Moderate Liver Damage Research Articles

399 HEPATIC ACTIVATION OF IKK/NF-KB SIGNALING INDUCES LIVER FIBROSIS VIA MACROPHAGE-MEDIATED CHRONIC INFLAMMATION

Liver damage in humans is induced by various insults including alcohol abuse, hepatitis B/C virus infection, autoimmune or metabolic disorders and, when persistent, leads to development of liver fibrosis. Because the nuclear factor-jB (NF-jB) system is activated in response to several of these stresses, we hypothesized that NF-jB activation in hepatocytes may contribute to fibrosis development. To activate the NF-jB signaling pathway in a timeand celltype-specific manner in the liver, we crossed transgenic mice carrying the tetracycline-responsive transactivator under the control of the liver activator protein promotor with transgenic mice carrying a constitutively active form of the Ikbkb gene (IKK2 protein [CAIKK2]). Double-transgenic mice displayed doxycycline-regulated CAIKK2 expression in hepatocytes. Removal of doxycycline at birth led to activation of NF-jB signaling, moderate liver damage, recruitment of inflammatory cells, hepatocyte proliferation, and ultimately to spontaneous liver fibrosis development. Microarray analysis revealed prominent up-regulation of chemokines and chemokine receptors and this induction was rapidly reversed after switching off the CAIKK2 expression. Turning off the transgene expression for 3 weeks reversed stellate cell activation but did not diminish liver fibrosis. The elimination of macrophages by clodronate-liposomes attenuated NF-jB-induced liver fibrosis in a liver-injury-independent manner. Conclusion: Our results revealed that hepatic activation of IKK/NF-jB is sufficient to induce liver fibrosis by way of macrophage-mediated chronic inflammation. Therefore, agents controlling the hepatic NF-jB system represent attractive therapeutic tools to prevent fibrosis development in multiple chronic liver diseases. (HEPATOLOGY 2012;56:1117-1128)

Children's toxicology from bench to bed - Liver Injury (3): Oxidative stress and anti-oxidant systems in liver of patients with wilson disease

The role of oxidative stress in the pathogenesis of liver disease in Wilson disease (WD), a genetic disorder characterized by excess hepatic deposition of copper, which generates free radicals, remains unclear. This study investigates oxidative stress on the liver and hepatic anti-oxidant responses in WD using liver specimens from affected patients showing mild liver damage (group I, n = 3), moderate or greater liver damage (group II, n = 5) and fulminant hepatic failure (group III, n = 5), and from asymptomatic carriers (n = 2). Decreased ratios of reduced glutathione (GSH) to oxidized glutathione (GSSG) and increased thiobarbituric acid reactive substance (TBARS), a lipid peroxidation product, were found in every affected patient, especially in groups II and III patients. Activities and protein expressions of Mn-dependent superoxide dismutase (Mn-SOD), CuZn-SOD, and catalase were decreased in all patients, especially in group III patients. Glutathione peroxidase activity was decreased only in group III patients. Asymptomatic carriers without any clinical manifestations showed normal TBARS level and GSH/GSSG ratio with increases in both GSH and GSSG levels. Their CuZn-SOD, Mn-SOD and catalase activities were increased. These results suggest that excessive copper-derived oxidants contribute to development and progression of liver disease in WD.

Murine glutathione S‐transferase A1‐1 in sickle transgenic mice

Patients with sickle cell anemia exhibit mild to moderate renal and liver damage. Glutathione S-transferase A1-1 is produced during kidney and liver damage. We hypothesized that cellular damage in sickle transgenic mice would lead to increased serum and urine murine glutathione S-transferase A1-1 levels. Levels of murine glutathione S-transferase A1-1 in the serum and urine of S+S-Antilles, NY1DD, and control mice were measured by ELISA, which revealed that the serum of S+S-Antilles mice, relative to controls, had elevated levels of murine glutathione S-transferase A1-1 (P = 0.005) as did NY1DD mice (P = 0.02, baseline vs. 2-day hypoxia). Serum liver enzymes, such as aspartate amino transferase and alanine amino transferase, as well as lactate dehydrogenase were increased in S+S-Antilles mice relative to controls (P = 0.000006, P = 0.0003, and P = 0.029, respectively). Urine murine glutathione S-transferase A1-1 of S+S-Antilles mice, as well as NY1DD mice under hypoxic stress, was not significantly different from controls. Murine glutathione S-transferase class-mu was measured by ELISA in the urine of sickle transgenic mice and control mice to define the location of tubular damage at the proximal convoluted tubule; murine Glutathione S-transferase class-mu was below the limit of detection. These findings suggest that elevated levels of murine glutathione S-transferase A1-1 in the serum reflect release during liver damage and that proximal tubular damage does not lead to appreciable urinary murine glutathione S-transferase A1-1.

