The potential of cytokines as safety biomarkers for drug-induced liver injury.

Drug-induced liver injury (DILI) is an event that has a detrimental impact on drug development and patient safety; therefore the identification of novel biomarkers that are both sensitive and specific to the liver would have great benefit. Inflammation is known to be associated with human cases of DILI, and given the role of cytokines in modulating the inflammatory response, changes in cytokine expression patterns certainly show promise as potential biomarkers of DILI. Cytokines are interesting candidates for novel biomarkers as they are relatively accessible (by blood sampling) and accurately quantifiable. In particular, recent interest has developed in mechanism-specific, rather than tissue-specific, biomarkers. However, without fully understanding the role of inflammation in DILI and the role of cytokines in modulating the inflammatory response, cytokines may be limited in their use, being either diagnostic of the type of injury that has occurred and/or prognostic of outcome (recovery from DILI, cirrhosis, acute liver failure). Intracellular components released by damaged hepatocytes, although inaccessible and currently difficult to quantify, may be better biomarkers for the prognosis of severity of injury. In both cases there is a pressing need for the development and validation of assays sensitive enough and with a sufficient dynamic range to detect changes upon drug treatment. Although promising candidates are appearing in the literature, much remains to be done to understand the role of inflammation in DILI and the role that a given cytokine has in the inflammatory cascade associated with DILI before cytokines are viewed as biomarkers for DILI.

Generation of T cell responses targeting the reactive metabolite of halothane in mice.

Immune-mediated adverse drug reactions (IADRs) represent a significant problem in clinical practice and drug development. Studies of the underlying mechanisms of IADRs have been hampered by the lack of animal models. Halothane causes severe allergic hepatitis with clinical features consistent with an IADR. Our ultimate goal is to develop a mouse model of halothane hepatitis. Evidence suggests that adaptive immune responses targeting liver protein adducts of the reactive metabolite (trifluoroacetyl (TFA)) play an important role in the pathogenesis. The present study demonstrated that the combination of an anti-CD40 antibody (Ab) and a Toll-like receptor (TLR) agonist served as a potent adjuvant in generating TFA-specific T cell responses in mice. Both CD4(+) and CD8(+) subsets of T cells were activated and the TFA-specific responses were detected not only in the spleen but also in the liver of mice immunized with mouse serum albumin adducts of TFA (TFA-MSA) plus the combined CD40/TLR agonist. Whereas all three TLR agonists examined were effective in eliciting TFA-specific immune responses in BALB/cByJ mice, only polyI:C was effective in DBA/1 mice and none of the TLR agonists could aid the generation of TFA-specific T cells in C57BL/6J mice. This result, combined with our previous finding that BALB/cByJ mice were the most susceptible to halothane-induced acute liver injury, provides the basis for employing this strain in future studies. Collectively, our data demonstrated the successful completion of a crucial first step in the development of a murine model of halothane hepatitis.

Hypersensitivity of laryngeal C-fibers induced by volatile anesthetics in young guinea pigs.

Inhalation induction of anesthesia with a single volatile anesthetic is commonly used in children but is sometimes associated with increased cough, secretion, and airway obstruction, which may result in part from stimulation of laryngeal C-fibers. We examined the effects of two popular volatile anesthetics, halothane and sevoflurane, on laryngeal C-fiber responsiveness in urethane-anesthetized guinea pigs (from age 4-5 weeks). After administration of halothane or sevoflurane to the functionally isolated upper airway, laryngeal C-fiber afferents recorded from the internal branch of the superior laryngeal nerve and identified by a conduction velocity of less than 2.0 m/second were tested for responsiveness to chemical and mechanical stimuli. Halothane doubled C-fiber responsiveness to capsaicin injected into the left atrium or nebulized to the larynx and to laryngeal hyperinflation, compared with sevoflurane, but it had no effect on baseline activity. The data indicate that, compared with sevoflurane, halothane more markedly enhances laryngeal C-fiber sensitivity to chemical and mechanical stimuli in young guinea pigs, which would explain the greater number of respiratory-related complications in children during induction of anesthesia with this agent.

Halothane effect on formalin-induced paw edema and flinching in rat.

