The aim of the study was to ascertain a value of computerized inhibitory control test (ICT), routine blood tests, peripheral blood ammonia and IL-6 concentration for diagnosis of cognitive disorders in patients with chronic liver diseases. Tasks: to assess a frequency of cognitive impairments and associated risk factors and to compare ICT and blood tests results in chronic hepatitis and cirrhotic patients; to ascertain ICT, IL-6 and routine blood tests values for diagnosis of minimal hepatic encephalopathy (MHE). Until now there were no studies performed whether chronic hepatitis patients with cognitive disorders have analogous ICT, IL-6 and other tests abnormalities as cirrhotic patients with MHE. It has not been studied which ICT and other tests results predict best the cognitive disorders in such patients. 62 cirrhotic patients without overt hepatic encephalopathy, 73 chronic hepatitis and 53 healthy individuals were enrolled. On the same day blood tests, psychometric and ICT tests were performed by every participant. Cognitive disorders were detected in 54,8% of chronic hepatitis patients. In cirrhotic patients MHE was found in 71,0%. Cognitive disorders predispose shorter study time, the fibrosis score, double etiologic factor, while age and gender has no influence. In chronic hepatitis patients the cognitive impairments correlate with ICT and elevated liver enzymes. In cirrhotic patients cognitive disorders correlate with ICT and IL-6 concentration. Conclusion: the... [to full text] / Darbo tikslas – nustatyti kompiuterizuoto inhibicinio kontrolės testo (IKT), IL-6, amoniako bei įprastinių kraujo rodiklių vertę diagnozuojant kognityvinius sutrikimus sergantiems lėtinėmis kepenų ligomis. Darbo uždaviniai: nustatyti kognityvinių sutrikimų dažnį, galimus rizikos veiksnius, palyginti IKT ir kraujo testų rezultatus lėtinio hepatito ir kepenų cirozės grupėse; nustatyti IKT bei IL-6, įprastinių kraujo testų vertę minimaliai hepatinei encefalopatijai (MHE). Iki šiol netirta ar pacientai, sergantys lėtiniu hepatitu ir kognityviniais sutrikimais, neturi analogiškų IKT rodiklių pakitimų, IL-6 koncentracijos padidėjimo kaip sergantieji kepenų ciroze ir MHE. Netirta kokie kraujo ar IKT rodikliai kognityvinius sutrikimus prognozuoja geriausia. Į tyrimą įtraukti 62 sergantieji kepenų ciroze be hepatinės encefalopatijos, 73 lėtiniu hepatitu bei 53 sveiki asmenys. Tą pačią dieną buvo atliekami kraujo tyrimai, psichometriniai testai ir IKT. Lėtinio hepatito grupėje kognityviniai sutrikimai nustatyti 54,8 %, о kepenų cirozės grupėje MHE ¬ 71,0 % tiriamųjų asmenų. Kognityvinius sutrikimus predisponuoja trumpesnė mokymosi trukmė, fibrozės laipsnis, dvigubas etiologinis veiksnys, amžius ir lytis įtakos neturi. Lėtinio hepatito grupėje kognityviniai sutrikimai koreliuoja su IKT rodikliais ir kepenų fermentų koncentracijos padidėjimu, o kepenų cirozių grupėje su IKT rodikliais ir IL-6 koncentracija kraujyje. Išvados: Kognityvinius sutrikimus sergant lėtiniu hepatitu ar... [toliau žr. visą tekstą]

Este estudo caracteriza a intoxicação por Trema micrantha em equinos, até então desconhecida nesta espécie. No primeiro artigo (artigo 1), é descrito um surto espontâneo de intoxicação por T. micrantha em equinos que ocorreu em junho de 2007, no Município de São José do Herval, na região da encosta da serra do Rio Grande do Sul. Dois equinos morreram na propriedade, após uma árvore de T. micrantha ter sido derrubada por um temporal e suas folhas terem sido consumidas pelos animais. O quadro clínico patológico apresentado foi característico de insuficiência hepática aguda, com desenvolvimento de encefalopatia hepática. Subsequentemente, para melhor caracterizar a intoxicação por Trema micrantha em equinos, desenvolveu-se um experimento (artigo 2). Quatro pôneis receberam e consumiram espontaneamente folhas de T. micrantha, em doses únicas de 30, 25 e 20g/kg. Um equino recebeu uma dose de 15 e outra de 25g/kg, 30 dias após. Três animais adoeceram e evoluíram para morte. Os principais sinais clínicos apresentados foram apatia, desequilíbrios, dificuldade de deglutição, decúbito esternal, decúbito lateral, movimentos de pedalagem coma e morte. Os três equinos afetados apresentaram elevação na atividade sérica de gama glutamil transferase (GGT), nos níveis séricos de amônia, além de diminuição da glicemia. Os principais achados patológicos foram encontrados no fígado e no encéfalo dos três animais. O fígado apresentava macroscopicamente acentuação do padrão lobular, enquanto que no encéfalo havia áreas amareladas na superfície de corte, mais evidentes na substância branca do cerebelo. Microscopicamente, o fígado apresentava necrose, predominantemente centrolobular e hemorragia. No encéfalo, havia edema perivascular generalizado e astrócitos Alzheimer tipo II na substância cinzenta. Esses astrócitos apresentaram marcação fraca ou negativa na imuno-histoquímica anti-GFAP e marcação positiva do antígeno S-100. A dose letal mínima de folhas de T. micrantha estabelecida nesse experimento foi de 20g/kg. A maior sensibilidade da espécie equina constatada nesse estudo, a ampla distribuição de T. micrantha, bem como sua palatabilidade reforçam a importância da planta em casos acidentais de intoxicação nessa espécie. / This study characterizes Trema micrantha poisoning in horses, previously unknown in this species. The first article (Article 1) describes an outbreak of T. micrantha poisoning in horses. The disease occurred in June 2007, in the Municipality of São José do Herval, Rio Grande do Sul State. Two horses died after consuming the leaves of the branches from a T. micrantha tree, which had been felled by a storm. Clinical pathology presented by the animals was characteristic of an acute liver failure with development of hepatic encephalopathy. To further characterize the Trema micrantha poisoning in horses, an experiment was carried out (Article 2). Four ponies received and spontaneously consumed green leaves of T. micrantha, at the doses of 30, 25, and 20 g/kg. One horse received two doses, 15 and 25 g/kg, 30 days apart. Three animals were affected and died. The main clinical signs were apathy, equilibrium deficit, deglutition difficulty, sternal or lateral recumbency, paddling, coma and death. These tree diseased ponies had also enhanced seric activity of gamma-glutamyl transferase (GGT), seric ammonia apart of diminished glycemia. The main pathological findings were observed in the liver and encephalon. There were enhanced lobular pattern of the livers and yellowish areas in the cut surface of the encephalon, especially visualized in the cerebral white matter. Microscopically, there was hepatic necrosis predominantly centrilobular apart of hemorrhages. Generalized perivascular edema and Alzheimer type II astrocytes were observed in the encephalon. The Alzheimer type II astrocytes showed weak or absent anti-glial fibrillar acid protein immunostaining associated with positive immunostaining for S-100 protein. The minimal lethal dose of Trema micrantha leaves was established at 20 g/kg. The high sensibility of this species to this plant, its wide distribution, and the high palatability of the plant reinforce the importance of Trema micrantha in accidental episodes of intoxication in horses.

