Background. Several approaches have been proposed to pharmacologically ameliorate hepatic ischemia/reperfusion injury (IRI). This study was designed to evaluate the effects of a preconditioning oral nutritional supplement (pONS) containing glutamine, antioxidants, and green tea extract on hepatic warm IRI in pigs. Methods. pONS (70？g per serving, Fresenius Kabi, Germany) was dissolved in 250？mL tap water and given to pigs 24, 12, and 2？hrs before warm ischemia of the liver. A fourth dose was given 3？hrs after reperfusion. Controls were given the same amount of cellulose with the same volume of water. Two hours after the third dose of pONS, both the portal vein and the hepatic artery were clamped for 40？min. 0.5, 3, 6, and 8？hrs after reperfusion, heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), portal venous flow (PVF), hepatic arterial flow (HAF), bile flow, and transaminases were measured. Liver tissue was taken 8？hrs after reperfusion for histology and immunohistochemistry. Results. HR, MAP, CVP, HAF, and PVF were comparable between the two groups. pONS significantly increased bile flow 8？hrs after reperfusion. ALT and AST were significantly lower after pONS. Histology showed significantly more severe necrosis and neutrophil infiltration in controls. pONS significantly decreased the index of immunohistochemical expression for TNF-α, MPO, and cleaved caspase-3 ( ). Conclusion. Administration of pONS before and after tissue damage protects the liver from warm IRI via mechanisms including decreasing oxidative stress, lipid peroxidation, apoptosis, and necrosis. 1. Introduction During liver surgery, the inflow occlusion maneuver to prevent blood loss as well as the liver manipulation itself have been shown to induce a cascade of molecular events, referred to as ischemia-reperfusion injury (IRI). IRI leads to the activation of Kupffer cells (KCs), the release of reactive oxygen species (ROS) and proinflammatory cytokines, microcirculatory disturbances, and eventually liver dysfunction and failure [1–10]. Different strategies have been proposed to prevent or ameliorate IRI. Among others, pharmacological preconditioning has been shown to be effective via mechanisms including, but not limited to, the direct neutralization of ROS, upregulation of anti-inflammatory, and downregulation of proinflammatory signaling pathways [11–27]. During IRI, intestinal endotoxins (LPS) leak through the altered gut membrane into the portal circulation and enhance the phagocytosis in hepatic KCs [28–35]. This interrelation between intestinal LPS and
References
[1]
C. Bremer, B. U. Bradford, K. J. Hunt et al., “Role of Kupffer cells in the pathogenesis of hepatic reperfusion injury,” American Journal of Physiology, vol. 267, no. 4, pp. 630–636, 1994.
[2]
P. Schemmer, R. Schoonhoven, J. A. Swenberg, H. Bunzendahl, and R. G. Thurman, “Gentle in situ liver manipulation during organ harvest decreases survival after rat liver transplantation: role of Kupffer cells,” Transplantation, vol. 65, no. 8, pp. 1015–1020, 1998.
[3]
P. Schemmer, H. D. Connor, G. E. Arteel et al., “Reperfusion injury in livers due to gentle in situ organ manipulation during harvest involves hypoxia and free radicals,” Journal of Pharmacology and Experimental Therapeutics, vol. 290, no. 1, pp. 235–240, 1999.
[4]
P. Schemmer, B. U. Bradford, M. L. Rose et al., “Intravenous glycine improves survival in rat liver transplantation,” American Journal of Physiology, vol. 276, no. 4, pp. 924–932, 1999.
[5]
P. Schemmer, R. Schoonhoven, J. A. Swenberg et al., “Gentle organ manipulation during harvest as a key determinant of survival of fatty livers after transplantation in the rat,” Transplant International, vol. 12, no. 5, pp. 351–359, 1999.
[6]
P. Schemmer, H. Bunzendahl, J. A. Raleigh, and R. G. Thurman, “Graft survival is improved by hepatic denervation before organ harvesting,” Transplantation, vol. 67, no. 10, pp. 1301–1307, 1999.
[7]
P. Schemmer, N. Enomoto, B. U. Bradford et al., “Activated Kupffer cells cause a hypermetabolic state after gentle in situ manipulation of liver in rats,” American Journal of Physiology, vol. 280, no. 6, pp. 1076–1082, 2001.
[8]
B. K. Hanboon, W. Ekataksin, G. Alsfasser et al., “Microvascular dysfunction in hepatic ischemia-reperfusion injury in pigs,” Microvascular Research, vol. 80, no. 1, pp. 123–132, 2010.
[9]
P. Schemmer, M. Golling, T. Kraus et al., “Extended experience with glycine for prevention of reperfusion injury after human liver transplantation,” Transplantation Proceedings, vol. 34, no. 6, pp. 2307–2309, 2002.
