Cytochrome P450 activity mirrors nitric oxide levels in postoperative sepsis: Predictive indicators of lethal outcome

doi:10.1016/j.surg.2006.08.011

Surgery

Volume 141, Issue 3, March 2007, Pages 376-384

https://doi.org/10.1016/j.surg.2006.08.011 Get rights and content

Background

The development of liver failure significantly influences prognosis during the course of major septic complications. Although the underlying cause for septic liver failure is still unclear, research using animal models has demonstrated that an increased nitric oxide (NO) synthesis compromises detoxification processes in the liver.

Methods

In the present study, serum NO levels were measured by high-performance liquid chromatography (HPLC) and aminopyrine breath test (ABT) scores, reflecting the in vivo activity of cytochrome P450-dependent liver enzymes, were investigated in 42 patients (23 who survived sepsis [survivors]/19 patients who ultimately died of sepsis [nonsurvivors]) suffering from major septic complications after abdominal surgery. Additionally, TNF-α serum levels, serving as indicators for major systemic inflammation, were monitored using enzyme-linked immunosorbent assay (ELISA).

Results

The increased serum NO levels that were found during sepsis correlated with the severity of the septic course. Compared with preoperative values of 42.77 ± 5.84 mM, nitrite/nitrate levels reached 72.88 ± 10.16 mM in early sepsis. An increased NO synthesis also was accompanied by a rise in serum TNF-α levels. Monitoring of liver function by ABT allowed an early differentiation between transient sepsis and sepsis with a lethal outcome (P = .006). In contrast, cytochrome P450 activity as measured by the ABT was significantly diminished in septic patients (0.45 ± 0.02 [% dose × kgBW per (mmol CO₂)⁻¹] before sepsis onset/0.16 ± 0.01 [% dose × kgBW per (mmol CO₂)⁻¹] in sepsis). Like the NO and TNF-α levels, ABT scores showed a difference between transient sepsis and sepsis with a lethal outcome. Serum NO levels were inversely correlated with ABT scores (P = .022) and positively correlated with TNF-α levels (P = 0.015) in the late phase of sepsis. Serum TNF-α levels and ABT scores were inversely correlated in the early (P = .027), as well as in the late (P = .015) phases of sepsis.

Conclusions

This study supports the hypothesis that septic liver failure is linked to the induction of NO synthesis in major systemic inflammation. Therefore, the ABT provides a clinically useful tool for predicting the outcome in the early stages of sepsis. This may aid in the decision-making process when early surgical intervention is considered.

Section snippets

Clinical profile and study design

The study included 42 consecutive patients treated on the surgical intensive care unit (ICU) for clinical sepsis. Sepsis occurred after major visceral surgery in all cases. The Table details the clinical profile of the patients enrolled in the study. Four patients were subjected to neoadjuvant radio- or chemotherapy. Patients on an immunosuppressive regimen and patients with acquired or inherited immune deficiencies were excluded from the study. For the diagnosis of sepsis, patients had to meet

Clinical profile of patients

A total of 42 consecutive patients who developed sepsis (defined by the criteria listed above) after major abdominal surgery were included in the study. The Table sketches the clinical profile of the study population. Overall mortality due to sepsis was 45.2% (19 of 42 patients). Survivors and nonsurvivors did not differ in any of the analyzed clinical parameters, including age, sex, underlying malignant disease, surgical procedures, septic focus, or type of infection (Table).

Increased NO levels during postoperative sepsis

The results of

Role of NO in sepsis and septic shock

During the course of sepsis the synthesis of inducible nitric oxide synthetases (iNOS) is stimulated by endotoxin and cytokines, leading to the production of large amounts of NO over an extended period of time.18, 19 iNOS can be induced in a variety of cells like macrophages, lymphocytes, neutrophils, vascular endothelia, hepatocytes, and Kupfer cells.18, 20, 21, 22 The cytokines mainly involved in the induction of iNOS are TNF-α, IFN-γ, and IL-1. The resulting overproduction of NO causes

Conclusion

NO serum levels as well as aminopyrine breath test (ABT) values in early sepsis could be clinically used for identifying individuals with an increased risk of death due to sepsis. Although the assessment of NO serum levels is time-consuming and expensive, the ABT seems to be an easy-to-perform and inexpensive method for monitoring patients during postoperative sepsis with prognostic as well as therapeutic implications. Low ABT values might aid in the early identification of potential lethal

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Cited by (23)