Relationship Between Oxidative Stress and Antioxidant Systems in the Liver of Patients With Wilson Disease: Hepatic Manifestation in Wilson Disease as a Consequence of Augmented Oxidative Stress

The role of oxidative stress in the pathogenesis of liver disease in Wilson disease (WD), a genetic disorder characterized by excess hepatic deposition of copper that generates free radicals, remains unclear. This study investigates oxidative stress on the liver and hepatic antioxidant responses in WD using liver specimens from affected patients showing mild liver damage (group I, n = 3), moderate or greater liver damage (group II, n = 5), and fulminant hepatic failure (group III, n = 5) and from asymptomatic carriers (n = 2). Decreased ratios of reduced glutathione (GSH) to oxidized glutathione (GSSG) and increased thiobarbituric acid reactive substance (TBARS), a lipid peroxidation product, were found in every affected patient, especially in group II and III patients. Activities and protein expressions of Mn-dependent superoxide dismutase (Mn-SOD), CuZn-dependent superoxide dismutase (CuZn-SOD), and catalase were decreased in all patients, especially in group III patients. Glutathione peroxidase (GPx) activity was decreased only in group III patients. Asymptomatic carriers without any clinical manifestations showed normal TBARS level and GSH/GSSG ratio with increases in both GSH and GSSG levels. Their CuZn-SOD, Mn-SOD, and catalase activities were increased. These results suggest that excessive copper-derived oxidants contribute to development and progression of liver disease in WD.

Dose-related effects of dexamethasone on liver damage due to bile duct ligation in rats

To evaluate the effects of dexamethasone on liver damage in rats with bile duct ligation. A total of 40 male Sprague-Dawley rats, weighing 165-205 g, were used in this study. Group 1 (sham-control, n = 10) rats underwent laparotomy alone and the bile duct was just dissected from the surrounding tissue. Group 2 rats (untreated, n = 10) were subjected to bile duct ligation (BDL) and no drug was applied. Group 3 rats (low-dose dexa, n = 10) received a daily dose of dexamethasone by orogastric tube for 14 d after BDL. Group 4 rats (high-dose dexa, n = 10) received a daily dose of dexamethasone by orogastric tube for 14 d after BDL. At the end of the two-week period, biochemical and histological evaluations were processed. The mean serum bilirubin and liver enzyme levels significantly decreased, and superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GSH-Px) values were significantly increased in low-dose dexa and high-dose dexa groups when compared to the untreated group. The histopathological score was significantly less in the low-dose and high-dose dexa groups compared to the untreated rats. In the low-dose dexa group, moderate liver damage was seen, while mild liver damage was observed in the high-dose dexa group. Corticosteroids reduced liver damage produced by bile duct obstruction. However, the histopathological score was not significantly lower in the high-dose corticosteroid group as compared to the low-dose group. Thus, low-dose corticosteroid provides a significant reduction of liver damage without increased side effects, while high dose is associated not with lower fibrosis but with increased side effects.