Este estudo caracteriza a intoxicação por Trema micrantha em equinos, até então desconhecida nesta espécie. No primeiro artigo (artigo 1), é descrito um surto espontâneo de intoxicação por T. micrantha em equinos que ocorreu em junho de 2007, no Município de São José do Herval, na região da encosta da serra do Rio Grande do Sul. Dois equinos morreram na propriedade, após uma árvore de T. micrantha ter sido derrubada por um temporal e suas folhas terem sido consumidas pelos animais. O quadro clínico patológico apresentado foi característico de insuficiência hepática aguda, com desenvolvimento de encefalopatia hepática. Subsequentemente, para melhor caracterizar a intoxicação por Trema micrantha em equinos, desenvolveu-se um experimento (artigo 2). Quatro pôneis receberam e consumiram espontaneamente folhas de T. micrantha, em doses únicas de 30, 25 e 20g/kg. Um equino recebeu uma dose de 15 e outra de 25g/kg, 30 dias após. Três animais adoeceram e evoluíram para morte. Os principais sinais clínicos apresentados foram apatia, desequilíbrios, dificuldade de deglutição, decúbito esternal, decúbito lateral, movimentos de pedalagem coma e morte. Os três equinos afetados apresentaram elevação na atividade sérica de gama glutamil transferase (GGT), nos níveis séricos de amônia, além de diminuição da glicemia. Os principais achados patológicos foram encontrados no fígado e no encéfalo dos três animais. O fígado apresentava macroscopicamente acentuação do padrão lobular, enquanto que no encéfalo havia áreas amareladas na superfície de corte, mais evidentes na substância branca do cerebelo. Microscopicamente, o fígado apresentava necrose, predominantemente centrolobular e hemorragia. No encéfalo, havia edema perivascular generalizado e astrócitos Alzheimer tipo II na substância cinzenta. Esses astrócitos apresentaram marcação fraca ou negativa na imuno-histoquímica anti-GFAP e marcação positiva do antígeno S-100. A dose letal mínima de folhas de T. micrantha estabelecida nesse experimento foi de 20g/kg. A maior sensibilidade da espécie equina constatada nesse estudo, a ampla distribuição de T. micrantha, bem como sua palatabilidade reforçam a importância da planta em casos acidentais de intoxicação nessa espécie. / This study characterizes Trema micrantha poisoning in horses, previously unknown in this species. The first article (Article 1) describes an outbreak of T. micrantha poisoning in horses. The disease occurred in June 2007, in the Municipality of São José do Herval, Rio Grande do Sul State. Two horses died after consuming the leaves of the branches from a T. micrantha tree, which had been felled by a storm. Clinical pathology presented by the animals was characteristic of an acute liver failure with development of hepatic encephalopathy. To further characterize the Trema micrantha poisoning in horses, an experiment was carried out (Article 2). Four ponies received and spontaneously consumed green leaves of T. micrantha, at the doses of 30, 25, and 20 g/kg. One horse received two doses, 15 and 25 g/kg, 30 days apart. Three animals were affected and died. The main clinical signs were apathy, equilibrium deficit, deglutition difficulty, sternal or lateral recumbency, paddling, coma and death. These tree diseased ponies had also enhanced seric activity of gamma-glutamyl transferase (GGT), seric ammonia apart of diminished glycemia. The main pathological findings were observed in the liver and encephalon. There were enhanced lobular pattern of the livers and yellowish areas in the cut surface of the encephalon, especially visualized in the cerebral white matter. Microscopically, there was hepatic necrosis predominantly centrilobular apart of hemorrhages. Generalized perivascular edema and Alzheimer type II astrocytes were observed in the encephalon. The Alzheimer type II astrocytes showed weak or absent anti-glial fibrillar acid protein immunostaining associated with positive immunostaining for S-100 protein. The minimal lethal dose of Trema micrantha leaves was established at 20 g/kg. The high sensibility of this species to this plant, its wide distribution, and the high palatability of the plant reinforce the importance of Trema micrantha in accidental episodes of intoxication in horses.