High serum nitrates levels in non-survivor COVID-19 patients
2022, Medicina Intensiva
Citation Excerpt :
Nitric oxide is a very unstable and short half-life gas that breaks rapidly to the stable products as nitrate and nitrite.17,18 Higher blood nitrate and nitrite levels has been found in patients with higher sepsis severity,19–23 and in non-survivor than in survivor septic patients.23 Increased blood nitrate and nitrite levels has been found in COVID-19 patients than in healthy subjects24; however, we have not found data about serum nitrate levels and prognosis of COVID-19 patients.
Higher blood nitrate and nitrite levels have been found in coronavirus disease 2019 (COVID-19) patients than in healthy subjects. The present study explores the potential association between serum nitrate levels and mortality in COVID-19 patients.
A prospective observation study was carried out.
Eight Intensive Care Units (ICUs) from 6 hospitals in the Canary Islands (Spain).
COVID-19 patients admitted to the ICU.
Determination of serum nitrate levels at ICU admission.
Mortality at 30 days.
Non-surviving (n = 11) compared to surviving patients (n = 42) showed higher APACHE-II (p < 0.001) and SOFA scores (p = 0.004), and higher serum nitrate levels (p = 0.001). Logistic regression analyses showed serum nitrate levels to be associated to 30-day mortality after controlling for SOFA (OR = 1.021; 95%CI = 1.006–1.036; p = 0.01) or APACHE-II (OR = 1.023; 95%CI = 1.006–1.041; p = 0.01). There were no differences in the area under the curve (AUC) for mortality prediction by serum nitrate levels (AUC = 83%; 95%CI = 73–92%; p < 0.001), APACHE II (AUC = 85%; 95%CI = 75–96%; p < 0.001) and SOFA (AUC = 78%; 95%CI = 63–92%; p = 0.005) based on the DeLong method. The Kaplan–Meier analysis found patients with serum nitrates levels > 68.4 μmol/l to have a higher mortality rate (hazard ratio = 138.8; 95%CI = 22.3–863.9; p < 0.001).
The main novel finding was the association between serum nitrate levels and mortality in COVID-19 patients controlling for the SOFA or APACHE-II scores, though larger studies are needed to confirm this observation.
Se han encontrado niveles más elevados de nitratos en la sangre de pacientes con enfermedad del coronavirus 2019 (COVID-19) que en sujetos sanos. Por lo tanto, el objetivo de estudio consistió en explorar la posible asociación entre los niveles séricos de nitratos y la mortalidad de pacientes por COVID-19.
Estudio observacional y prospectivo.
Ocho unidades de cuidados intensivos (UCI) de 6 hospitales de las Islas Canarias (España).
Pacientes COVID-19 ingresados en la UCI.
Se midieron los niveles séricos de nitratos al ingreso en la UCI.
Mortalidad a los 30 días.
Los pacientes fallecidos (n = 11) comparados con los supervivientes (n = 42) presentaron mayores APACHE-II (p < 0,001), SOFA (p = 0,004) y niveles séricos de nitratos (p = 0,001). Los análisis de regresión logística mostraron una asociación entre los niveles séricos de nitratos al ingreso en la UCI y la mortalidad a los 30 días controlando por SOFA (OR: 1.021; IC 95%: 1.006-1.036; p = 0,01) o APACHE-II (OR: 1.023; IC 95%: 1.006-1.041; p = 0,01). No encontramos diferencias en el área bajo la curva (ABC) para la predicción de mortalidad entre los niveles séricos de nitratos (ABC: 83%; IC 95%: 73-92%; p < 0,001), APACHE-II (ABC: 85%; IC 95%: 75-96%; p < 0,001) y SOFA (ABC: 78%; IC 95%: 63-92%; p = 0,005) con el método de DeLong. El análisis de Kaplan-Meier mostró que los pacientes que tenían niveles séricos de nitratos al ingreso en la UCI > 68,4 μmol/l presentaban mayor riesgo de fallecer (hazard ratio: 138,8; IC 95%: 22,3-863,9; p < 0,001).
El principal nuevo hallazgo fue la asociación entre los niveles séricos de nitratos y la mortalidad de pacientes COVID-19 controlando por SOFA o APACHE-II; pero estudios de mayor tamaño muestral son necesarios para confirmar este resultado.
Blood optical absorption of rats with hepatic damage and turmeric treatment: Methemoglobin analysis
2019, Journal of Molecular Liquids
Citation Excerpt :
Blue symbols revealed a new absorption band around 430 nm to 525 nm. One component of this absorption band could be related to the methemoglobin (Mth) [31], another component could be due to the cytochrome P450 (CP450) [32]; this absorption band is not possible to observe from the original absorption spectra (Black symbols). In the group corresponding to liver cancer (Fig. 4B), blue symbols show slightly greater absorption in the range of 450–600 nm, while the group of Sham + Turmeric (Fig. 4C) has a lower absorption compared to the other groups in the same range.
Photoacoustic spectroscopy (PAS) is singled out by its capability to resolve the optical absorption spectra of each element, of a multicomponent system, by the named phase resolved method. The possibility of the use of this method is due to the fact that the Photoacoustic signal is not only sensitive to the optical absorption of the sample as well as the non-radiative relaxation times of its elements. In the present study we compare and analyze, by phase resolved method, Fisher rat blood in four groups: healthy rat blood, liver cancer rat blood, healthy rat blood given by a daily dose of Curcuma longa, and liver cancer rat blood given by a daily dose of Curcuma longa (turmeric), where the optical absorption spectra of the analyzed blood samples was obtained by PAS, in a wavelength range from 350 nm to 650 nm. Three repetitions of 60 μl of blood for each group was done. By using the phase resolved method a new optical absorption band suggestive of methemoglobin was found, observing the benefits of the intake of turmeric due to the fact that the optical absorption spectrum of the Cancer + turmeric group diminish 14% with respect to the Cancer group, anticipating a lower concentration of methemoglobin in blood.