128 SERUM TRANSAMINASE ACTIVITIES IN ENDOMETRITIC, REPEAT BREEDER AND ESTRUS CROSSBRED COWS

This study was carried out to determine the serum transaminase activities in endometritic, repeat breeder, and anestrus crossbred (Sahiwal Friesian) cows. A total of 60 blood samples were studied for enzyme activity in serum, with a Spectronic 20 using the commercial diagnostic kit adjusted at 546 nm wavelengths. The performance of liver and the intensity of liver damage were studied by iodine flocculation test. The highest mean (142.2 ± 2.10 μ/L) value of (GOT) activity was observed in the anestrus group, while the lowest mean (58.36 ± 2.1 μ/L) value of GOT was seen in the control group. Analysis of variance revealed a significant (P < 0.01) difference for GOT activity in anestrus compared to control, repeat breeder, and endometritic groups. The highest mean (18.45 ± 3.05 μ/L) value of GPT activities was recorded in repeat breeders while the lowest mean (11.81 ± 1.99 μ/L) value was noted in the control. The occurrence of moderate liver damage was 41.67%, whereas the prevalences of mild and normal damage were 41.67 and 16.66%, respectively. The highest activity (134.80 ± 1.27 μ/L) of GOT was recorded in cows with moderate liver damage, while the lowest activity (50.54 ± 2.72 μ/L) of GOT was observed in cows with normal livers. Mild liver-damaged animals had lower mean (62.13 ± 3.14 μ/L) GOT values compare to moderate liver-damaged animals. Analysis of variance revealed that the moderate liver-damaged group differed significantly in GOT activity from the normal and mild liver-damaged groups. The highest mean values of GOP (91.42 ± 2.8 μ/L) and GPT (20.83 ± 3.40 μ/L) activities were seen in cows with weak body condition, while lowest activities of GOP (82.56 ± 6.42 μ/L) and GPT (13.25 ± 1.55 μ/L) activities were recorded in animals with satisfactory body condition. When the milk yield was considered, the highest mean value of GOT (91.73 ± 3.59 μ/L) and GPT (16.09 ± 3.23 μ/L) activities were recorded in high yielder and the lowest mean values of GOP (72.58 ± 4.79 μ/L) and GPT (13.05 ± 1.99 μ/L) activities were observed in low yielder cows. Based on the findings of this study, it was concluded that although the occurrence of moderate fatty liver was 41.67%, this could be associated with the infertility condition of crossbred dairy cows. It is quite possible that cows showing mild liver damage were in recovery stage after severe or moderate liver damage, as the postpartum period in cross bred cows under study varied from 1.5 to 8 months.

Simultaneous detoxification and decolorization of molasses spent wash by the immobilized white-rot fungus Flavodon flavus isolated from a marine habitat

The wastewaters of molasses-based alcohol distilleries contain brown colored melanoidin pigments that are one of the major pollutants. We reported decolorization of such intensely brown colored molasses spent wash (MSW) by Flavodon flavus, a white-rot basidiomycete fungus isolated from a marine habitat. We have further attempted to improve the process of decolorization of MSW by this fungus by immobilization. Polyurethane foam-immobilized-fungus decolorized 10% diluted MSW by 60 and 73% by days 5 and 7, respectively. The immobilized fungus could be effectively used for a minimum of three cycles repeatedly to decolorize MSW. Besides decolorization, the fungus also removed the toxicity of MSW. Toxicity bioassay of the fungus-treated molasses spent wash using an estuarine fish Oreochromis mossambicus showed no liver damage in contrast to untreated effluent, which showed moderate liver damage. We detected benzo(a)pyrene, a polycyclic aromatic hydrocarbon (PAH) in the MSW and this appears to be one of the causes of toxicity of the MSW. The concentration of PAH in the MSW decreased by 68% by day 5 on treatment with the fungus. This is the first report where decolorization of MSW is accompanied by simultaneous detoxification and decrease in PAH content of the MSW. A comparison of gel filtration chromatography of MSW, before and after treatment with the immobilized F. flavus showed disappearance of the most of the colored fractions in the fungus-treated MSW. A possible mechanism of decolorization of MSW is via the action of glucose oxidase accompanied by production of hydrogen peroxide that may ultimately act as a bleaching agent.

