Significance of mycophenolate monitoring in liver transplant recipients: toward the cut-off level.

Mycophenolate mofetil blocks the "de novo" -purine synthesis to reduce the incidence and severity of acute rejection episodes. There has been an increased interest in utility of monitoring mycophenolic acid (MPA) levels, however currently the MPA monitoring is not part of the protocol following liver transplantation. We assessed whether trough MPA monitoring could be advisable in liver transplant patients or not. For this reason MPA levels of 56 liver transplants were measured on 3, 5, 10, 14, 21, 30, 60, and 180 posttransplant days. The optimal cut-off of MPA level (≥1.73 mg/L) for all (56) and ≥1.34 mg/L for ciclosporin-treated- and ≥1.98 mg/L for the tacrolimus-treated transplants were calculated by statistical analysis to reduce the incidence of acute rejection. MPA concentrations of 3 days period before the day of clinical diagnosis acute rejection were well below the cut-off value. Only 3 (16%) out 19 patients with acute rejection had higher MPA levels than the cut-off value on the day of diagnosis of acute rejection. In conclusion, our data suggests that MPA predose level monitoring, especially in the early "filling phase" after transplantation, is applicable in liver allograft recipients given adjunctive MMF, protecting them from the ineffective immunosuppression.

Small difference in international normalized ratio may yield a significant impact on prioritizing patients listed for liver transplantation.

Priority for liver transplantation is currently based on the Model for End-stage Liver Disease (MELD) score. The aim of our study was to assess in detail the contribution of international normalized ratio (INR) differences for MELD scores because of interlaboratory variability. The samples from 92 cirrhotic patients were measured on different systems combining three coagulometers and three thromboplastin products to determine variations in INR and MELD score. The INR differences among the first four systems varied between 0 and 0.2, resulting in MELD differences of 0 to 2. The MELD scores of 92 patients changed only among 10 possible integers so that normally 2 to 10 patients shared the same MELD value. In some cases, one MELD score difference resulted in a 10 superpositioning on the waiting list. Including one more system (mechanical vs optical) into our investigations achieved a five MELD difference. Supposing an extreme situation where one patient competes with his or her lowest, all the other with their highest possible score (and visa versa), the difference may be even 20 positions, overturning the complete waiting list. In conclusion substantial interlaboratory differences in MELD score have profound clinical consequences.

Some aspects of interindividual variations in the metabolism of xenobiotics.

Differences in drug metabolism among individuals are caused by numerous factors: differences in production and stability of mRNA of xenobiotic metabolizing enzymes, differences in the rate of enzyme synthesis and degradation, or enzyme inhibition. One of the most important reasons is genetic polymorphism of cytochrome P450 genes or cytochrome P450 regulatory factors. Nuclear receptors play great role in the regulation of these genes. The presence of the ligand induces the nuclear receptor to bind to the dimerisation partner and as a hetero/homodimer it can activate the DNA responsive element. In addition, several co-activators, co-repressors and other factors can modulate the effect of nuclear receptors. Hepatic levels of cytochrome P450 enzymes are reduced in multiple models of inflammation or infection. Cytochrome P450 enzymes of four families (CYP1-CYP4) are known to be involved in xenobiotic metabolism. Their genetic polymorphism and regulation are discussed in this review.

The effect of dexamethasone on P450 activities in regenerating rat liver.

The aim of our study was to detect four P450s (CYP1A, CYP2B, CYP2E1, CYP3A) on the basis of selective enzyme activities and protein amount, and to investigate the effect of dexamethasone treatment during liver regeneration. Partial hepatectomy of rats resulted in the loss of CYP1A, CYP2B, CYP2E1, and CYP3A activities. The reduction of enzyme activities and the loss of enzyme protein of CYP2B1/2, CYP2E1, and CYP3A1/2 were the most pronounced. In the case of CYP1A1, only slight decrease was observed. Dexamethasone treatment seems to counteract this loss mainly in the first 12 h.

[About paracetamol again]. / Ismét a paracetamolról.