Regulation of Drug-Metabolizing Enzymes and Drug Metabolism by Inflammatory Responses
2017, Drug Metabolism in Diseases
Inflammation caused by activation of innate immune responses can have a significant impact on drug metabolism via regulation of drug-metabolizing enzymes, particularly the cytochrome P450s. Clinical evidence exists for significant impact of viral, bacterial, and parasitic as well as sterile inflammatory diseases in humans. Proinflammatory cytokines known to regulate hepatic acute phase proteins are also the major players in regulating drug-metabolizing enzymes, although their relative roles may vary according to the specific disease state. Downregulation can result in increased incidence of adverse effects, or reduced bioactivation of drugs or toxicants, and is the basis for disease-dependent interactions of antiinflammatory therapeutic proteins with small-molecule drugs. Mechanisms behind these effects include direct and indirect transcriptional suppression as well as posttranscriptional mechanisms, including microRNA and nitric oxide‒mediated effects.
The effect of inflammation on drug metabolism: A focus on pediatrics
2011, Drug Discovery Today
Citation Excerpt :
It is likely that cytokines have an important role in the suppression of CYP activity in these patients. This is further supported by the results of Novotny et al., who found a significant decrease in overall CYP450 activity, measured by the aminopyrine breath test, in patients with sepsis and this reduction was inversely correlated with TNF-α serum levels [26]. In addition, mephenytoin and chlorzoxazone (CYP2C19 and CYP2E1, respectively) metabolism was depressed in severely injured patients, who also display an intense inflammatory response [27].
The Effect of Selective Inhibition of Inducible Nitric Oxide Synthase on Cytochrome P450 After Liver Transplantation in a Rat Model
2008, Transplantation Proceedings
Citation Excerpt :
Our data showed that a significant elevation of CYP activity caused by iNOS inhibition reflected graft function.2,3 So far, clinical results after human OLT have revealed that microsomal graft function in acute rejections followed by NO upregulation lead to reduced CYP activity.1,9 As shown in other solid organ transplantation models, acute rejection reactions are frequently associated with elevated NO levels.
Activity levels of cytochrome P450 (CYP) provide markers for liver function and graft rejection episodes after orthotopic liver transplantation (OLT). Some in vitro studies have shown decreased CYP activation of inducible nitric oxide synthase (iNOS) in rejecting liver grafts. The aim of this study was to evaluate CYP isoenzyme activity changes in vivo and to examine histopathologic aspects during inhibition of iNOS after treatment with aminoguanidine (AG) using OLT in the rat.
Thirty DA-(RT1av1) rats that served as donors and LEWIS-(RT¹) rats as recipients were divided into three groups: group I (controls, syngeneic rats; n = 6), group II (allogeneic rats without immunosupression; n = 11), and group III (allogeneic rats with AG treatment; n = 13). On postoperative days 5, 8, and 10 we performed laboratory investigations and liver biopsies for histopathologic investigations.
On postoperative day 5, activities of CYP-1A1 and -3A4 were significantly lower (P = .022) in group III and the activity of CYP-1A2 higher (P < .05) compared with group II. At postoperative days 8 and 10, the activities of all CYP isoenzymes were significant higher in AG-treated rats (group III) in contrast with group II after allogeneic OLT without immunosuppression. Histopathologic findings revealed less distinct rejection signs in group III specimens after AG treatment compared with group II.
Summarizing our results, we concluded that AG treatment led to increased CYP activity and less distinction of graft rejection after OLT in rats.
Nitric Oxide Inhibition and Consecutive Aspisol Application Show a Prolonged Survival of Orthotopic Transplanted Livers in a Rat Model
2008, Transplantation Proceedings
It is generally accepted that nitric oxide (NO) plays a crucial role in acute rejection caused by inflammatory responses. Therefore, the purpose of this study was to investigate the effect on survival following arterialized orthotopic rat liver transplantations (o-RLTx) of NO inhibition and consequent blockade of platelet aggregation by application of Aspisol.
Inbred LEWIS-(RT¹) rats underwent arterialized o-RLTx under ether anesthesia with DA-(RT1av1) rats as organ donors. After liver transplantation, serum parameters were determined and hepatic biopsy specimens were sampled on postoperative days 5, 8, 10, 30, and 90. Sixty-one rats were divided into 5 groups: syngenic controls (group I, n = 12); allogenic controls (group II, n = 11); allogenic with FK506 immunosuppression (group III, n = 12); allogenic with AGH-treatment (group IV, n = 13); and allogenic with AGH/low- dose Aspisol treatment for 5 days after liver transplantation (group V, n = 13) (Bayer, Leverkusen, Germany).
Rats of group V with AGH/low-dose Aspisol treatment showed significantly longer graft survival (18.2 days +/− 1.8 days) compared with group II rats with untreated grafts (11.3 days +/− 1.7 days) the allogenic group IV with AGH treatment (11.2 days +/− 1.8 days; P < .05). Histological examination revealed moderate graft rejection among the AGH-treated group IV; however, marked platelet aggregation in sinusoids was present, which was not observed in the AGH/low-dose Aspisol-treated animals (group V).
Our data suggested that simultaneous treatment with AGH/low-dose Aspisol leads to a significant increase in survival and inhibition of platelet aggregation in the graft after orthotopic liver transplantation.