O presente estudo avaliou a autorregulação encefálica (ARE) em doentes com insuficiência hepática fulminante (IHF) antes e após transplante hepático. Foram avaliados 25 pacientes com diagnóstico de IHF, 17 foram avaliados antes e após o transplante hepático, sendo seis (24,0%) do sexo masculino e 19 (76,0%) feminino. A média de idade foi de 33,8 anos, que variou de 14 a 56 anos, com desvio padrão de 13,1 anos. A hemodinâmica encefálica foi avaliada pela velocidade de fluxo sanguíneo encefálico (VFSE) nas artérias cerebrais médias e artéria basilar (AB), que usou o ultrassom Doppler transcraniano (DTC), dispositivo de dois canais, com transdutores de 2 mega Hertz (MHz). A autorregulação encefálica foi mensurada pelo índice de autorregulação (IARE) estática que leva em conta os efeitos do aumento da pressão arterial média (PAM) sobre a VFSE. Para isso, promoveu-se o aumento da PAM (20 mmHg a 30 mmHg) com infusão de noradrenalina.. Ao se avaliar o IARE considerando a velocidade de fluxo sanguíneo em quatro momentos (pré-transplante, 1°, 2° e 3° dia após o transplante), observou-se que houve diferença estatística em artéria cerebral média (ACM) à direita (p=0,008), esquerda (p=0,007), máxima (p=0,005), e AB (p=0,006); assim como na análise em cada tempo do IARE, observou-se diferença estatística em ACM à direita (p=0,012), esquerda (p=0,009), máxima (p=0,006), e AB (p=0,011). A análise categórica do IARE na artéria cerebral média e basilar descreveu que a maioria dos doentes reestabeleceu a AR no 2° dia em ACM e 3° na AB (índice > 0,6), enquanto com o índice > 0,8 em ambas as artérias a ARE reestabeleceu no 2° dia. As variáveis sistêmicas como pressão parcial de CO2 e hemoglobina nos tempos da avaliação não apresentaram diferença estatística p=0,100 e p=0,093 respectivamente. Os resultados obtidos apontam para o comprometimento da ARE antes e após transplante hepático, tanto em circulação anterior como posterior, e que tende a ser reestabelecido entre 48 a 72 horas. Os achados deste estudo favorecem o manejo adequado de doentes nestas fases (antes e após transplante) e podem evitar a evolução para complicações neurológicas, como tumefação encefálica e hipertensão intracraniana, que indicam prognóstico ruim para a evolução clínica destes doentes. Estudos futuros necessitam ser realizados para que se consolide o uso da monitoração contínua com métodos não invasivos como o DTC para direcionar o manejo hemodinâmico encefálico na IHF / This study evaluated cerebral autoregulation in patients with fulminant hepatic failure (FHF) before and after liver transplantation. A total of 25 patients comprising six (24.0%) males and 19 (76.0%) females with FHF were evaluated. Seventeen patients were evaluated both before and after liver transplantation. Mean age of the patients was 33.8 years, with a range of 14-56 years and standard deviation of 13.1 years. Brain hemodynamics was assessed by cerebral blood flow velocity in the middle cerebral arteries (MCA) and basilar artery (BA) using transcranial Doppler ultrasound on a two-channel device with 2 MHz transducers. Cerebral autoregulation was measured by static cerebral autoregulation index (SCAI), which accounts for the effects of increase in mean arterial blood pressure (ABP) on cerebral blood flow velocity. An increase in ABP (20 mmHg to 30 mmHg) was induced with norepinephrine infusion. Evaluation of SCAI based on blood flow velocity (BVF) at four timepoints (pre-transplant and on 1st, 2nd and 3rd days post-transplant) revealed a statistical difference in the MCA right (p = 0.008) left (p = 0.007), maximum (p = 0.005) and the BA (p = 0.006). In addition, analysis by timepoint showed a statistical difference in MCA (p = 0.012), left (p = 0.009), maximum (p = 0.006) and in the BA (p = 0.011). Categorical analysis of autoregulation in the MCA and BA showed that most patients reestablished autoregulation in the MCA on the 2nd day post-transplant and in the BA (index > 0.6) on the 3rd day, while autoregulation was reestablished in both arteries (index > 0.8) on the 2nd day. On the assessment by timepoint, the systemic variables CO2 partial pressure and hemoglobin showed no statistically significant differences (p = 0.100 and p = 0.093, respectively). The results reveal impaired SCAI before and after liver transplantation, both in anterior and posterior circulation, with a tendency to reestablish at 48 to72 hours. The findings of this study can help improve management of patients at these stages (pre and post transplantation), preventing neurological complications such as brain swelling and intracranial hypertension, associated with poor prognosis for the clinical course. Future studies should be conducted to consolidate the use of continuous monitoring with noninvasive method (TCD), to provide more accurate information to guide brain hemodynamic management in FHF

L'encéphalopathie hépatique (HE) est un syndrome neuropsychiatrique complexe, une complication majeure de la maladie du foie. L'œdème cytotoxique est une complication grave de l'encéphalopathie hépatique, connu comme étant le résultat d'un gonflement des astrocytes. Les facteurs pathogéniques dérivés du sang tels que l'ammoniaque (NH4+) et le stress oxydatif (SO) sont connus pour être synergiquement impliqués. Les cellules endothéliales (CE) de la barrière hémato-encéphalique (BHE), régulant le passage vers le cerveau, sont les premières cellules à entrer en contact avec les molécules circulantes. L'effet de l'ammoniaque et du SO sur le transport et le métabolisme des CE n'a jamais été complètement exploré. Par conséquent, notre objectif était d'évaluer les effets de NH4+ et des espèces réactives de l'oxygène (ROS) sur les CE de la BHE en utilisant des systèmes de modèles in vivo et in vitro. Il a été démontré que le cotransporteur Na-K-2Cl (NKCC1) était impliqué dans la pathogenèse de l'œdème cérébral dans de nombreuses affections neurologiques. Le NKCC1 peut transporter NH4+ vers le cerveau et est régulé par les ROS. Par conséquent, l'expression de NKCC1 a été évaluée dans des CE primaires soumises à différentes concentrations de ROS et de NH4+ ainsi que dans des microvaisseaux cérébraux (MVC) isolés chez le rat BDL (bile-duct ligated), un modèle d'EH induit par une maladie hépatique chronique. Aucune régulation à la hausse de NKCC n'était présente chez les CE traitées ou les MVC. La glutamine synthétase (GS) est une enzyme qui joue un rôle compensatoire important dans la détoxification du NH4+ au cours de la maladie du foie. La GS est exprimée dans le muscle et le cerveau (astrocytes), mais n'a jamais été totalement explorée dans les CE de la BHE. L'expression et l'activité de la protéine GS ont été trouvées dans les CE de la BHE in vitro (CE primaires) et in vivo (MVC isolés de rats naïfs). Dans le modèle BDL, l'expression de GS dans les MVC n'était pas significativement différente des témoins (SHAM). Par ailleurs, nous avons traité des CE avec