The mechanism of hepatotoxicity caused by paracetamol (acetaminophen) overdose and the treatment of patients is reviewed. Paracetamol is widely used over-the-counter drug with analgesic and antipyretic properties. Although it is considered to be safe at therapeutic doses, the incidence of hepatotoxicity caused by overdose or inadvertent application has been increasing lately. N-acetyl-p-benzoquinonimine, one of the metabolites formed from paracetamol is responsible for the hepatotoxicity. Until now there is no complete therapeutic strategy for the effective treatment of hepatotoxicity caused by paracetamol. Gut decontamination, N-acetylcysteine antidote administration and enhancement of elimination is used for the management of paracetamol overdose. Those with severe hepatotoxicity and neurological symptoms can benefit from removal of necrotic liver and undergo transplantation.

Glucuronidation of thyroxine in primary monolayer cultures of rat hepatocytes: in vitro induction of UDP-glucuronosyltranferases by methylcholanthrene, clofibrate, and dexamethasone alone and in combination.

Induction of UDP-glucuronosyltransferases (UGTs) toward thyroxine (T4) and p-nitrophenol (pNP) by 3-methylcholanthrene (MC), dexamethasone (DEX), clofibrate (Cl), and MC combined with DEX or Cl was studied in rat hepatocyte culture. We have developed a sensitive method for the measurement of glucuronide conjugates of the two substrates based on HPLC analysis of culture medium. MC, Cl, or DEX increased the activity of T4 UGT. Combination of MC and Cl showed additive effect, enzyme activity was enhanced compared with either MC or Cl treatment alone (617, 441, and 217% of the control, respectively). Combination of MC and DEX did not result in higher T4 UGT activity than MC treatment alone. Both MC and DEX enhanced the pNP UGT activity (182 and 162% of the control, respectively). Combination of MC with DEX resulted in additive effect. Cl treatment did not affect pNP conjugation either alone or in combination with MC. Western blot analysis revealed that only the amount of UGT1A1 was elevated by Cl and DEX. In contrast, concentration of UGT1A6 was increased by MC. Previous studies demonstrated that UGT1A1 inducers like phenobarbital have no effect on T4 conjugation (). Our results suggest that Cl, a known inducer of UGT1A1, enhances the activity of other enzyme(s) involved in T4 glucuronidation as well. It is well documented that DEX potentiates the inductory effect of polycyclic aromatic hydrocarbon on UGT1A6 (). In our study, MC increased the rate of T4 glucuronidation, and DEX had no additional effect on this reaction, suggesting that UGT1A6 is not the only enzyme inducible by MC that can catalyze T4 conjugation.

The in vitro biosynthesis and stability measurement with agyl-glycuronide isoformes of the main metabolite of ipriflavone.

The formation and stability of 1-beta-glucuronide conjugate of the main metabolite of ipriflavone [7-(1-carboxy-ethoxy)-isoflavone] (CI)--were studied by using liver microsomes, hepatocytes, and isolated perfused liver of untreated and 3-methylcholanthrene (MC) treated dog and rat, and human liver microsomes. MC treatment enhanced the rate of conjugation twice as much as that of the control in the microsomes of both dogs and rats. Conjugation of CI by microsomes results in two metabolites, both sensitive to pH and temperature. Other two glucuronide forms appeared in experiments with hepatocytes and perfused liver. Mass spectrometry supported. The conclusion, assumption that both metabolites produced by microsomes are glucuronide conjugate isoforms of CI, and that they could be distinguished according to the intensity of peaks on FAB-MIKE spectra. The beta-glucuronidase enzyme hydrolysed only the 1-beta-glucuronide isomer, the other, migrated form remained unchanged. D-saccharic-acid-1,4-lactone, a specific inhibitor of beta-glucuronidase enzyme, decreased the rate of enzymatic cleavage. Standard curves of CI were prepared by HPLC, and 1-beta-CI-glucuronide was quantified according to the amount of CI formed by hydrolysis. The stability of conjugates greatly depends on pH and temperature, and the rate of degradation and isomerization is sensitive to the value of both. Lowering the pH from 7.4 to 5.0 and the temperature from 37 degrees C to 18 degrees C increased the stability of glucuronides. Increasing the pH to 12.0 results in very rapid acyl migration and hydrolysis.

[Human drug metabolizing enzymes. I. Oxidative enzymes]. / Human gyógyszermetabolizáló enzimek. I. Oxidációs enzimek.