The formalin test is a model of injury-produced inflammatory pain. Anesthetics, in clinically relevant concentrations, affect neutrophils and immune suppression. This study was to determine whether halothane reliably inhibits inflammatory reaction and formalin induced pain behavior or does not. Rats were exposed to 100% oxygen (control) or halothane, respectively for 30 min and then 24 hr later five percent formalin test was assessed. The base values of the paw's diameter were obtained earlier, and then formalin induced edema was assessed by measuring diameters of the injected paws at 5 min, 1 hr, 4 hr and 24 hr after the injection. Nociceptive behavior was quantified by counting the number of times with the paw flinched at 5 min intervals for 60 min. The diameters of edema in the halothane group lessened more than those in the oxygen group at 1 and 24 hr in each following of the injection (p<0.05). The rats pre-administered with oxygen or halothane were similar appearances in nociceptive behaviors. It suggests that halothane anesthesia might inhibit slightly the inflammatory reaction with the formalin-induced edema but might not inhibit the formalin-induced pain behavior in the event of pre-administration halothane 24 hr earlier before the formalin test of rat.

Halothane effect on formalin-induced paw edema and flinching in rat

The formalin test is a model of injury-produced inflammatory pain. Anesthetics, in clinically relevant concentrations, affect neutrophils and immune suppression. This study was to determine whether halothane reliably inhibits inflammatory reaction and formalin induced pain behavior or does not. Rats were exposed to 100% oxygen (control) or halothane, respectively for 30 min and then 24 hr later five percent formalin test was assessed. The base values of the paw's diameter were obtained earlier, and then formalin induced edema was assessed by measuring diameters of the injected paws at 5 min, 1 hr, 4 hr and 24 hr after the injection. Nociceptive behavior was quantified by counting the number of times with the paw flinched at 5 min intervals for 60 min. The diameters of edema in the halothane group lessened more than those in the oxygen group at 1 and 24 hr in each following of the injection (p<0.05). The rats pre-administered with oxygen or halothane were similar appearances in nociceptive behaviors. It suggests that halothane anesthesia might inhibit slightly the inflammatory reaction with the formalin-induced edema but might not inhibit the formalin-induced pain behavior in the event of pre-administration halothane 24 hr earlier before the formalin test of rat.

Halogenated anesthetics form liver adducts and antigens that cross-react with halothane-induced antibodies.

Two halogenated anesthetics, enflurane and isoflurane, have been associated with an allergic-type hepatic injury both alone and following previous exposure to halothane. Halothane hepatitis appears to involve an aberrant immune response. An antibody response to a protein-bound biotransformation product (trifluoroacetyl adduct) has been detected on halothane hepatitis patients. This study was performed to determine cross-reactivity between enflurane and isoflurane with the hypersensitivity induced by halothane. The subcellular and lobular production of hepatic neoantigens recognized by halothane-induced antibodies following enflurane and isoflurane, and the biochemical nature of these neoantigens was investigated in two animal models. Enflurane administration resulted in neoantigens detected in both the microsomal and cytosolic fraction of liver homogenates and in the centrilobular region of the liver. In the same liver, biochemical analysis detected fluorinated liver adducts that were up to 20-fold greater in guinea pigs than in rats. This supports and extends previous evidence for a mechanism by which enflurane and/or isoflurane could produce a hypersensitivity condition similar to that of halothane hepatitis either alone or subsequent to halothane administration. The guinea pig would appear to be a useful model for further investigations of the immunological response to these antigens.

Trifluoroacetylation potentiates the humoral immune response to halothane in the guinea pig.

Halothane hepatitis appears to result from an inappropriate immune response to the products of halothane metabolism. Attempts to produce an animal model for halothane hepatitis have been largely unsuccessful. Although guinea pigs produce neoantigens following treatment with halothane, the subsequent antibody response is weak, possibly accounting for the failure to produce halothane hepatitis in these animals. In order to increase the antibody response to halothane neoantigens, three methods for trifluoroacetylating proteins were used. Guinea pigs were either treated with S-ethylthiotrifluoroacetate, autologous lymphocytes trifluoroacetylated ex vivo, or immunized with trifluoroacetylated mycobacterial protein, followed by exposure to halothane, and examined for anti-halothane metabolite antibodies (anti-TFA antibodies). Animals treated with S-ethylthiotrifluoroacetate developed anti-TFA antibodies, and following exposure to halothane exhibited an enhanced antibody response. Treatment with trifluoroacetylated lymphocytes also resulted in an enhanced anti-TFA antibody response following halothane exposure. Immunization with trifluoroacetylated mycobacterial proteins resulted in very high anti-TFA antibody titers. However, subsequent exposure to halothane had no observable effect on specific antibody titers. Exposure to halothane, regardless of treatment, resulted in the production of anti-microsomal protein antibodies. Signs of halothane hepatitis were not observed, indicating that enhancement of the humoral immune response does not appear to be sufficient for production of halothane hepatitis.