[10]
P. Schemmer, A. Mehrabi, T. Kraus et al., “New aspect on reperfusion injury to liver—impact of organ harvest,” Nephrology Dialysis Transplantation, vol. 19, no. 4, pp. 26–35, 2004.
[11]
S. P. Luntz, K. Unnebrink, M. Seibert-Grafe et al., “HEGPOL: randomized, placebo controlled, multicenter, double-blind clinical trial to investigate hepatoprotective effects of glycine in the postoperative phase of liver transplantation [ISRCTN69350312],” BMC Surgery, vol. 5, article 18, 2005.
[12]
P. Schemmer, R. Liang, M. Kincius et al., “Taurine improves graft survival after experimental liver transplantation,” Liver Transplantation, vol. 11, no. 8, pp. 950–959, 2005.
[13]
M. Kincius, R. Liang, A. Nickkholgh et al., “Taurine protects from liver injury after warm ischemia in rats: the role of Kupffer cells,” European Surgical Research, vol. 39, no. 5, pp. 275–283, 2007.
[14]
C. Jahnke, A. Mehrabi, M. Golling et al., “Evaluation of microperfusion disturbances in the transplanted liver after Kupffer cell destruction using GdCl3: an experimental porcine study,” Transplantation Proceedings, vol. 38, no. 5, pp. 1588–1595, 2006.
[15]
A. Nickkholgh, H. Schneider, J. Encke, M. W. Büchler, J. Schmidt, and P. Schemmer, “PROUD: effects of preoperative long-term immunonutrition in patients listed for liver transplantation,” Trials, vol. 8, article 20, 2007.
[16]
A. Nickkholgh, M. Barro-Bejarano, R. Liang et al., “Signs of reperfusion injury following CO2 pneumoperitoneum: an in vivo microscopy study,” Surgical Endoscopy and Other Interventional Techniques, vol. 22, no. 1, pp. 122–128, 2008.
[17]
P. Schemmer, A. Nickkholgh, H. Schneider et al., “PORTAL: pilot study on the safety and tolerance of preoperative melatonin application in patients undergoing major liver resection: a double-blind randomized placebo-controlled trial,” BMC Surgery, vol. 8, article 2, 2008.
[18]
X. Guan, G. Dei-Anane, R. Liang et al., “Donor preconditioning with taurine protects kidney grafts from injury after experimental transplantation,” Journal of Surgical Research, vol. 146, no. 1, pp. 127–134, 2008.
[19]
R. Liang, A. Nickkholgh, K. Hoffmann et al., “Melatonin protects from hepatic reperfusion injury through inhibition of IKK and JNK pathways and modification of cell proliferation,” Journal of Pineal Research, vol. 46, no. 1, pp. 8–14, 2009.
[20]
Z. Li, A. Nickkholgh, X. Yi et al., “Melatonin protects kidney grafts from ischemia/reperfusion injury through inhibition of NF-kB and apoptosis after experimental kidney transplantation,” Journal of Pineal Research, vol. 46, no. 4, pp. 365–372, 2009.
[21]
R. Liang, H. Bruns, M. Kincius et al., “Danshen protects liver grafts from ischemia/reperfusion injury in experimental liver transplantation in rats,” Transplant International, vol. 22, no. 11, pp. 1100–1109, 2009.
[22]
X. Guan, G. Dei-Anane, H. Bruns et al., “Danshen protects kidney grafts from ischemia/reperfusion injury after experimental transplantation,” Transplant International, vol. 22, no. 2, pp. 232–241, 2009.
[23]
K. Hoffmann, M. W. Büchler, and P. Schemmer, “Supplementation of amino acids to prevent reperfusion injury after liver surgery and transplantation—where do we stand today?” Clinical Nutrition, vol. 30, no. 2, pp. 143–147, 2011.
[24]
H. Bruns, I. Watanpour, M. M. Gebhard et al., “Glycine and taurine equally prevent fatty livers from Kupffer cell-dependent injury: an in vivo microscopy study,” Microcirculation, vol. 18, no. 3, pp. 205–213, 2011.
[25]
G. O. Ceyhan, A. K. Timm, F. Bergmann et al., “Prophylactic glycine administration attenuates pancreatic damage and inflammation in experimental acute pancreatitis,” Pancreatology, vol. 11, no. 1, pp. 57–67, 2011.
[26]
S. Mikalauskas, L. Mikalauskiene, H. Bruns et al., “Dietary glycine protects from chemotherapy-induced hepatotoxicity,” Amino Acids, vol. 40, no. 4, pp. 1139–1150, 2011.
