Me o min Inhibi s Glu aminase Ac i i y and P o ec s
agains Hepa ic Encephalopa hy
Ja ie Ampue o
1
, Isido a Ranchal
1
, Da id Nun
˜ez
1
, Ma ı
´a del Ma Dı
´az-He e o
2
, Ma a Ma a e
1
, Jose
´
An onio del Campo
1
,A
´ngela Rojas
1
,Ine
´s Camacho
1
, Blanca Figue uela
1
, Juan D. Bau is a
2
,
Manuel Rome o-Go
´mez
1
*
1Uni o Clinical Managemen o Diges i e Diseases and CIBERehd, Hospi al Uni e si a io de Valme, Uni e si y o Se illa, Se illa, Spain, 2Depa men o Molecula
Biology, Uni e si y o Se illa, Se illa, Spain
Abs ac
Aim:
To in es iga e he in luence o me o min use on li e dys unc ion and hepa ic encephalopa hy in a e ospec i e
coho o diabe ic ci ho ic pa ien s. To analyze he impac o me o min on glu aminase ac i i y and ammonia p oduc ion
in i o.
Me hods:
Eigh y- wo ci ho ic pa ien s wi h ype 2 diabe es we e included. Fo y-one pa ien s we e classi ied as insulin
sensi ize s expe ienced (me o min) and 41 as con ols (ci ho ic pa ien s wi h ype 2 diabe es melli us wi hou me o min
ea men ). Baseline analysis included: insulin, glucose, glucagon, lep in, adiponec in, TNF 2, AST, ALT. HOMA-IR was
calcula ed. Baseline HE isk was calcula ed acco ding o minimal hepa ic encephalopa hy, o al glu amine challenge and
mu a ions in glu aminase gene. We pe o med an expe imen al s udy in i o including an enzyma ic ac i i y assay whe e
glu aminase inhibi ion was measu ed acco ding o di e en me o min concen a ions. In Caco2 cells, glu aminase ac i i y
inhibi ion was e alua ed by ammonia p oduc ion a 24, 48 and 72 hou s a e me o mina ea men .
Resul s:
Hepa ic encephalopa hy was diagnosed du ing ollow-up in 23.2% (19/82): 4.9% (2/41) in pa ien s ecei ing
me o min and 41.5% (17/41) in pa ien s wi hou me o min ea men (logRank 9.81; p = 0.002). In mul i a ia e analysis,
me o min use [H.R.11.4 (95% CI: 1.2–108.8); p = 0.034], age a diagnosis [H.R.1.12 (95% CI: 1.04–1.2); p = 0.002], emale sex
[H.R.10.4 (95% CI: 1.5–71.6); p = 0.017] and HE isk [H.R.21.3 (95% CI: 2.8–163.4); p = 0.003] we e ound independen ly
associa ed wi h hepa ic encephalopa hy. In he enzyma ic assay, glu aminase ac i i y inhibi ion eached 68% wi h
me o min 100 mM. In Caco2 cells, me o min (20 mM) dec eased glu aminase ac i i y up o 24% a 72 hou s pos -
ea men (p,0.05).
Conclusions:
Me o min was ound independen ly ela ed o o e hepa ic encephalopa hy in pa ien s wi h ype 2 diabe es
melli us and high isk o hepa ic encephalopa hy. Me o min inhibi s glu aminase ac i i y in i o. The e o e, me o min use
seems o be p o ec i e agains hepa ic encephalopa hy in diabe ic ci ho ic pa ien s.
Ci a ion: Ampue o J, Ranchal I, Nun
˜ez D, Dı
´az-He e o MdM, Ma a e M, e al. (2012) Me o min Inhibi s Glu aminase Ac i i y and P o ec s agains Hepa ic
Encephalopa hy. PLoS ONE 7(11): e49279. doi:10.1371/jou nal.pone.0049279
Edi o : Ca los M. Isales, Geo gia Heal h Sciences Uni e si y, Uni ed S a es o Ame ica
Recei ed July 25, 2012; Accep ed Oc obe 8, 2012; Published No embe 15, 2012
Copy igh : ß2012 Ampue o e al. This is an open-access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion License, which pe mi s
un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal au ho and sou ce a e c edi ed.
Funding: P oyec o de Excelencia (CTS-7991/2011). Conseje ı
´a de Economı
´a. Jun a de Andalucı
´a. Go e men o Andalusia, Spain. The unde s had no ole in s udy
design, da a collec ion and analysis, decision o publish, o p epa a ion o he manusc ip .