Anesthesia-induced modulation of in vivo antibody levels: a study of pentobarbital, chloral hydrate, methoxyflurane, halothane, and ketamine/xylazine.

The influence of anesthesia on long-term changes in in vivo antibody levels after antigen challenge was examined. Rats experienced a surgical plane of various anesthetics alone (anesthesia/intact) or in combination with laparatomy (anesthesia/laparatomy) and were given 1 or 3 wk to recover. Antigen, keyhole limpet hemocyanin, was then administered, and antibody levels specific to the antigen were measured during the next 14 days. Comparisons were made between anesthesia-treated animals and home cage controls. Pentobarbital and chloral hydrate produced decreases in in vivo antibody levels even 3 wk after exposure, whereas halothane, methoxyflurane, and ketamine/xylazine did not. Ketamine/xylazine produced moderate but not significant decreases in antibody levels when 1 wk intervened between exposure and antigen administration, but not when 3 wk intervened. Surgery did not produce larger changes in antibody levels than did anesthesia itself. These data suggest the possibility that some anesthetics, per se, may contribute to infection that may occur postoperatively.

Metabolic activation of halothane to neoantigens in C57Bl/10 mice: immunochemical studies.

C57Bl/10 mice were given halothane (10 mmol/kg, intraperitoneally) and microsomal proteins were analysed for the presence of trifluoroacetylated (TFA) neoantigens by SDS-gel electrophoresis followed by immunoblotting using a polyclonal anti-TFA antibody. In microsomal preparations from liver, lung and olfactory tissues, a 54 kDa TFA adduct was detectable 1 h after dosing. After 3-48 h, multiple bands were detected in liver (45-100 kDa) and in the lung (26-57 kDa) and in one experiment in which [14C]halothane was given, several immunoreactive bands from liver microsomes were shown to contain a covalently bound metabolite of the drug. In olfactory tissue, initially (1 h), a major band of 54 kDa and a less prominent component of about 50 kDa were seen. The number of bands increased at later times but the additional bands were far fewer than in liver. The rate of decay of the 54 kDa adduct was also measured in both liver and olfactory microsomes and found to be compatible with the reported turnover of total liver cytochrome P-450. 24 h after treating mice with halothane (10 mmol/kg), no TFA neoantigens could be detected on the outer cell surface of isolated viable hepatocytes when analysed by fluorescence activated flow cytometry. In contrast, non-viable cells, or those fixed in acetone were all positive. Using immunohistochemistry, TFA neoantigens were demonstrated in the centrilobular area of the liver, the non-ciliated bronchiolar epithelial (Clara) cells of the lung, proximal tubular cells of the kidney and the respiratory and olfactory epithelium of nasal tissues.

Screening for antibodies associated with halothane hepatitis.

The diagnosis of halothane hepatitis (HH) may be assisted by detection of antibodies reacting to trifluoroacetylated proteins (anti-TFA antibodies). An enzyme-linked immunosorbent assay (ELISA) utilizing trifluoroacetylated rabbit serum albumin (TFA-RSA) as antigen detected anti-TFA antibodies in 67% of sera from patients for whom a clinical diagnosis of HH was made. Anti-TFA antibodies were detected in 33% of sera when using an ELISA with liver microsomal protein from halothane-treated rabbits as antigen. Absorption of the sera with untreated rabbit liver microsomal protein before using the microsomal protein ELISA resulted in detection of anti-TFA antibodies in 42% of sera. Using the presumptive hapten N-epsilon-trifluoroacetyl-1-lysine to block antibody binding in an ELISA resulted in positive detection in 50% of sera: the results did not always agree with the other ELISA methods. The TFA-RSA ELISA was the most sensitive method and, combined with the TFA-lysine blocking ELISA, resulted in 92% of sera from HH patients testing positive for HH-associated antibodies.