du milieu conditionné à partir de plasma de rats BDL et avons trouvé une diminution de l’expression de la protéine GS et de l'activité par rapport aux SHAM. De plus, les CE traitées avec NH4+ augmentaient en activité de GS tandis que les traitements avec SO avec et sans NH4+ diminuent l'activité de GS. Globalement, ces résultats démontrent pour la première fois que la GS est présente dans les CE, à la fois in vivo et in vitro. La GS est régulée à la baisse dans les CE traitées avec du plasma de BDL (mais pas dans les MVC de BDL). Il est intéressant de noter que le NH4+ stimule l'activité de GS dans les CE, alors que le SO inhibe l'activité de GS, ce qui justifie possiblement les résultats de nos études avec les milieux conditionnés. Nous supposons que le SO empêche la régulation à la hausse de GS de la BHE, en diminuant la capacité des CE à détoxifier l'ammoniaque et à limiter l'entrée d'ammoniaque dans le cerveau. Nous envisageons qu'une régulation à la hausse de GS dans les CE de la BHE pourrait devenir une nouvelle cible thérapeutique de l'EH. / Hepatic encephalopathy (HE) is a complex neuropsychiatric syndrome, which is a major complication of liver disease. Cytotoxic edema is a serious complication of HE, known to be the result of astrocyte swelling. Blood derived pathogenic factors such as ammonia (NH4+) and oxidative stress’ (OS) are known to be synergistically implicated. Endothelial cells (EC) of the blood brain barrier (BBB) are the first cells regulating passage into the brain and to contact blood-derived molecules. The effect of ammonia and oxidative stress on EC transport and metabolism has never been thoroughly explored. Therefore, our aim was to evaluate the effects of NH4+ and reactive oxygen species (ROS) on EC of the BBB using in vivo and in vitro models systems. The Na–K–2Cl cotransporter (NKCC1) has been demonstrated to be involved in the pathogenesis of brain edema in numerous neurological conditions. NKCC1 can transport NH4+ into the brain and is regulated by ROS. Therefore, the expression of NKCC1 was evaluated in primary EC submitted to different concentrations of ROS and NH4+ as well as in cerebral microvessels (CMV) isolated from the bile-duct ligated (BDL) rat, a model HE induced by chronic liver disease. No upregulation of NKCC1 was present in either the treated EC or CMV. Glutamine synthetase (GS) is an enzyme with an important compensatory role in NH4+ detoxification during liver disease. GS is expressed in muscle and brain (astrocytes) but has never been thoroughly explored in ECs of the BBB. GS protein expression and activity was found in EC of the BBB in vitro (primary EC) and in vivo (CMV isolated from naive rats). In the BDL model, GS expression in CMVs was not significantly different from SHAM-operated controls. In addition, we treated ECs with conditioned medium from plasma of BDL rats and found a decrease in GS protein and activity when compared to SHAM. Furthermore, EC treated with NH4+ increased GS activity while treatments with ROS with and without NH4+ decreased GS activity. Overall these results demonstrate for the first time that GS is present in EC both in vivo and in vitro. GS is downregulated in EC treated with BDL plasma (but not in BDL CMV). Interestingly, NH4+ stimulates GS activity in ECs, while ROS inhibits GS activity, possibly justifying the results found from the conditioned medium studies. We speculate that ROS prevents the upregulation of GS in the BBB, decreasing the capacity of the EC to detoxify ammonia and to limit ammonia entry into the brain. We foresee that upregulating GS in ECs of the BBB could become a new therapeutic target for HE.

L'encéphalopathie hépatique (EH) est une complication grave de la cirrhose, provoquant des troubles de mémoire, de coordination motrice et de sommeil, avec une progression vers le coma et la mort. Le stress oxydatif dû au foie défaillant et l'ammoniac provenant de la dégradation des protéines alimentaires sont des facteurs pathogènes connus. Simultanément, l'hyperammoniémie et la malnutrition protéino-calorique contribuent à la sarcopénie. Comme les muscles sont le principal mécanisme d'élimination de l'ammoniac pendant la cirrhose, il existe un cercle vicieux où l'hyperammonémie contribue à l'EH et à la sarcopénie, et la sarcopénie contribue à l'hyperammonémie et à l'EH. Notre objectif était de déterminer les effets d’un régime riche en protéines de lactosérum ou de soja administré à long terme, sur la masse musculaire, l'hyperammonémie, et l'EH chez les rats cirrhotiques. Ensuite, nous voulions déterminer les effets d’un gavage aigu de protéines sur l'hyperammonémie et l'EH. Nos résultats montrent qu'un apport élevé en protéines à long terme n'a pas maintenu la masse musculaire ou diminué l'ammoniac, mais que le stress oxydatif a été réduit, ce qui a conduit à la prévention de l'EH, améliorant la mémoire à court et à long terme, l'anxiété, et l'activité locomotrice. Un gavage aigu de protéines chez les rats cirrhotiques n’a pas augmenté l'ammoniac ni précipité l'EH. Cette étude est la première à évaluer l'effet d'un régime élevé en protéines chez des rats cirrhotiques pour observer la masse musculaire, l'ammoniac et l'EH. Nos résultats soutiennent la sécurité et l'efficacité d'une stratégie nutritionnelle riche en protéines dans la cirrhose. / Hepatic encephalopathy (HE) is a serious complication of liver disease, causing impairments in memory, motor coordination, sleep, with progression to coma and death. It affects up to 70% of patients, severely impacting quality of life. Oxidative stress from the failing liver and ammonia from the breakdown of dietary protein are known pathogenic factors. Concurrently, hyperammonemia and protein-calorie malnutrition contribute to muscle wasting, sarcopenia. As muscle is the main clearance mechanism for ammonia during cirrhosis, a vicious cycle exists where elevated ammonia contributes to HE and sarcopenia, and sarcopenia in turn contributes further to hyperammonemia and HE. Our aim was to determine whether long-term high protein whey or soy diets administered from the onset of liver disease in rats could maintain muscle mass, decrease hyperammonemia, and prevent symptoms of HE. Secondly, we wanted to determine the effects an acute load of high protein on hyperammonemia and HE in cirrhotic rodents. Our results show that long-term high protein intake did not maintain muscle mass or decrease ammonia, but oxidative stress was reduced, leading to HE prevention, as shown by the improvement of short- and long-term memory, anxiety, and locomotor activity. An acute load of protein was shown to be safe in cirrhotic rodents, with no increase in ammonia or precipitation of HE. This study is the first of its kind to evaluate the effect of high protein intake in cirrhotic rodents to observe muscle mass, ammonia, and HE. Our results support the safety and efficacy of a high protein nutritional strategy in cirrhosis.