Compe ing In e es s: The au ho s ha e decla ed ha no compe ing in e es s exis .
* E-mail: m ome [email protected]
In oduc ion
Hepa ic encephalopa hy (HE) is one o he majo complica ions
o li e ci hosis a ec ing one hi d o ci ho ic pa ien s [1]. I has
ele an socio-economic impac since HE educes quali y-o -li e
and is associa ed wi h highe mo ali y a e [2]. HE occu s as a
esul o he coexis ence o hype ammonemia and in lamma ion in
pa ien s wi h li e dys unc ion and/o po o-sys emic shun s [3].
Ammonia p oduc ion akes place mainly in he small in es ine
whe e glu aminase ype K ac i i y is c ucial o he pa hogenesis o
HE [4]. Type 2 diabe es melli us and insulin esis ance (IR) a e
cha ac e ized by he elease o p o-in lamma o y cy okines, such
as TNFaand IL-6, esul ing in an in lamma o y s a e [5]. Diabe es
has been independen ly ela ed o con ol o ac i e a iceal
bleeding [6] and is associa ed wi h an inc eased isk o
hepa ocellula ca cinoma de elopmen [7]. Type 2 diabe es
melli us has also been ound associa ed wi h hepa ic encephalop-
a hy in pa ien s wi h HCV- ela ed ci hosis [8]. Insulin sensi ize s,
like me o min, dec ease insulin sec e ion and educe hype insu-
linemic s a e. Me o min inc eases be a oxida ion and educes he
hepa ic gluconeogenesis ia ac i a ion o AMP-K pa hway;
dec eases in es inal glucose abso p ion and inc eases glucose
up ake in skele al muscle [9]. Recen ly, i has been ound able o
modula e he exp ession o cy okines, such as TNFa[10]. Thus,
IR s a e could in luence hepa ic encephalopa hy de elopmen in
pa ien s wi h ci hosis. Insulin-sensi ize s seem o dec ease HCC in
pa ien s wi h ci hosis C [11]. The e o e, he ammonia p oduc-
ion, IR and he p o-in lamma o y s a e seem o igge ci hosis
PLOS ONE | www.plosone.o g 1 No embe 2012 | Volume 7 | Issue 11 | e49279
p og ession, and may be in e es ing as he apeu ic a ge s in he
nea u u e, imp o ing he p ognosis o ci ho ic pa ien s.
The aim o his s udy was o de e mine whe he he me o min
use was associa ed wi h dec eased isk o hepa ic encephalopa hy
in diabe ic ci ho ic pa ien s and o analyze he abili y o
me o min o inhibi glu aminase ac i i y in i o.
Me hods
Pa ien s
Eigh y- wo consecu i e diabe ic ci ho ic pa ien s om he Uni
o Clinical Managemen o Diges i e Diseases, Uni e si y
Hospi al o Valme, we e included. The s udy s a ed ei he wi h
he i s isi o Hepa ology o ice o wi h he i s hospi al
admission and ou comes o inish we e su i al and li e
ansplan a ion. Exclusion c i e ia we e: age#18 yea s; non-
diabe ic pa ien s; pa ien s wi h ype 1 diabe es melli us; and
pa ien s wi h ea men ongoing o ci hosis. The p o ocol was
app o ed by he CEIC o Uni e si y Hospi al o Valme (Se illa,
Spain) and all pa ien s p o ided w i en in o med consen o
pa icipa e in his s udy. The s udy was conduc ed in acco dance
wi h he e hical guidelines o he Decla a ion o Helsinki and
In e na ional Con e ence on Ha moniza ion Guidelines o Good
Clinical P ac ice. A o al o 41 cases and 41 con ols we e
included. They we e classi ied acco ding o insulin sensi ize s
expe ienced. Cases we e de ined as pa ien s who unde wen
me o min ea men , while con ols we e de ined as ci ho ic
pa ien s wi h ype 2 diabe es melli us wi hou me o min
ea men . Me o min-expe ienced a e age ime was 33.4626.7
mon hs. Type 2 diabe es melli us was diagnosed acco ding o he
Ame ican Diabe es Associa ion [12].
Biochemical and Clinical Pa ame e s
Baseline analysis, using comme cial es s, included: insulin,
glucose, glucagon, TNF 2, lep in, adiponec in, AST and ALT.
HOMA-IR was calcula ed [glucose (mmol/L) * Insulin (IU/ml)/
Table 1. Compa ison o baseline cha ac e is ics be ween g oups.