RENAL FUNCTION IN PAEDIATRIC PATIENTS WITH ALPHA-1-ANTITRYPSIN DEFICIENCY(AATD) AND LIVER DAMAGE

190 Renal function was investigated in 16 paediatric patients with AATD(Pi-type ZZ) and liver involvement. Ten of them were girls. Eleven of them had had overt neonatal cholestasis while in the rest of them no such episode has been observed. The patients were followed up with physical check-ups, biochemical parameters and liver histology. According to the results an overall “liver score” was given describing the grade and natural course of the liver damage: 1) slight liver damage without progression during the follow-up; 2) moderate liver damage with advanced fibrosis but no unequivocal evidence of future need for liver transplantation (OLT) and 3) unequivocal progression to cirrhosis. Renal function was investigated as glomerular filtration rate (GFR), effective renal plasma flow (ERPF), determined by the clearance of inulin and para-amino-hyppuric acid. Fifty-three children (mean age 11.8 years, 3.5-21.5 years) without signs of renal disease, served as controls. Eight children were investigated once, the others on two or more occasions. The mean age of the 16 patients at the first renal investigation was 5.9 years (0.7-18.5). Four patients were investigated both before and after OLT. Results: groups 1 and 2 had slightly but significantly lower GFR than the controls (107 ± 6, vs. 116 ± 1, p < 0.05). Group 3 had significantly higher GFR than the controls (143 ± 24, p < 0.005). There was no significant difference in the ERPF between patients and controls. In the 8 patients who were investigated repeatedly there was no significant change in GFR from the first to the last investigation, although the 4 of them who belonged to group 3 showed a tendency to a decrease in GFR. Here again, there was no difference in ERPF. In the 4 patients in whom the investigation was performed both before and after OLT, the preoperative GFR(112 ± 8) decreased significantly to 54 ± 5 (p < 0.0005). The patients with AATD had a more marked decrease in GFR than those paediatric patients who were liver transplanted of other indications. We conclude that in paediatric patients with AATD but without severe liver damage renal function is subnormal but unchanged during follow-up in severe juvenile liver disease due to AATD a hyperfiltration was observed which might be a precursor of later renal damage in patients with AATD in whom OLT is performed renal function has to be followed carefully and nephrotoxic immunosuppresive drugs have to be administered with caution.

Estimation of remnant liver function before hepatectomy by means of technetium-99m-diethylenetriamine-pentaacetic acid galactosyl human albumin.

To improve the results of hepatectomy in cirrhotic patients, the likely reserve function of the liver was evaluated before surgery. Asialoglycoprotein receptor (ASGP-R) is a hepatic cell surface receptor specific for galactose-terminated glycoproteins. Technetium-99m-diethylene triamine pentaacetic acid-galactosyl human serum albumin (99mTc-GSA) is a newly developed analog ligand to ASPG-R. The probable functional reserve of the remnant liver after hepatectomy was estimated preoperatively as the hepatic binding protein (HBP) concentration specific for ASGP-R on the hepatocellular membrane of the remnant liver. This estimate was based on the effective liver volume rate, obtained by the uptake of 99mTc-GSA. In all, 3 normal volunteers, 3 patients with chronic hepatitis (CH), 9 patients with liver cirrhosis (LC), 2 patients with hepatic cystadenoma, 3 patients with hepatocellular carcinoma (HCC) associated with CH, and 21 HCC patients with LC were studied. The mean value +/- SD obtained for HBP in normal volunteers (three cases) and in patients with mild (four cases), moderate (two cases), and severe liver damage (five cases) were 0.74 +/- 0.03 microM, 0.43 +/- 0.042 microM, 0.31 +/- 0.05 microM, and 0.20 +/- 0.05 microM, respectively. Most of the cases in which the preoperative HBP of the remnant liver was above 0.22 microM had a good postoperative course irrespective of the type of hepatectomy. On the other hand, in subjects with a remnant liver HBP of between 0.22 and 0.11 microM, postoperative severe liver dysfunction occurred in about 50% of cases. In all cases with a remnant liver HBP below 0.1 microM, the prognosis was very poor, indicating that hepatectomy should be avoided. The HBP concentration detected by the 99mTc-GSA study is a very sensitive indicator of changes in the hepatic functional reserve, and the HBP value for the functional reserve of the remnant liver is extremely useful for estimating the liver function before and after hepatectomy.

Quality of life of liver transplant recipients. A pilot study.

In a cross-sectional survey of the quality of life of 45 liver transplant recipients, physical and psychological status, physical complaints, capability to participate in daily life, social support, and global quality of life were assessed. The average time of follow-up was 9 months after transplantation. Nine patients had moderate liver damage, 12 suffered from drug side effects, and 10 had extrahepatic diseases. Physical complaints, especially rheumatism, exhaustion, and gastric complaints, were higher than in the general population. Most patients were able to participate in daily life (do housework, take part in family life, etc.). Apart from the complex "health" (use of body), they did not differ in this respect from healthy individuals. Eighty percent of the patients reported having very good social support. The psychological status was generally good, with only 5% complaining of anxiety and nervousness. Sixty percent regarded their quality of life to be very high, 31% reported medium quality of life, and 9% felt very bad. No relationship was found between low quality of life and transplant malfunction; patients with extrahepatic diseases had the lowest quality of life. Among all subgroups, the individuals who were actively working again felt best. Psychological qualities necessary for coping with daily life (self-assurance, self-realization, satisfaction, and happiness) correlated most with the global quality of life (r = 0.80), whereas no relationship was found between quality of life and complaints in total (r = -0.32). This survey shows that during the first year after transplantation, transplant recipients report a high quality of life in important areas of living, despite many physical complaints, and even display an almost euphoric mood.