L’encéphalopathie hépatique (EH) est une complication neuropsychiatrique de la maladie de foie telle que la cirrhose, caractérisée par des dysfonctions cognitives et motrices. Le seul traitement curatif est la transplantation hépatique (TH). Historiquement, l’EH est considérée comme un désordre métabolique réversible et il est attendu qu’il soit résolu suivant la TH. Cependant, il a été démontré que des complications neurologiques persistent chez 47% des patients transplantés. La TH est une opération chirurgicale complexe accompagnée de stress péri-opératoire telle que la perte sanguine et l’hypotension. L’hypothèse de ce projet d’étude est que l’EH minimale (EHm) rend le cerveau plus susceptible à une perte neuronale suite à une insulte hypotensive. Nous avons donc caractérisé un modèle d’hypotension chez des rats cirrhotiques avec ligation de la voie biliaire (BDL) dans lequel une hypovolémie de l’artère fémorale a été faite. Avec ce modèle, nous avons étudié l’impact de différentes pressions sanguines de 120 minutes sur le compte neuronal. Nos résultats démontrent que les BDL hypotendus à une pression artérielle moyenne de 60 mmHg et 30 mmHg ont une diminution du compte neuronal et que les neurones mourraient par apoptose (observée par la présence de caspase-3 clivée). Nous avons également déterminé que le flot sanguin cérébral était altéré chez les rats cirrhotiques BDL. Le second objectif était d’évaluer si le traitement de l’EHm par l’ornithine phénylacétate (OP) permettait d’éviter la perte neuronale chez les BDL hypotendus. Nos résultats ont démontrés que l’OP permettait de partiellement rétablir les fonctions cognitives chez les rats BDL. De plus, les rats BDL traités avec l’OP peuvent éviter la mort neuronale. Cependant, le processus apoptotique est toujours enclenché. Ce résultat suggère la possibilité de mort cellulaire retardée par l’OP. Ces résultats suggèrent que les patients cirrhotiques avec EHm sont plus susceptibles à une mort neuronale induite par hypotension. La combinaison de l’EHm et l’hypotension permet d’expliquer les complications neurologiques rencontrées chez certains patients. Le diagnostic et le traitement de ce syndrome doit donc être fait chez les patients cirrhotiques pour éviter ces complications post-TH. / Hepatic encephalopathy (HE) is a major neuropsychiatric complication caused by chronic liver disease such as cirrhosis and is characterized by cognitive and motor dysfunction. The only curative treatment to date remains liver transplantation (LT). Historically, HE has always been considered to be a reversible metabolic disorder and has therefore been expected to completely resolve following LT. However, persisting neurological complications remain a common problem affecting as many as 47% of LT recipients. LT is a major surgical procedure accompanied by intraoperative stress and confounding factors, including blood loss and hypotension. We hypothesize, in the setting of minimal HE (MHE), the compromised brain becomes susceptible to hypotensive insults, resulting in cell injury and death. To investigate this hypothesis, six-week bile-duct ligated (BDL) rats with MHE and respective controls (SHAM) were used. Blood is withdrawn from the femoral artery (inducing hypovolemia) until a mean arterial pressure of 30, 60 and 90 mmHg (hypotension) and maintained for 120 minutes. Our results demonstrated that BDL with following hypotension of 30 and 60 mmHg have a lower neuronal cell count compared to SHAM-operated animals. Furthermore, we provide evidence neuronal cell death is occurring due to apoptosis (observed by presence of cleaved caspase-3). In addition, cerebral blood flow is reduced in BDL rats compared to SHAM-operated controls. Second objective was to assess the therapeutic potential of the ammonia-lowering agent ornithine phenylacetate (OP) in preventing hypotension-induced neuronal loss in BDL rats. OP-treated BDL rats, in addition to lowering blood ammonia, also ameliorated cognitive function. However, cleaved caspase-3 levels were still elevated in the brains of OP-treated BDL rats therefore suggesting OP delays the onset of neuronal death in BDL rats. Overall, these findings strongly suggest that cirrhotic patients with MHE are more susceptible to hypotension-induced neuronal cell loss. Moreover, these results suggest a patient with HE (even MHE), with a “frail brain”, will fare worse during LT transplantation and consequently result in poor neurological outcome. Combination of MHE and hypotension may account for the persisting neurological complications observed in a number of cirrhotic patients following LT. Therefore, MHE, i) should not be ignored and therefore diagnosed and ii) merits to be treated in order to reduce the risk of neurological complications occurring post-LT

INTRODUÇÃO: No transplante do fígado a reperfusão do enxerto é um momento crítico onde as alterações hemodinâmicas ocorrem com maior freqüência e intensidade podendo se associar a mortalidade intra-operatória, à falência de múltiplos órgãos e sistemas, e ao aumento da incidência de não funcionamento do enxerto. Neste estudo testamos a hipótese de que os efeitos benéficos decorrentes da administração da solução salina hipertônica na ressuscitação do choque hemorrágico, considerado fenômeno de isquemia e reperfusão generalizado, possam atenuar os fenômenos hemodinâmicos que sucedem a reperfusão hepática no transplante do fígado. MÉTODOS: 30 pacientes adultos submetidos ao transplante hepático na Disciplina de Transplante e Cirurgia do Fígado do HC-FMUSP foram divididos em 2 grupos: Grupo-1 (n =15) recebeu solução salina hipertônica (NaCl a 7,5%), na dose de 4 mL/kg, na velocidade de 20 mL/min em veia central no início da anastomose de veia porta e Grupo- 2 (n =15) recebeu solução salina isotônica nas mesmas condições citadas. As variáveis utilizadas para a análise da hemodinâmica sistêmica foram: pressão arterial média, pressão venosa