In this review we focus on human oxidative enzymes that are responsible for the metabolism of xenobiotics. More and more publications prove that the reactions catalysed by these enzymes very often lead to activated molecules that may attack macromolecules (proteins, RNAs, DNAs), resulting in toxicity (liver, neuro-, embryotoxicity, allergy, carcinogenecity). We have summarised the data available on these enzymes, concerning their catalytic profile and specificity, inhibition, induction properties, their possible role in the generation of toxic compounds, their importance in clinical practice and drug development.

Ipriflavone as an inhibitor of human cytochrome P450 enzymes.

1. Reduction of theophylline metabolism and elimination were observed in a theophylline-treated patient during ipriflavone administration. After withdrawal of ipriflavone, the serum theophylline level decreased to an extent similar to that found before administration of ipriflavone. The effects of ipriflavone and its major metabolites 7-hydroxy-isoflavone and 7-(1-carboxy-ethoxy)-isoflavone on cytochrome P450 activities were studied in vitro in human liver microsomes from three donors. 2. Ipriflavone and 7-hydroxy-isoflavone competitively inhibited phenacetin O-deethylase and tolbutamide hydroxylase activity. The parent compound and its dealkylated metabolite were strong inhibitors exhibiting Ki values around 10-20 microM, while 7-(1-carboxy-ethoxy)-isoflavone had no effect on the cytochrome P450 activities investigated. 7-Hydroxy-isoflavone is the only one that influenced nifedipine oxidase activity. It competitively inhibited this activity with a Ki value of 129.5 microM. 3. The steady state concentrations of ipriflavone and 7-hydroxy-isoflavone in plasma of patients receiving 3 x 200 mg daily doses of ipriflavone for 48 weeks were found to be 0.33 +/- 0.32 microM and 1.44 +/- 0.77 microM, respectively. 4. The results indicate that the decrease in theophylline metabolism observed in a patient treated with ipriflavone may be due to a competitive interaction of ipriflavone or its metabolite, 7-hydroxy-isoflavone with CYP1A2. On the other hand, our in vitro findings predict some more interaction with CYP2C9.

Human liver cytochrome P-450 and conjugating enzymes. Hungarian data.

Cytochrome P-450 and the conjugating enzymes of the liver are the most important enzymes in the detoxification of xenobiotics. In order to get direct data in the Hungarian human population the activity of liver cytochrome P-450 enzymes (CYP1A2, 2A6, 2C19, 2D6, E1, 3A4) and of the conjugating enzymes has been determined in 11 Hungarian tissue donors died in accidents or in brain vascular catastrophe, by using specific enzymic reactions. In the activity of cytochrome P-450 enzymes a wide range has been found, a ten-fold difference being rather common. In the activities of conjugating enzymes the differences seem to be less.

Species differences in metabolism of panomifene, an analogue of tamoxifen.

In vitro metabolism of panomifene (E-1,2-diphenyl-1--4-(2-(2-hydroxyethyl-amino)-ethoxy)-phenyl--3,3,3- trifluoropropene), a novel antiestrogen against hormone dependent tumors, has been investigated using liver microsomes from mouse, rat, dog, and human. Hydroxylation and side chain modifications were the routes of panomifene metabolism. Microsomal biotransformation showed some qualitative similarities, but several differences were observed in the metabolic profiles of the four species tested. Seven metabolites were detected in the incubation mixtures analyzed by thin layer chromatography and autoradiography, although there was only one produced by all species that had lost the side chain. Among the side chain shortened metabolites, the compound that had lost the hydroxyethyl-amino group was formed by the microsomal system of rodents, whereas the one that had lost the hydroxyethyl group was detected in the incubation mixtures with rat, dog, and human microsomes. Three metabolites (M1, M3, and M4) were produced exclusively by the dog. The structure of M3 was identified by mass spectroscopy as 4-hydroxy-panomifene. Furthermore, human liver microsomes formed a metabolite (M8) that was not detectable in the mixtures with mouse, rat, or dog microsomes. Its structure is suspected to be an oxidized form of panomifene with a double bound in the side chain. The structure of panomifene is analogous to tamoxifen, an antiestrogen currently used as a therapeutic agent against breast cancer, and there are some similar routes in their metabolism. The main difference is that the rate of tamoxifen biotransformation seems faster than that of panomifene. On the other hand, 4-hydroxy-panomifene is produced by only dog, while 4-hydroxylated derivative is one of the main metabolites of tamoxifen that has potent antiestrogenic activity and is considered to be responsible for the formation of DNA-adducts.