Human liver injuries and the effects on udp glucuronosyltransferase

UDP glucuronosyltransferases (UDPGT) are found in the hepatic endoplasmic reticulum and conjugate a vast array of drugs and endogenous compounds to the acidic sugar glucuronic acid. These enzymes play a major role in the elimination of many drugs. Patients with liver disease have impairment in the elimination of drugs metabolized by phase I enzymes (oxidation), while many drugs metabolised via the glucuronidation pathway have normal elimination. The expression of UDPGT has been studied in patients with normal liver biopsies (N=4), moderate liver damage (N=5) and cirrhosis (N=6) due to chronic alcohol abuse, and primary biliary cirrhosis (PBC) in an active inflammatory and mildly cirrhotic stage (N=2). Immunohistochemistry using polyclonal antisera to the r 2-5 isoforms of UDPGT, which were raised in goats, was performed. Specific staining in hepatocytes with marked centrilobular accentuation was seen in the normal human livers. Increased staining for UDPGT in all remaining hepatocytes was present in livers damaged by chronic alcohol intake but most marked immunoreactivity was observed in those with cirrhosis. The liver biopsies of patients with PBC also showed increased UDPGT immunostaining in all hepatocytes and in 1 case, periportal accentuation was observed. In conclusion, there is zonal distribution of UDPGT concentration in normal human liver. Chronic liver damage induced by alcohol and PBC resulted in a marked increase in UDPGT activity in remaining viable hepatocytes. These findings may explain the apparent preservation of glucuronidation in patients with chronic liver disease.

Functional hepatic imaging with receptor-binding radiopharmaceutical: clinical potential as a measure of functioning hepatocyte mass.

Asialoglycoprotein receptor (ASGP-R) is a hepatic cell surface receptor specific for galactose-terminated glycoproteins. Technetium-99m diethylenetriaminepentaacetic acid-galactosyl human serum albumin (TcGSA) is a newly developed analog ligand to ASGP-R. Fourteen human subjects were studied: three normal volunteers, one with chronic hepatitis, 6 with liver cirrhosis, and 4 with hepatocellular carcinoma associated with liver cirrhosis. The receptor index parameter (LHL15), was obtained from the liver and heart time-activity data as the ratio of radioactivity of the liver over that of the liver plus heart at 15 min after intravenous injection of 1 mg of TcGSA. Means +/- standard deviations of LHL15 in normal volunteers (3 cases), patients with mild (4 cases), moderate (2 cases), and severe liver damage (5 cases) were 0.933 +/- 0.006, 0.789 +/- 0.045, 0.723 +/- 0.033, and 0.488 +/- 0.094, respectively. The difference between the mean values of each group was statistically significant (P less than 0.05). LHL15 correlated well with classical indicators for hepatic functional capacity such as serum albumin level, serum bilirubin level, prothrombin time, ICG R15 or Child-Turcotte criteria score. Our preliminary experiences of high correlations of TcGSA functional imaging data with clinical data suggest that the dynamic data using this receptor-binding radiopharmaceutical provides invaluable information with regard to liver function, and thus, the TcGSA study is potentially a noninvasive practical tool to measure functioning hepatocyte mass.

Ovine White-Liver Disease (OWLD). Changes in Blood Chemistry

Changes in blood chemistry were examined in vitamin B12 deficient lambs which developed ovine white-liver disease (OWLD), and were compared with values of cobalt/B12 supplemented lambs on the same pastures, as well as clinically healthy, but sometimes B12 deficient, lambs on other pastures (H). In the OWLD group, signs of hepatic damage were seen concurrently with reduction in weight gain, or 1-3 weeks before, and comprised elevation of serum glutamate dehydrogenase (GLDH) and decrease of phospholipid and cholesterol. Drop of plasma glucose and elevation of gamma GT also came in the earlier phase of the disease. All other blood changes developed later, and were partly regarded as reflections of the inappetence or hepatic injury. The changes included a drop in packed cell volume (PCV) and mean corpuscular volume (MCV), elevation of serum iron, and reduction of total serum protein and urea. Generally Co/B12 supplementation prevented hepatic damage and normalized blood values. The clinically healthy H lambs also showed signs of hepatic damage, especially one year when they were B12 deficient, indicating that simple B12 deficiency causes a moderate liver damage as well. For diagnostic purposes, clinical pathology is recommended mainly on a flock basis.