central e pressão de artéria pulmonar ocluída, índice cardíaco e índice de resistência vascular sistêmica. A análise da pressão intracraniana foi incluída no estudo dos pacientes com hipertensão intracraniana secundária a hepatite fulminante. Os dados foram coletados em 6 tempos: no término da fase de dissecção, no início da fase anepática, após a administração da solução teste, e no 1o, 5o e 30o minutos após a reperfusão. A síndrome pós-reperfusão foi determinada por três métodos: pela ocorrência de pressão arterial média inferior a 60 mmHg no 1o ou no 5o minuto da reperfusão ou queda maior que 30% do valor pré-reperfusão nos primeiros 5 minutos da reperfusão. RESULTADOS: 1) A pressão arterial média no 1o e no 5o minuto da reperfusão no Grupo 1 (84,9 ± 12,33 e 77,4 ± 4,58 mmHg) foi significativamente maior que no Grupo 2 (62,9 ± 5,22 e 73,9 ± 3,47 mmHg), p < 0,001 e p = 0,046 respectivamente. 2) A incidência de síndrome pós-reperfusão no Grupo 1 (0.0%) foi significativamente menor que no Grupo 2 (33,33%), p = 0,021. 3) O aumento do índice cardíaco imediatamente após o término de infusão da solução teste no Grupo 1 (31,27%) foi significativamente maior que no Grupo 2 (7,54%), p < 0,001. 4) O aumento do índice cardíaco após a reperfusão no Grupo 1 (70,42%) foi significativamente menor que no Grupo 2 (125,91%), p < 0,001. 5) O índice cardíaco no 5o e no 30o minuto da reperfusão no Grupo 1 (6,51 ± 0,81 e 5,56 ± 0,86 L.min-1.m-2) foi significativamente menor que no Grupo 2 (7,41 ± 0,87 e 6,34 ± 0,93 L.min-1.m-2), p= 0,007 e p = 0,024 respectivamente. 6) O índice cardíaco no 5o e no 30ominuto da reperfusão quando comparados aos momentos basais (início da cirurgia) apresentou aumentos no Grupo 1 (26,16% e 7,75%) significativamente menores que no Grupo 2 (45,57% e 24,80%), p= 0,019 e p= 0,021 respectivamente. 7) O índice de resistência vascular sistêmica imediatamente após o término de infusão da solução teste no Grupo 1 apresentou queda de 18,83% enquanto no Grupo 2 foi registrado aumento de 9,21%, p < 0.001. 8) A diminuição do índice de resistência vascular sistêmica após a reperfusão no Grupo 1 (44,52%) foi significativamente menor que no Grupo 2 (61,80%), p < 0,001. 9) O índice de resistência vascular sistêmica no 5o e no 30o minuto após a reperfusão no Grupo 1 (799,35 ± 131,51 e 963,10 ± 171,33 dyn.s.cm-5.m-2) foi significativamente maior que no Grupo 2 (652,14 ± 115,47 e 831,47 ± 113,84 dyn.s.cm-5.m-2), p = 0,003 e p = 0,020 respectivamente. 10) A infusão de líquidos após a reperfusão no Grupo 1 (12,80 ± 1,47 mL/kg/h) foi significativamente menor que no Grupo 2 (15,47 ± 2,23 mL/kg/h), p = 0,001. 11) A natremia média imediatamente após a infusão da solução teste e ao final da cirurgia no Grupo 1 (152,66 ± 4,45 e 148,92 ± 3,60 mEq/L) foi significativamente maior que no Grupo 2 (143,59 ± 3,92 e 142,76 ± 3,17 mEq/L), p < 0,001. 12) A cloremia média imediatamente após a infusão da solução teste e ao final da cirurgia no Grupo 1 (124,03 ± 4,01 e 119,41 ± 3,04 mEq/L) foi significativamente maior que no Grupo 2 (111,20 ± 3,80 e 111,93 ± 6,26 mEq/L), p < 0,001. 13) O pH sangüíneo imediatamente após a infusão da solução teste no Grupo 1 (7,29 ± 0,05) foi significativamente menor que no Grupo 2 (7,34 ± 0,06), p = 0,039. 14) A pressão intracraniana diminuiu 48,77% nos pacientes com hipertensão intracraniana após a administração da solução salina hipertônica, efeito que se sustentou até o final da cirurgia. CONCLUSÕES: A administração da solução salina hipertônica no transplante do fígado aboliu a síndrome pós-reperfusão, atenuou as alterações hemodinâmicas secundárias a reperfusão hepática e reduziu a necessidade de reposição volêmica. / INTRODUCTION: The reperfusion phase during orthotopic liver transplantation is a critical event which sometimes promoves profound hemodynamic and cardiac changes that may be responsible for intraoperative death, multiple organ dysfunction syndrome and early graft loss. In the present study we hypothesized that the beneficial effects of hypertonic saline solution infusion during hemorrhagic shock resuscitation, considered as an ischemia and reperfusion phenomenon of the entire organism, may attenuate the hemodynamic instability that follows graft reperfusion during liver transplantation. METHODS: Thirty adult patients presenting for liver transplantation in Hospital das Clínicas of University of São Paulo Medical School were divided in two groups: Group 1 received hypertonic (7.5%) saline solution (4 mL/kg) at a rate of 20mL/min through a central line at the beginning of portal vein anastomosis; Group 2 received normal saline solution under the same conditions. Hemodynamic profiles were evaluated using mean arterial pressure, central venous pressure, pulmonary capillary wedge pressure, cardiac index and systemic vascular resistance index. Intracranial pressure study was included for those patients presenting intracranial hypertension. Data were collected at six different times: at the end of the dissection phase, at the beginning of the anhepatic phase, after the end of test solution infusion, and at 1, 5, and 30 minutes after reperfusion. Postreperfusion syndrome was defined by the occurrence of mean arterial pressure lower than 60mmHg at 1 or 5 minutes after reperfusion, and by a decrease in mean arterial pressure of more than 30% of the baseline values within the first 5 minutes after reperfusion. RESULTS: 1) Mean arterial pressure at 1 and 5 minutes after reperfusion were significantly higher in Group 1 (84.9 ± 12,33 and 77.4 ± 4.58 mmHg) than in Group 2 (62.9 ± 5.22 and 73.9 ± 3.47 mmHg), p< 0.001 and p= 0.046 respectively. 2) Postreperfusion syndrome was absent in Group 1, but present in 33.33% of patients in Group 2, p= 0.021. 3) The cardiac index increase immediately after the test solution infusion was significantly higher in Group 1 (31.27%) than in Group 2 (7.54%), p< 0.001. 