The term hepatic encephalopathy (HE) refers to a number of potentially reversible neurological deficits resulting from liver dysfunction [11]. Chronic HE, as seen in alcohol-induced liver cirrhosis, is characterised by personality changes, altered mood and diminished intellectual ability.Acute HE occurs following acute liver failure, resulting from for example viral hepatitis and paracetamol intoxication, is associated with neurological deficits ranging from impairment of fine motor skill to muscle spasticity [uncoordinated movements (ataxia)], and finally impaired consciousness and coma. In most patients with acute liver failure, cerebral oedema ensues and is the predominate cause of death (80-90% mortality rate). The only effective treatment presently available for the cerebral oedema in ALF is an emergency liver transplantation. Ammonium (NH 4 + and ammonia (NH 3 ) are considered the primary toxins responsible for the functional deficits observed in HE, the treatment of which is based primarily on reducing blood and brain NH 4 + /NH 3 concentrations. The arterial concentration of NH 4 + /NH 3 in HE patients and HE animal models is increased, and predicts the severity of the symptoms [1]. In the portocaval anastomosis animal model of chronic HE, a surgically placed shunt allows blood from the intestine to bypass the liver (unfiltered) and enter the main circulatory system, increasing arterial NH 4 + /NH 3 concentrations. Under physiological conditions, NH 4 + /NH 3 concentrations in arterial blood are 50-100 µmol/l; this level doubles in chronic HE, while in the central nervous system it rises three-to four-fold. In contrast, at the coma stage of acute HE the NH 4 + / NH 3 concentrations in the CNS of animal models reach 1-5 mM [1].
Ammonium's central role
Astrocytes and HERecent evidence suggests that astrocytes are an important cellular site of action for NH 4 + /NH 3 in the pathology of HE (see [1,3]). In particular, astrocytic swelling observed in animal models following exposure to NH 4 + /NH 3 likely contributes to the brain oedema, a frequent cause of mortality in acute HE. In addition, neuronal loss is rarely observed in the mature brain following NH 4 + /NH 3 exposure [1], and the neuropsychiatric symptoms characteristic of acute or chronic HE are reversible following recovery of hepatic function [11].The greater sensitivity of astrocytes to NH 4 + /NH 3 compared with neurones likely reflects the mechanism of NH 4 + cellular influx (see below) and/or astrocyte specific pathway(s) particularly sensitive to NH 4 + /NH 3 . In regard to the latter, astrocytes are the cellular site for NH 4 + detoxification in the CNS. Ammonium is detoxified in the CNS by the enzyme glutamine synthetase, which is located almost exclusively in astrocytes. In this process, the conversion of glutamate to glutamine incorporates ammonium, glutamine is converted back into glutamate after neuronal uptake (glutamate-glutamine shuttle; see Box. 1). Furthermore, increases in cellular glutamine concentrations are a consistent hallm...