Plasma glutathione S-transferase and F protein are more sensitive than alanine aminotransferase as markers of paracetamol (acetaminophen)-induced liver damage.

Concentrations of glutathione S-transferase (GST; glutathione transferase; EC 2.5.1.18) B1 subunits, F protein, and the activity of alanine aminotransferase (ALT; EC 2.6.1.2) were measured in sequential plasma samples taken from nine patients with self-administered paracetamol (acetaminophen) poisoning. GST exceeded the reference interval in all patients at the time of admission, and F protein was increased in seven. In contrast, abnormal activities of ALT in plasma were found in only one of the nine on admission, a patient admitted 12 h after poisoning. Subsequent to admission nine, eight, and five patients, respectively, had abnormal concentrations of GST, F protein, and ALT. When expressed as multiples of the upper reference limit, the highest values for GST measured in each patient always far exceeded the greatest abnormalities in ALT; this was true for F protein in only five patients. Patients in whom the concentration of GST exceeded 10 micrograms/L on admission subsequently went on to develop moderate or severe liver damage, despite treatment with N-acetylcysteine. F protein and ALT measurements on admission were not as efficient as GST at predicting the clinical outcome of the patients. We conclude that GST and F protein offer clear advantages over ALT for detecting minor degrees of acute liver dysfunction, particularly when only centrilobular damage may be involved.

Toxicity-distribution relationships among 3-alkylfurans in mouse liver and kidney

The present study was designed to extend previous observations regarding toxicity of furans and related compounds to liver and kidney. It was desired to test a series of homologous 3-alkylfurans, where changes in lipophilic character might be related to changes in toxicity. Additionally, it was desired to measure distribution of toxins to the target organs to ascertain whether organ selectivity might be determined by the concentrations attained in the target organs by the toxins. A synthesis for 3-ethylfuran and 3-pentylfuran was devised, and the toxicity of these, in addition to 3-methylfuran and furan itself, to mouse liver and kidney at 2.6 mmol/kg was determined. 2-Furamide and 2-ethylfuran were used as examples of substances known to be toxic to liver and kidney, respectively. 3-Methylthiophene was also included to determine whether results with furans extend to the closely related thiophenes. Histopathological examination of both organs was done, and quantitative estimates of liver toxicity were obtained from plasma levels of glutamate-pyruvate transaminase. Renal urine concentrating ability and plasma urea nitrogen levels were useful as quantitative indices of nephrotoxicity. It was found that both 3-ethyl and 3-pentylfuran exhibited pronounced toxicity to the kidney, and that both also caused moderate liver damage. Furan caused serious damage to the liver and produced somewhat lesser effects on the kidney. Equimolar doses of 3-methylfuran did not significantly damage either organ. Among the 3-alkyl furans, there is an impression that the more volatile compounds damage lung (3-methylfuran is reported to be a potent lung toxin), with liver and kidney toxicity increasing with molecular weight, and that compounds found in higher concentration produce greater damage in liver and kidney. However, among compounds other than alkyl furans, there is no obvious correlation between toxicity and organ concentration of toxin.

A [14C]phenacetin breath test to measure hepatic function in man.

Phenacetin, a high-clearance drug, was labeled as [14C-ethyl]phenacetin and used in a breath test of hepatic function. 14CO2 appeared rapidly in breath such that more than 30% of the administered radioactivity was expired in 2 hr. For all means of expression used to describe the appearance of 14CO2 in breath, normal controls and hospitalized patients without liver disease were clearly separated from cirrhotic subjects with moderate and severe liver damage. The phenacetin breath test was validated by the close correlation of 14CO2 appearance with the disposition of the parent compound examined after its intravenous administration, and by demonstration that the rate-limiting step in 14CO2 generation from labeled phenacetin occurred proximal to 14CO2 generation from [14C]acetate given intravenously. Correcting for the actual volume of CO2 exhaled by control and cirrhotic subjects did not increase the sensitivity of the test. The phenacetin breath test has potential as a simple procedure to quantitate hepatic metabolism of drugs, particularly those mediated by cytochrome P448.

