Liver ammonia metabolism

While ammonia, derived mainly from the a-amino nitrogen of amino acids, is highly toxic, tissues convert ammonia to the amide nitrogen of nontoxic glutamine. Subsequent deamination of glutamine in the liver releases ammonia, which is then converted to nontoxic urea. If liver function is compromised, as in cirrhosis or hepatitis, elevated blood ammonia levels generate clinical signs and symptoms. Rare metabolic disorders involve each of the five urea cycle enzymes. 

Pharmacokinetics Methenamine is orally administered. In addition to formaldehyde, ammonium ion is produced in the bladder. Because the liver rapidly metabolizes ammonia to form urea, methenamine is contraindicated in patients with hepatic insufficiency, in which elevated levels of circulating ammonium ions would be toxic to the CNS. Methenamine is distributed throughout the body fluids, but no decomposition of the drug occurs at pH 7.4 thus, systemic toxicity does not occur. The drug is eliminated in the urine. 

The absolute level of ammonia and its metabolites, such as glutamine, in the blood or cerebrospinal fluid in patients with hepatic encephalopathy correlates only roughly with the presence or severity of the neurologic signs and symptoms. y-Aminobutyric acid (GABA), an important inhibitory neurotransmitter in the brain, is also produced in the gut lumen and is shunted into the systemic circulation in increased amounts in patients with hepatic failure. In addition, other compounds (such as aromatic amino acids, false neurotransmitters, and certain short-chain fatty acids) bypass liver metabolism and accumulate in the systemic circulation, adversely affecting central nervous system function. Their relative importance in the pathogenesis of hepatic encephalopathy remains to be determined. 

A compound formed by the combination of ammonium with glutamate. Most glutamine is metabolized by the liver to form glutamate and the ammonium nitrogen is converted to urea. In severe liver disease, ammonia is not removed and this leads to increased glutamine synthesis by the brain. Thus increased blood glutamine levels are often found in liver disease. 

Ammonia (NH3) is just one of the toxins implicated in HE. It is a metabolic by-product of protein catabolism and is also generated by bacteria in the GI tract. In a normally functioning liver, hepatocytes take up ammonia and degrade it to form urea, which is then renally excreted. In patients with cirrhosis, the conversion of ammonia to urea is retarded and ammonia accumulates, resulting in encephalopathy. This decrease in urea formation is manifest on laboratory assessment as decreased blood urea nitrogen (BUN), but BUN levels do not correlate with degree of HE. Patients with HE commonly have elevated serum ammonia concentrations, but the levels do not correlate well with the degree of central nervous system impairment.20... 

Ammonia concentrations in arterial blood of patients with liver failure rise to 0.5-1 mmol/1, in contrast to the normal range of 0.01-0.02 mmol/1. Using positron emission tomography (PET see Ch. 58), increases of the cerebral metabolic rate for ammonia (CMRA), i.e. the rate at which ammonia is taken up and metabolized by the brain, have been reported in chronic liver failure [9]. Increased CMRA in chronic liver failure is accompanied... 

FIGURE 34-3 Positron emission tomography using 13NH3 showing increased brain ammonia uptake in a patient with liver cirrhosis and mild hepatic encephalopathy. CMRA, cerebral metabolic ratio for ammonia HE, hepatic encephalopathy PS, permeability/surface area product. (With permission from reference [9].)... 

Lockwood, A. H., Yap, E. W. H. and Wong, W. H. Cerebral ammonia metabolism in patients with severe liver disease and minimal hepatic encephalopathy. /. Cereb. Blood Flow Metab. 11 337-341,1991. 

The physiological relevance together with chnical importance of transamination and deamination is wide-ranging. As an aid to understanding the somewhat complex nature of amino acid metabolism, it can be considered (or imagined) as a metabolic box (represented in Figure 8.13). Some pathways feed oxoacids into the box whereas others remove oxoacids and the ammonia that is released is removed to form urea. The box illustrates the role of transdeamination as central to a considerable amount of the overall metabolism in the liver cell (i.e. protein, carbohydrate and fat metabohsm, see below). 