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^⁎: The first two authors contributed equally to this publication.

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Original communicationCytochrome P450 activity mirrors nitric oxide levels in postoperative sepsis: Predictive indicators of lethal outcome

Background

Methods

Results

Conclusions

Section snippets

Clinical profile and study design

Clinical profile of patients

Increased NO levels during postoperative sepsis

Role of NO in sepsis and septic shock

Conclusion

J Biol Chem

Chest

Am J Surg

Surgery

Gastroenterology

J Surg Res

Biochem Biophys Res Commun

J Hepatol

Relationship between the enzymes of detoxication and host defense mechanism

Serum levels of end products of nitric oxide synthesis correlate positively with tumor necrosis factor alpha and negatively with body temperature in patients with postoperative abdominal sepsis

Shock

Stimulation of the nitric oxide synthase pathway in human hepatocytes by cytokines and endotoxin

J Exp Med

Inhibition of cytochromes P4501A by nitric oxide

Proc Natl Acad Sci U S A

Inhibition of nitric oxide synthesis improves detoxication in inflammatory liver dysfunction in vivo

Am J Physiol

Cytochrome P450 mediated-drug metabolism is reduced in children with sepsis-induced multiple organ failure

Intensive Care Med

Pharmacokinetics and pharmacodynamics of vecuronium in rats with systemic inflammatory response syndrome: treatment with NG-monomethyl-L-arginine

Anesthesiology

Systemic neuropeptide levels as predictive indicators for lethal outcome in patients with postoperative sepsis

Crit Care Med

Differential regulation of systemic IL-18 and IL-12 release during postoperative sepsis: high serum IL-18 as an early predictive indicator of lethal outcome

Shock

Acute liver allograft rejection and liver function: quantitative evaluation using the [14C] aminopyrine breath test

Transplant Proc

Original communication
Cytochrome P450 activity mirrors nitric oxide levels in postoperative sepsis: Predictive indicators of lethal outcome