Predicting outcome of paracetamol poisoning by use 14C-aminopyrine breath test.

The 14C-aminopyrine (14C-amidopyrine) breath test, carried out within 24-36 hours of an overdosage of paracetamol, was used to predict the extent of liver damage in 30 seriously poisoned patients. Mean 14CO2 excretion was 4.4% in 20 healthy control subjects; 5.5% in six patients who escaped injury; and 2.9%, 1.5%, and 0.2% in those with mild to moderate (12 patients), severe (eight patients), and fatal (four patients) liver damage respectively. This test proved to be a more reliable predictor of the extent of liver damage than plasma paracetamol concentration or half life or the results of conventional liver function tests and may enable treatment of hepatic failure to be started at an early stage.

The early removal of amatoxins in the treatment of amanita phalloides poisoning (author's transl)

In a 3 year period (1975-77) 50 patients have been admitted to the I.C.U. of Polyclinic Hospital of Milan for poisoning from mushrooms of Amanita genus. In 47 cases the diagnosis was confirmed "a posteriori" by serum or urinary detection of amtoxins and/or by clinical evidence of typical liver injury. Besides the symptomatologic support, the therapeutic treatment included combined removal procedures, such as peritoneal dialysis, plasmapheresis, forced diuresis. The detection by radioimmunoassay of amatoxins [6] in the serum and in the urine of these patients proves that this therapeutic treatment can be effective within about 36 hours from ingestion time. The intensive medical care and the removal approach yielded as the whole favourable results in our patients (overall mortality was 6 patients, i.e. 12,7%). It should moreover be emphasized that of the 35 patients, who had been treated with early removal techniques, 12 with ascertained amanita poisoning, had neither clinical nor biochemical evidence of hepatic damage; 14 had a moderate liver damage; 9 experienced a severe liver failure and hepatic coma occurred in 4 of the latter. These poor results can be ascribed to the severity of the poisoning as well as to a peculiar kinetic of amatoxins in each subject.

Early prediction of the outcome of a paracetamol overdose based on an analysis of 163 patients.

Clinical and biochemical data obtained from 163 patients who had taken an overdose of paracetamol were examined to determine which factors or measurements were of value in predicting the severity of ensuing liver damage early after ingestion of tablets. Although the overall severity of hepatic necrosis was found to increase with the dose of paracetamol ingested, correlation was not sufficiently close to provide an accurate prognostic index in individuals. Severe hepatic damage was less likely if the patient had vomited or had a stomach wash-out within 6 hr of overdose. The plasma concentrations of paracetamol, measured at known times after overdose, distinguished those who developed hepatic dysfunction from those who did not, but there was a poor correlation, particularly in the first 6 hr after ingestion of tablets, between these values and the severity of ensuing liver damage. Estimates of early plasma paracetamol half-lives from three or more samples taken within 4 hr of admission showed that all patients developing moderate or severe liver damage had half-lives greater than 4 hr, but this was also the case in nearly one-third of those with minimal liver lesions only. It is concluded that there is no completely reliable early prognostic test for individual patients with paracetamol overdose. If each patient is selected for treatment with cysteamine (mercaptamine) or other agents on the basis of plasma paracetamol levels, up to 30% may receive this agent who are at risk from trivial hepatic damage only.

Disturbances in glucose metabolism in patients with liver damage due to paracetamol overdose.

1. Intravenous glucose tolerance test were performed in fourteen patients with mild or moderate liver damage due to paracetamol overdose. 2. In patients managed conservatively there was glucose intolerance associated with a diminished early insulin response to glucose, suggesting inadequate nutrition in the period between the overdose and the glucose tolerance test. 3. Patients given intravenous glucose supplements to maintain nutrition were also glucose intolerant and, in these, insulin responses to glucose were normal. The decreased fractional disappearance rate was partly due to an increase in glucose distribution space and partly due to a decrease in absolute glucose disappearance rate. 4. Impaired gluconeogenesis was suggested by mild fasting hypoglycaemia in four patients and raised fasting blood lactate concentrations. Serum growth hormone concentrations showed a paradoxical increase after glucose. 5. All these variables had returned to normal in four patients re-tested after recovery.