheep erythrocytes was observed in infected animals over noninfected controls. The results of the present study indicate that during copper deficiency, there are significant changes in food consumption and body weight and enhanced susceptibility to infection as measured by an increased parasitemia and depression in the antibody responses.     

Copper-induced hepatotoxicosis with hepatic stellate cell activation and severe fibrosis in North Ronaldsay lambs: a model for non-Wilsonian hepatic copper toxicosis of infants

Copper-sensitive North Ronaldsay sheep represent a possible model for certain hepatic-overload syndromes of infancy and childhood that are clinically, pathologically and genetically distinct from Wilson's disease. The purpose of this study was to simulate in artificially reared lambs the syndrome produced by copper exposure in susceptible human infants. Twenty four North Ronaldsay lambs were assigned to three groups of eight animals, namely, an unsupplemented control group and two trial groups given milk replacer to which copper (CuSO4) had been added at the rate of 5 mg/litre and 10 mg/litre. Four lambs from each group were killed at 40 or 69 days. Livers were fixed in 10% formalin and analysed for copper by mass spectrometry. Paraffin wax-embedded sections were stained with rhodanine for copper and labelled immunohistochemically for alpha smooth muscle actin (ASMA). At 40 days the maximum amounts of copper in the livers of both copper-supplemented groups was 1466-1605 microg/g dry weight (control group 172-201 microg/g Cu dry weight). Histochemically, copper was demonstrated within hepatocytes, together with marked apoptosis. At 69 days there was a florid pericellular fibrosis complemented by strong ASMA immunolabelling, confirming phenotypic modulation of hepatic stellate cells. Such primary copper-induced fibrogenesis confirms the unique status of this animal model in respect of childhood copper toxicosis.