[27]
A. Nickkholgh, H. Schneider, M. Sobirey et al., “The use of high-dose melatonin in liver resection is safe: first clinical experience,” Journal of Pineal Research, vol. 50, no. 4, pp. 381–388, 2011.
[28]
J. P. Nolan, “Endotoxin, reticuloendothelial function, and liver injury,” Hepatology, vol. 1, no. 5, pp. 458–465, 1981.
[29]
K. B. Cowper, R. T. Currin, T. L. Dawson, K. A. Lindert, J. J. Lemasters, and R. G. Thurman, “A new method to monitor Kupffer-cell function continuously in the perfused rat liver: dissociation of glycogenolysis from particle phagocytosis,” Biochemical Journal, vol. 266, no. 1, pp. 141–147, 1990.
[30]
P. Schemmer, N. Enomoto, B. U. Bradford, H. Bunzendahl, J. A. Raleigh, and R. G. Thurman, “Autonomic nervous system and gut-derived endotoxin: involvement in activation of Kupffer cells after in situ organ manipulation,” World Journal of Surgery, vol. 25, no. 4, pp. 399–406, 2001.
[31]
K. Monden, S. Arii, S. Itai et al., “Enhancement of hepatic macrophages in septic rats and their inhibitory effect on hepatocyte function,” Journal of Surgical Research, vol. 50, no. 1, pp. 72–76, 1991.
[32]
R. L. Schultze, A. Gangopadhyay, O. Cay, D. Lazure, and P. Thomas, “Tyrosine kinase activation in LPS stimulated rat Kupffer cells,” Cell Biochemistry and Biophysics, vol. 30, no. 2, pp. 287–301, 1999.
[33]
R. Tokyay, S. T. Zeigler, D. L. Traber et al., “Postburn gastrointestinal vasoconstriction increases bacterial and endotoxin translocation,” Journal of Applied Physiology, vol. 74, no. 4, pp. 1521–1527, 1993.
[34]
S. E. Morris, N. Navaratnam, C. M. Townsend, and D. N. Herndon, “Decreased mesenteric blood flow independently promotes bacterial translocation in chronically instrumented sheep,” Surgical Forum, vol. 40, pp. 88–91, 1989.
[35]
M. Golling, C. Jahnke, H. Fonouni et al., “Distinct effects of surgical denervation on hepatic perfusion, bowel ischemia, and oxidative stress in brain dead and living donor porcine models,” Liver Transplantation, vol. 13, no. 4, pp. 607–617, 2007.
[36]
R. Liang, A. Nickkholgh, M. Kern et al., “Green tea extract ameliorates reperfusion injury to rat livers after warm ischemia in a dose-dependent manner,” Molecular Nutrition and Food Research, vol. 55, no. 6, pp. 855–863, 2011.
[37]
H. U. Bergmeyer, Methods of Enzymatic Analysis, Academic Press, New York, NY, USA, 1988.
[38]
R. G. Thurman, I. Marzi, G. Seitz, J. Thies, J. J. Lemasters, and F. Zimmerman, “Hepatic reperfusion injury following orthotopic liver transplantation in the rat,” Transplantation, vol. 46, no. 4, pp. 502–506, 1988.
[39]
N. N. Rahbari, M. N. Wente, P. Schemmer et al., “Systematic review and meta-analysis of the effect of portal triad clamping on outcome after hepatic resection,” British Journal of Surgery, vol. 95, no. 4, pp. 424–432, 2008.
[40]
H. Jaeschke and A. Farhood, “Kupffer cell activation after no-flow ischemia versus hemorrhagic shock,” Free Radical Biology and Medicine, vol. 33, no. 2, pp. 210–219, 2002.
[41]
G. K. Glantzounis, H. J. Salacinski, W. Yang, B. R. Davidson, and A. M. Seifalian, “The contemporary role of antioxidant therapy in attenuating liver ischemia-reperfusion injury: a review,” Liver Transplantation, vol. 11, no. 9, pp. 1031–1047, 2005.
[42]
M. K. Sharma and G. R. Buettner, “Interaction of vitamin C and vitamin E during free radical stress in plasma: an ESR study,” Free Radical Biology and Medicine, vol. 14, no. 6, pp. 649–653, 1993.
[43]
E. Nagel, A. Meyer zu Vilsendorf, M. Bartels, and R. Pichlmayr, “Antioxidative vitamins in prevention of ischemia/reperfusion injury,” International Journal for Vitamin and Nutrition Research, vol. 67, no. 5, pp. 298–306, 1997.
[44]
Z. Zhong, M. Froh, H. D. Connor et al., “Prevention of hepatic ischemia-reperfusion injury by green tea extract,” American Journal of Physiology, vol. 283, no. 4, pp. 957–964, 2002.