The effect of ipriflavone and its main metabolites on theophylline biotransformation.

The effect of ipriflavone and its major metabolites, 7-hydroxy-isoflavone and 7-(1-carboxy-ethoxy)-isoflavone on theophylline metabolism was examined in vitro in human liver microsomes. The compounds inhibited the N-demethylation to 1- or 3-methylxanthine, the major pathway of theophylline metabolism. The effect showed concentration dependence. The oxidation of theophylline to 1,3-dimethyluric acid was slightly affected by ipriflavone and its metabolites and the effect was non-specific. Results indicate that the reduction of theophylline clearance by concomitant ipriflavone administration observed by Takahashi et al. [Takahashi J., Kawakatsu K., Wakayama T., Sawaoka H. (1992): Elevation of serum theophylline levels by ipriflavone in a patient with chronic obstructive pulmonary disease. Eur. J. Clin. Pharmacol., 43, 207-208] is primarily due to an interaction of the inhibitory ipriflavone and/or its metabolites with cytochrome P450 enzyme(s) that mediate N-demethylation of theophylline.

Xenobiotic metabolizing enzymes in fish: diversity, regulation and biomarkers for pollutant exposure.

Cytochromes P450 play key roles in biotransformation of pollutant chemicals and in the activation or inactivation of many toxic or carcinogenic compounds. Multiple P450 isozymes have been purified from different fish species. Fish monooxygenase activity shows temperature compensation and sex-related variation. Several xenobiotics can induce cytochrome P450 monooxygenases altering toxicity of chemical contaminants. Polycyclic aromatic hydrocarbons can increase transcription of CYP1A gene in fish as it has been observed in mammals, but phenobarbital-type agents do not induce in fish at all. The presence of conjugation enzymes in fish has also been proved, although their induction by xenobiotics is poorly investigated. Since exposure of fish to environmental contaminants can result in the induction of specific cytochrome P450 enzymes, monitoring of their catalytic activities can identify polluted areas.

[Role of human cytochrome P-450 enzymes in the metabolism of xenobiotics]. / Humán citokróm P450 enzimek szerepe a xenobiotikumok metabolizmusában.

Cytochrome P450 enzymes play essential role in metabolism of exogenous compounds. They are found mainly in endoplasmic reticulum of hepatocytes. Purification of different P450 isoforms and determination of their structures and catalytic activities allowed to investigate their participation in metabolism of xenobiotics. Numerous factors cause variations in the expression of these P450: the effect of genetic and environmental factors results in the production of series of enzymes catalyzing biotransformation of xenobiotics. Several genetic polymorphisms have been described: CYP2D6, CYP2C and 'Ah locus' polymorphism. Some P450 (CYP1A, CYP3A, CYP2E1) are inducible by xenobiotics. Additionally, P450 expression and inducibility vary depending on tissues. It is now possible to determine which isoform(s) is (are) responsible for the production of a metabolite and to predict the fate of a compound in vivo.

Interaction of theophylline and ipriflavone at the cytochrome P450 level.

The effect of ipriflavone administered at a dose of 25 mg/kg and 100 mg/kg and coadministered with theophylline was investigated in selective assays of particular P450 isoenzyme activities. Significant changes could be detected in the activities of CYP2E1 and CYP3A in liver microsomes from male Wistar rats treated with ipriflavone. Induction of CYP2E1 was shown by aniline or p-nitro-phenol hydroxylation as a result of ipriflavone treatment. Aniline hydroxylation activity of CYP2E1 was induced by theophylline + ipriflavone (100 mg/kg) coadministration as well. It should be noted that theophylline does not cause alteration in CYP2E1 activity. On the other hand, ipriflavone inhibited ethylmorphine and aminopyrine N-demethylation activities catalysed by CYP3A. An additional effect in the inhibition of aminopyrine N-demethylation could be observed in microsomes from theophylline + ipriflavone treated groups. Our results suggest that the decrease in theophylline metabolism increasing level of serum theophylline of theophylline-treated patient during ipriflavone administration [Takahashi J. et al. (1992): Eur. J. Clin. Pharmacol., 43, 207-208] may be related to CYP3A inhibition by ipriflavone.