Immunological assays following exposure to halothane in clinical usage.

Venous blood samples were obtained from 30 patients undergoing surgical intervention, as well as 25 anaesthetists and operating-room personnel. Twenty non-exposed physicians served as a control group. Blood samples were subjected to total and differential leucocyte counts, T- and B-lymphocyte counts, serum immunoglobulin estimation, and in-vitro T-lymphocyte proliferative response to Con A-mitogen. In comparison with values from control subjects, halothane anaesthesia resulted in an increased number of T- and B-lymphocytes, whilst the serum immunoglobulins level and lymphoproliferative response were decreased. Three days after surgery, all the estimated parameters had returned to the pre-operative value. Chronic exposure to trace halothane concentrations resulted in decreased proliferative responses, lymphocytosis, and decreased immunoglobulins levels. It is concluded that halothane has different effects on the human immune system, depending on the particular conditions of the groups studied.

Detection of cysteine conjugate metabolite adduct formation with specific mitochondrial proteins using antibodies raised against halothane metabolite adducts.

Antibodies raised against halothane metabolite adducts cross-react with S-(1,1,2,2-tetrafluoroethyl)-L-cysteine (TFEC) and S-(2-chloro-1,1,2-trifluoroethyl)-L-cysteine metabolite adducts. Using these antibodies in immunohistochemical experiments, metabolite binding was localized to the damaged areas of the proximal tubule after treatment of male rats with TFEC. Immunoblot analysis of subcellular fractions of rat kidney tissue after in vivo treatment with TFEC revealed a high specificity for binding of metabolites to proteins of the mitochondrial fraction. These proteins may represent target molecules which play a role in cysteine conjugate induced nephrotoxicity.

Immunomodulating effects of halothane in mice.

Twenty mice were acutely exposed to 1.5% halothane anaesthesia for 4 h. The mice were sequentially killed during the first 3 days after halothane exposure. Another 14 mice were chronically exposed to 0.25% halothane for 1 h daily, four times weekly for 3 months. The mice were sequentially killed every week. Acute exposure to halothane anaesthesia resulted in an increase in lymphocyte count per spleen, a decrease in serum IgG concentrations (Day 2), a reduction in spontaneous 3H-thymidine lymphocytic uptake (Day 1), and an increase in concanavalin-A-stimulated uptake. All immunometric assays returned to control levels on Day 3 after halothane exposure. Chronic non-anaesthetic concentrations of halothane exposure produced a decrease in serum IgG concentrations and an increase in spontaneous and stimulated lymphocyte 3H-thymidine uptake. It is concluded that acute exposure of mice to anaesthetic halothane results in a transient depression of the immune response, while chronic non-anaesthetic concentrations produce a differential effect on the two moieties of the immune system, a depressed humoral response and overactive cellular response.

Generation and detection of neoantigens in guinea pig liver slices incubated with halothane.

The volatile anesthetic halothane can be biotransformed by the hepatic cytochrome P-450 system to produce a reactive intermediate, trifluoroacetyl chloride, capable of covalently binding to liver proteins. The product of this reaction, the trifluoroacetyl lysinyl moiety, can act as an epitope to alter protein antigenicity. An in vitro system has been developed to produce halothane induced neoantigens and to study conditions for formation in the liver. Liver slices, capable of halothane biotransformation, provide a viable means for mechanistic studies. Liver slices (1 cm diameter, 300 microns thick) from male Hartley guinea pigs (600-800 g) were exposed to either 1.0 or 1.7 mM halothane (media concentration) in 95% O2/5% CO2 for 12 h. Covalent binding was determined using 14C-halothane. Neoantigens were detected by Western immunoblot analysis using rabbit anti-trifluoroacetylated albumin antiserum. Covalent binding was detected by 1 h of incubation and increased linearly through 12 h (20.7-48.5 nmole equiv/mg protein). Covalent binding preceded and correlated with the appearance of neoantigens. By 12 h of incubation, five neoantigens were seen with molecular weights ranging from 51 to 97 kD. These neoantigens have molecular weights similar to those seen in vivo. Liver slices exposed to deuterated halothane, which is oxidatively metabolized to a lower extent, did not develop neoantigens. This in vitro model system can be used to examine the mechanism for covalent binding and neoantigen production in the hepatocyte.