4) The rise in cardiac index after reperfusion was significantly lower in Group 1 (70.42%) than in Group 2 (125.91%), p< 0.001. 5) Cardiac index at 5 and 30 minutes after reperfusion was significantly lower in Group 1 (6.51 ± 0.81 and 5.56 ± 0.86 L.min-1.m-2) than in Group 2 (7.41 ± 0.87 and 6.34 ± 0.93 L.min-1.m-2), p= 0.007 and p= 0.024 respectively. 6) When compared to their baseline moments, beginning of surgery, cardiac index at 5 and 30 minutes after reperfusion presented significantly lower increases in Group 1 (26.16% and 7.75%) than in Group 2 (45.57% and 24.80%), p = 0.019 and p = 0.021 respectively. 7) Systemic vascular resistance index immediately after the test solution infusion dropped by 18.83% in Group 1 while it increased by 9.29% in Group 2, p < 0.001. 8) The decrease in systemic vascular resistance index immediately after reperfusion was significantly lower in Group 1 (44.52%) than in Group 2 (61.80%), p < 0.001. 9) Systemic vascular resistance index at 5 and 30 minutes after reperfusion were significantly higher in Group 1 (799.35 ± 131.51 and 963.10 ± 171.33 dyn.s.cm-5.m-2) than in Group 2 (652.14 ± 115.47 and 831.47 ± 113.84 dyn.s.cm-5.m-2), p= 0.003 and p= 0.020 respectively. 10) Fluid requirements after reperfusion were significantly lower in Group 1 (12.80 ± 1.47 mL/kg/h) compared to Group 2 (15.47 ± 2.23 mL/kg/h), p= 0.001. 11) Serum sodium after the test solution infusion and at the end of surgery was significantly higher in Group 1 (152.66 ± 4.45 and 148.92 ± 3.60 mEq/L) than in Group 2 (143.59 ± 3.92 and 142.76 ± 3.17 mEq/L), p< 0.001. 12) Serum chloride after the test solution infusion and at the end of surgery was significantly higher in Group 1 (124.03 ± 4.01 and 119.41 ± 3.04 mEq/L) than in Group 2 (111.20 ± 3.80 and 111.93 ± 6.26 mEq/L), p< 0.001. 13) Blood pH immediately after the test solution infusion was significantly lower in Group 1 (7.29 ± 0.05) than in Group 2 (7.34 ± 0.06), p < 0.039. 14) In those patients with intracranial hypertension, the intracranial pressure decreased 48.77% immediately after hypertonic saline solution infusion, an effect that was sustained throughout graft reperfusion to the end of the surgical procedure. CONCLUSIONS: Hypertonic saline solution infusion during orthotopic liver transplantation abolished the postreperfusion syndrome, attenuated the hemodynamic changes secondary to graft reperfusion and lowered fluid requirements.

No description available.

INTRODUÇÃO: No transplante do fígado a reperfusão do enxerto é um momento crítico onde as alterações hemodinâmicas ocorrem com maior freqüência e intensidade podendo se associar a mortalidade intra-operatória, à falência de múltiplos órgãos e sistemas, e ao aumento da incidência de não funcionamento do enxerto. Neste estudo testamos a hipótese de que os efeitos benéficos decorrentes da administração da solução salina hipertônica na ressuscitação do choque hemorrágico, considerado fenômeno de isquemia e reperfusão generalizado, possam atenuar os fenômenos hemodinâmicos que sucedem a reperfusão hepática no transplante do fígado. MÉTODOS: 30 pacientes adultos submetidos ao transplante hepático na Disciplina de Transplante e Cirurgia do Fígado do HC-FMUSP foram divididos em 2 grupos: Grupo-1 (n =15) recebeu solução salina hipertônica (NaCl a 7,5%), na dose de 4 mL/kg, na velocidade de 20 mL/min em veia central no início da anastomose de veia porta e Grupo- 2 (n =15) recebeu solução salina isotônica nas mesmas condições citadas. As variáveis utilizadas para a análise da hemodinâmica sistêmica foram: pressão arterial média, pressão venosa central e pressão de artéria pulmonar ocluída, índice cardíaco e índice de resistência vascular sistêmica. A análise da pressão intracraniana foi incluída no estudo dos pacientes com hipertensão intracraniana secundária a hepatite fulminante. Os dados foram coletados em 6 tempos: no término da fase de dissecção, no início da fase anepática, após a administração da solução teste, e no 1o, 5o e 30o minutos após a reperfusão. A síndrome pós-reperfusão foi determinada por três métodos: pela ocorrência de pressão arterial média inferior a 60 mmHg no 1o ou no 5o minuto da reperfusão ou queda maior que 30% do valor pré-reperfusão nos primeiros 5 minutos da reperfusão. RESULTADOS: 1) A pressão arterial média no 1o e no 5o minuto da reperfusão no Grupo 1 (84,9 ± 12,33 e 77,4 ± 4,58 mmHg) foi significativamente maior que no Grupo 2 (62,9 ± 5,22 e 73,9 ± 3,47 mmHg), p < 0,001 e p = 0,046 respectivamente. 2) A incidência de síndrome pós-reperfusão no Grupo 1 (0.0%) foi significativamente menor que no Grupo 2 (33,33%), p = 0,021. 3) O aumento do índice cardíaco imediatamente após o término de infusão da solução teste no Grupo 1 (31,27%) foi significativamente maior que no Grupo 2 (7,54%), p < 0,001. 4) O aumento do índice cardíaco após a reperfusão no Grupo 1 (70,42%) foi significativamente menor que no Grupo 2 (125,91%), p < 0,001. 5) O índice cardíaco no 5o e no 30o minuto da reperfusão no Grupo 1 (6,51 ± 0,81 e 5,56 ± 0,86 L.min-1.m-2) foi significativamente menor que no Grupo 2 (7,41 ± 0,87 e 6,34 ± 0,93 L.min-1.m-2), p= 0,007 e p = 0,024 respectivamente. 6) O índice cardíaco no 5o e no 30ominuto da reperfusão quando comparados aos momentos basais (início da cirurgia) apresentou aumentos no Grupo 1 (26,16% e 7,75%) significativamente menores que no Grupo 2 (45,57% e 24,80%), p= 0,019 e p= 0,021 respectivamente. 7) O índice de resistência vascular sistêmica imediatamente após o término de infusão da solução teste no Grupo 1 apresentou queda de 18,83% enquanto no Grupo 2 foi registrado aumento de 9,21%, p < 0.001. 8) A diminuição do índice de resistência vascular sistêmica após a reperfusão no Grupo 1 (44,52%) foi significativamente menor que no Grupo 2 (61,80%), p < 0,001. 9) O índice de resistência vascular sistêmica no 5o e no 30o minuto após a reperfusão no Grupo 1 (799,35 ± 131,51 e 963,10 ± 171,33 dyn.s.cm-5.m-2) foi significativamente maior que no Grupo 2 (652,14 ± 115,47 e 831,47 ± 113,84 dyn.s.cm-5.m-2), p = 0,003 e p = 0,020 respectivamente. 