The effect of phenobarbital and dexamethasone coadministration on the activity of rat liver P450 system.

Phenobarbital, the potent inducer of CYP2B and CYP3A, and dexamethasone, that induces CYP3A, are not able to elevate p-nitrophenol hydroxylase activity of CYP2E1. However, rats treated with phenobarbital and dexamethasone in combination showed threefold increase in p-nitrophenol hydroxylation and the activity correlates with an elevated amount of a 53.000 dalton protein. Biosynthesis of mRNA and P450 protein is required for the induction. 3-amino-1,2,4-triazole and anti CYP2E1 IgG inhibition studies show that CYP2E1 is not responsible for enhanced p-nitrophenol hydroxylation, but the residual activity indicates the participation of other isozyme(s). As a result of double induction, changes in the amount of CYP2E1 of microsomes were not detected by Western blot analysis compared to untreated rat liver microsomes.

Combined action of phenobarbital and dexamethasone on the activity of rat liver P450 system.

Phenobarbital and dexamethasone are potent inducers of the same cytochrome P450 form, CYP3A1, but the mechanism of action is not quite clear. If the mechanism of induction by phenobarbital and dexamethasone is different, additive effect may be observed in the specific activities of CYP3A1: ethylmorphine or aminopyrine N-demethylation of liver microsomes from rats treated with phenobarbital and dexamethasone in combination. The results of recent work could not display differences in CYP3A1 activities between the groups of animals single-administered and coadministered with phenobarbital and dexamethasone. However, p-nitrophenol hydroxylation surprisingly increased threefold as a result of double induction. 3-amino-1,2,4-triazole inhibition study shows that CYP2E1 is responsible for 60% of enhanced p-nitrophenol hydroxylase activity, but the residual 40% indicates the participation of other isoenzyme(s).

[Cytochrome P-450: structure, function, induction and practical significance]. / Citokróm P-450 enzimek: szerkezet, aktivitás, indukció és gyakorlati jelentöségek.

The liver contains a series of microsomal hemoproteins, called cytochromes P-450 which are mixed-function oxygenases involved in the metabolic oxygenation of diverse xenobiotic chemicals (drugs, pesticides, etc.). This enzyme system converts lipophilic foreign compounds into more water soluble products, thereby facilitating their elimination from the body. In general, cytochrome P-450-catalyzed oxidation results in detoxification, however the cytochromes P-450 can also convert certain xenobiotics to more toxic or carcinogenic products. Many of the individual isoenzyme forms of cytochrome P-450 are inducible by a wide variety of chemicals. After induction the concentration of total cytochrome P-450 in liver microsomes and the activity of different cytochrome P-450 forms increase. Elevated levels of cytochrome P-450 are the result of multiple mechanisms. Increased transcription of P-450 genes is a major mechanism of cytochrome P-450 induction. Higher levels of specific mRNAs are detectable soon after treatment with either "phenobarbital-like" or polycyclic aromatic compounds. Although increased transcription plays some role in the induction of cytochromes P-450 by other inducers like pregnenolone-16 alpha-carbonitrile (PCN)/glucocorticoids and "ethanol-type" compounds, post-transcriptional events are also very important. Cytochrome P-450 induction can be achieved by message stabilization and enhanced transport of mRNA from the nucleus to the cytoplasm that also increase the specific mRNA levels at the site of protein synthesis. Elevated cytochrome P-450 levels may also result from protein stabilization. Stabilization of cytochrome P-450 protein and/or mRNA are the main processes of induction by PCN/glucocorticoids and ethanol-type inducers. Although these mechanisms exist, they do not seem to be important in the induction by "phenobarbital-like" and "3-methylcholanthrene-like" inducers. The fact that induction is produced by a large variety of xenobiotics and is mediated by multiple mechanisms suggests that cytochrome P-450 system can provide increased protection for organisms in potentially hostile chemical environment. Since cytochrome P-450 induction is a characteristic response to chemicals for various living organisms ranging from microorganisms to man, it seems to be an adaptive mechanism for organisms to increase the chance for survival.