Figure 8.29 The initial reactions of glutamine metabolism in kidney, intestine and cells of the immune system. The initial reaction in all these tissues is the same, glutamine conversion to glutamate catalysed by glutaminase the next reactions are different depending on the function of the tissue or organ. In the kidney, glutamate dehydrogenase produces ammonia to buffer protons. In the intestine, the transamination produces alanine for release and then uptake and formation of glucose in the liver. In the immune cells, transamination produces aspartate which is essential for synthesis of pyrimidine nucleotides required for DNA synthesis otherwise it is released into the blood to be removed by the enterocytes in the small intestine or by cells in the liver.

Figure 8.30 Different roles of periportal and perivenous cells in the liver in respect of glutamine metabolism. Glutamine is converted to glucose in periportal cells via gluconeogenesis in perivenous cells, ammonia is taken up, to form glutamine, which is released into the blood. This emphasises the importance of the liver in removing ammonia from the blood, i.e. if possesses two process to ensure that all the ammonia is removed.

VPA is metabolized in the liver and may cause mild, transient elevations in serum transaminases and lactate dehydrogenase. These elevations usually appear early in therapy, are dose-dependent, and resolve spontaneously. Laboratory abnormalities may be noted in 20% to 40% of patients and do not predispose to the development of more serious hepatic injury. VPA can also interfere with the conversion of ammonia to urea and result in hyperammonemia in approximately 20% of patients. This is usually asymptomatic but infrequently may cause lethargy (77, 350). 

Urea is a colorless, odorless crystalline substance discovered by Hilaire Marin Rouelle (1718—1779) in 1773, who obtained urea by boiling urine. Urea is an important biochemical compound and also has numerous industrial applications. It is the primary nitrogen product of protein (nitrogen) metabolism in humans and other mammals. The breakdown of amino acids results in ammonia, NH3, which is extremely toxic to mammals. To remove ammonia from the body, ammonia is converted to urea in the liver in a process called the urea cycle. The urea in the blood moves to the kidney where it is concentrated and excreted with urine. 

In man, BH4 is degraded either nonenzymatically by side-chain cleavage to pterin or is enzymatically metabolized in the gastrointestinal tract to become a lumazine [2]. Pterin and dihydropterin are converted by xanthine dehydrogenase to isoxanthopterin and xanthopterin, respectively [3,4]. It is assumed, however, that most of the ingested BH4 is used as a cofactor (mainly for PAH in the liver) and is catabolized to nonfluorescing compounds it may even be degraded to C02 and ammonia. 

Figure 18-2a provides an overview of the catabolic pathways of ammonia and amino groups in vertebrates. Amino acids derived from dietary protein are the source of most amino groups. Most amino acids are metabolized in the liver. Some of the ammonia generated in this... 

In contrast to transamination reactions that transfer amino groups, oxidative deamination by gutamate dehydrogenase results in the lib eration of the amino group as free ammonia (Figure 19.11). These reactions occur primarily in the liver and kidney. They provide a-ketoacids that can enter the central pathway of energy metabolism, and ammonia, which is a source of nitrogen in urea synthesis. 

Ammonia is produced by all tissues during the metabolism of a variety of compounds, and it is disposed of primarily by formation of urea in he liver. However, the level of ammonia in the blood must be kept very fcw, because even slightly elevated concentrations (hyperammonemia) ae toxic to the central nervous system (CNS). There must, therefore, be a metabolic mechanism by which nitrogen is moved from peripheral tissues to the liver for ultimate disposal as urea, while at the same hre low levels of circulating ammonia must be maintained. 

Mammals other than primates further oxidize urate by a liver enzyme, urate oxidase. The product, allantoin, is excreted. Humans and other primates, as well as birds, lack urate oxidase and hence excrete uric acid as the final product of purine catabolism. In many animals other than mammals, allantoin is metabolized further to other products that are excreted Allantoic acid (some teleost fish), urea (most fishes, amphibians, some mollusks), and ammonia (some marine invertebrates, crustaceans, etc.). This pathway of further purine breakdown is shown in figure 23.22. 

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