10) A infusão de líquidos após a reperfusão no Grupo 1 (12,80 ± 1,47 mL/kg/h) foi significativamente menor que no Grupo 2 (15,47 ± 2,23 mL/kg/h), p = 0,001. 11) A natremia média imediatamente após a infusão da solução teste e ao final da cirurgia no Grupo 1 (152,66 ± 4,45 e 148,92 ± 3,60 mEq/L) foi significativamente maior que no Grupo 2 (143,59 ± 3,92 e 142,76 ± 3,17 mEq/L), p < 0,001. 12) A cloremia média imediatamente após a infusão da solução teste e ao final da cirurgia no Grupo 1 (124,03 ± 4,01 e 119,41 ± 3,04 mEq/L) foi significativamente maior que no Grupo 2 (111,20 ± 3,80 e 111,93 ± 6,26 mEq/L), p < 0,001. 13) O pH sangüíneo imediatamente após a infusão da solução teste no Grupo 1 (7,29 ± 0,05) foi significativamente menor que no Grupo 2 (7,34 ± 0,06), p = 0,039. 14) A pressão intracraniana diminuiu 48,77% nos pacientes com hipertensão intracraniana após a administração da solução salina hipertônica, efeito que se sustentou até o final da cirurgia. CONCLUSÕES: A administração da solução salina hipertônica no transplante do fígado aboliu a síndrome pós-reperfusão, atenuou as alterações hemodinâmicas secundárias a reperfusão hepática e reduziu a necessidade de reposição volêmica. / INTRODUCTION: The reperfusion phase during orthotopic liver transplantation is a critical event which sometimes promoves profound hemodynamic and cardiac changes that may be responsible for intraoperative death, multiple organ dysfunction syndrome and early graft loss. In the present study we hypothesized that the beneficial effects of hypertonic saline solution infusion during hemorrhagic shock resuscitation, considered as an ischemia and reperfusion phenomenon of the entire organism, may attenuate the hemodynamic instability that follows graft reperfusion during liver transplantation. METHODS: Thirty adult patients presenting for liver transplantation in Hospital das Clínicas of University of São Paulo Medical School were divided in two groups: Group 1 received hypertonic (7.5%) saline solution (4 mL/kg) at a rate of 20mL/min through a central line at the beginning of portal vein anastomosis; Group 2 received normal saline solution under the same conditions. Hemodynamic profiles were evaluated using mean arterial pressure, central venous pressure, pulmonary capillary wedge pressure, cardiac index and systemic vascular resistance index. Intracranial pressure study was included for those patients presenting intracranial hypertension. Data were collected at six different times: at the end of the dissection phase, at the beginning of the anhepatic phase, after the end of test solution infusion, and at 1, 5, and 30 minutes after reperfusion. Postreperfusion syndrome was defined by the occurrence of mean arterial pressure lower than 60mmHg at 1 or 5 minutes after reperfusion, and by a decrease in mean arterial pressure of more than 30% of the baseline values within the first 5 minutes after reperfusion. RESULTS: 1) Mean arterial pressure at 1 and 5 minutes after reperfusion were significantly higher in Group 1 (84.9 ± 12,33 and 77.4 ± 4.58 mmHg) than in Group 2 (62.9 ± 5.22 and 73.9 ± 3.47 mmHg), p< 0.001 and p= 0.046 respectively. 2) Postreperfusion syndrome was absent in Group 1, but present in 33.33% of patients in Group 2, p= 0.021. 3) The cardiac index increase immediately after the test solution infusion was significantly higher in Group 1 (31.27%) than in Group 2 (7.54%), p< 0.001. 4) The rise in cardiac index after reperfusion was significantly lower in Group 1 (70.42%) than in Group 2 (125.91%), p< 0.001. 5) Cardiac index at 5 and 30 minutes after reperfusion was significantly lower in Group 1 (6.51 ± 0.81 and 5.56 ± 0.86 L.min-1.m-2) than in Group 2 (7.41 ± 0.87 and 6.34 ± 0.93 L.min-1.m-2), p= 0.007 and p= 0.024 respectively. 6) When compared to their baseline moments, beginning of surgery, cardiac index at 5 and 30 minutes after reperfusion presented significantly lower increases in Group 1 (26.16% and 7.75%) than in Group 2 (45.57% and 24.80%), p = 0.019 and p = 0.021 respectively. 7) Systemic vascular resistance index immediately after the test solution infusion dropped by 18.83% in Group 1 while it increased by 9.29% in Group 2, p < 0.001. 8) The decrease in systemic vascular resistance index immediately after reperfusion was significantly lower in Group 1 (44.52%) than in Group 2 (61.80%), p < 0.001. 9) Systemic vascular resistance index at 5 and 30 minutes after reperfusion were significantly higher in Group 1 (799.35 ± 131.51 and 963.10 ± 171.33 dyn.s.cm-5.m-2) than in Group 2 (652.14 ± 115.47 and 831.47 ± 113.84 dyn.s.cm-5.m-2), p= 0.003 and p= 0.020 respectively. 10) Fluid requirements after reperfusion were significantly lower in Group 1 (12.80 ± 1.47 mL/kg/h) compared to Group 2 (15.47 ± 2.23 mL/kg/h), p= 0.001. 11) Serum sodium after the test solution infusion and at the end of surgery was significantly higher in Group 1 (152.66 ± 4.45 and 148.92 ± 3.60 mEq/L) than in Group 2 (143.59 ± 3.92 and 142.76 ± 3.17 mEq/L), p< 0.001. 12) Serum chloride after the test solution infusion and at the end of surgery was significantly higher in Group 1 (124.03 ± 4.01 and 119.41 ± 3.04 mEq/L) than in Group 2 (111.20 ± 3.80 and 111.93 ± 6.26 mEq/L), p< 0.001. 13) Blood pH immediately after the test solution infusion was significantly lower in Group 1 (7.29 ± 0.05) than in Group 2 (7.34 ± 0.06), p < 0.039. 14) In those patients with intracranial hypertension, the intracranial pressure decreased 48.77% immediately after hypertonic saline solution infusion, an effect that was sustained throughout graft reperfusion to the end of the surgical procedure. CONCLUSIONS: Hypertonic saline solution infusion during orthotopic liver transplantation abolished the postreperfusion syndrome, attenuated the hemodynamic changes secondary to graft reperfusion and lowered fluid requirements.