[45]
C. Zapletal, S. Heyne, R. Breitkreutz, M. M. Gebhard, and M. Golling, “The influence of selenium substitution on microcirculation and glutathione metabolism after warm liver ischemia/reperfusion in a rat model,” Microvascular Research, vol. 76, no. 2, pp. 104–109, 2008.
[46]
Y. Horie, R. Wolf, S. C. Flores, J. M. McCord, C. J. Epstein, and D. N. Granger, “Transgenic mice with increased copper/zinc-superoxide dismutase activity are resistant to hepatic leukostasis and capillary no-reflow after gut ischemia/reperfusion,” Circulation Research, vol. 83, no. 7, pp. 691–696, 1998.
[47]
S. Vertuani, A. Angusti, and S. Manfredini, “The antioxidants and pro-antioxidants network: an overview,” Current Pharmaceutical Design, vol. 10, no. 14, pp. 1677–1694, 2004.
[48]
M. H. Wijnen, R. M. H. Roumen, H. L. Vader, and R. J. A. Goris, “A multiantioxidant supplementation reduces damage from ischaemia reperfusion in patients after lower torso ischaemia. A randomised trial,” European Journal of Vascular and Endovascular Surgery, vol. 23, no. 6, pp. 486–490, 2002.
[49]
G. Schindler, M. Kincius, R. Liang et al., “Fundamental efforts toward the development of a therapeutic cocktail with a manifold ameliorative effect on hepatic ischemia/reperfusion injury,” Microcirculation, vol. 16, no. 7, pp. 593–602, 2009.
[50]
G. L. Su, S. M. Goyert, M. H. Fan et al., “Activation of human and mouse Kupffer cells by lipopolysaccharide is mediated by CD14,” American Journal of Physiology, vol. 283, no. 3, pp. 640–645, 2002.
[51]
E. S. van Amersfoort, T. J. C. van Berkel, and J. Kuiper, “Receptors, mediators, and mechanisms involved in bacterial sepsis and septic shock,” Clinical Microbiology Reviews, vol. 16, no. 3, pp. 379–414, 2003.
[52]
M. van Oosten, E. van de Bilt, T. J. C. van Berkel, and J. Kuiper, “New scavenger receptor-like receptors for the binding of lipopolysaccharide to liver endothelial and Kupffer cells,” Infection and Immunity, vol. 66, no. 11, pp. 5107–5112, 1998.
[53]
A. Tsung, R. A. Hoffman, K. Izuishi et al., “Hepatic ischemia/reperfusion injury involves functional TLR4 signaling in nonparenchymal cells,” Journal of Immunology, vol. 175, no. 11, pp. 7661–7668, 2005.
[54]
B. Vollmar and M. D. Menger, “The hepatic microcirculation: mechanistic contributions and therapeutic targets in liver injury and repair,” Physiological Reviews, vol. 89, no. 4, pp. 1269–1339, 2009.
[55]
R. G. dos Santos, M. L. Viana, S. V. Generoso, R. E. Arantes, M. I. Davisson Correia, and V. N. Cardoso, “Glutamine supplementation decreases intestinal permeability and preserves gut mucosa integrity in an experimental mouse model,” Journal of Parenteral and Enteral Nutrition, vol. 34, no. 4, pp. 408–413, 2010.
[56]
J. Schroeder, B. Alteheld, P. Stehle, M. C. Cayeux, R. L. Chioléro, and M. M. Berger, “Safety and intestinal tolerance of high-dose enteral antioxidants and glutamine peptides after upper gastrointestinal surgery,” European Journal of Clinical Nutrition, vol. 59, no. 2, pp. 307–310, 2005.
[57]
M. Kul, S. Vurucu, E. Demirkaya et al., “Enteral glutamine and/or arginine supplementation have favorable effects on oxidative stress parameters in neonatal rat intestine,” Journal of Pediatric Gastroenterology and Nutrition, vol. 49, no. 1, pp. 85–89, 2009.
[58]
H. Jaeschke, “Mechanisms of liver injury. II. Mechanisms of neutrophil-induced liver cell injury during hepatic ischemia-reperfusion and other acute inflammatory conditions,” American Journal of Physiology, vol. 290, no. 6, pp. 1083–1088, 2006.
[59]
J. El-Benna, P. M. C. Dang, M. A. Gougerot-Pocidalo, and C. Elbim, “Phagocyte NADPH oxidase: a multicomponent enzyme essential for host defenses,” Archivum Immunologiae et Therapiae Experimentalis, vol. 53, no. 3, pp. 199–206, 2005.
[60]
H. Jaeschke, “Molecular mechanisms of hepatic ischemia-reperfusion injury and preconditioning,” American Journal of Physiology, vol. 284, no. 1, pp. 15–26, 2003.