MET g oup (n = 41) Non-MET g oup (n = 41) Signi icance
Age (yea s) 60.269 60.4610 0.908
Sex, males 34 (82.9%) 28 (68.3%) 0.123
Child-Pugh sco e 5.961.0 6.361.6 0.194
MELD sco e 9.062.4 9.964.2 0.285
E iology o ci hosis 0.476
Alcohol 26 (63.4%) 20 (48.8%)
HCV 9 (22%) 13 (31.7%)
HBV 1 (2.4%) 1 (2.4%)
Au oimmune 0(0%) 2(4.9%)
O he s 5 (12.2%) 5 (12.2%)
HOMA-IR 8.365.2 6.764.3 0.203
Insulin (mU/mL) 24.2616.7 19.5612.9 0.231
Glucose (mmol/L) 8.565.4 9.363.4 0.619
Glucagon (pg/mL) 101.2645.5 111.9666 0.547
TNF 2 (pg/mL) 14.368.9 18.267.7 0.203
Lep in (ng/mL) 20.2616.6 20616.9 0.977
Adiponec in (mg/L) 12.763.4 17.6611.7 0.159
AST (IU/L) 55.1663.8 44.3625.8 0.553
ALT (IU/L) 43.6643.9 45.3645.3 0.905
Asci es 7 (17.1%) 18 (43.9%) 0.008
Va iceal bleeding 5 (12.2%) 6 (14.6%) 0.746
Follow-up (mon hs) 39.6628.3 45.4626.5 0.344
doi:10.1371/jou nal.pone.0049279. 001
Table 2. Uni a ia e analysis be ween hepa ic
encephalopa hy and ou comes.
Hepa ic
encephalopa hy Signi icance
Me o min use 0.002 (Log Rank 9.81)
Yes 4.9% (2/41)
No 41.5% (17/41)
GLS gene al e a ion 0.018 (Log Rank 5.57)
Yes 21.4% (6/28)
No 45.4% (10/22)
Al e ed OGC & MHE 0.006 (Log Rank 7.57)
Yes 45.8% (11/24)
No 19.2% (5/26)
GLS: glu aminase. OGC: o al glu amine challenge. MHE: minimal hepa ic
encephalopa hy.
doi:10.1371/jou nal.pone.0049279. 002
Me o min Inhibi s Glu aminase Ac i i y
PLOS ONE | www.plosone.o g 2 No embe 2012 | Volume 7 | Issue 11 | e49279
22,5]. Ci hosis was de ined and based on li e biopsy, ul asound,
endoscopic analysis and biochemical pa ame e s.
Encephalopa hy Managemen
Minimal hepa ic encephalopa hy (MHE) was diagnosed based
on psychome ic hepa ic encephalopa hy sco e (PHES) and c i ical
licke equency (CFF) (Hepa ono m
TM
Analyze (R&R Medi-
Business F eibu g GmbH, F eibu g, Ge many)). This ba e y
comp ises he digi symbol es (DST), he numbe connec ion es
A (NCT-A), he numbe connec ion es B (NCT-B), he se ial
do ing es (SDT), and he line d awing es (LDT). Pa ien s we e
classi ied as ha ing MHE when he PHES sco e was less han 24
poin s o he CFF alue was below he cu -o (38 Hz) [13]. Fo
o al glu amine challenge (OGC) analysis, blood samples we e
aken a baseline and 60 minu es ollowing glu amine load (10 g
glu amine dissol ed in 100 ml wa e (L-Glu amine, SHS S.A.,
Spain)). Ammonia was measu ed using he DaFonseca-Whollheim
me hod in an au o-analyze (Hi achi 911; Roche Diagnos ics,
Mannheim, Ge many). A pa hological esponse cu e o glu a-
mine ole ance was de ined as an ammonia ise o .128 mg/dL a
60 minu es a e he glu amine in ake [14]. Gene ic s udies
included leng h o mic osa elli es in he 59UTR egion o
glu aminase gene oge he wi h haplo ype TACC, as p e iously
desc ibed [15]. Baseline high isk o hepa ic encephalopa hy was
de ined acco ding o MHE, al e ed OGC and gene ic al e a ions.
Pa ien s wi h MHE (PHES,24 o CFF,38 Hz) and al e ed
OGC (NH3.128 mg/dl a 60 minu es) o showing gene ic
(La ge/la ge mic osa elli e o non-TACC haplo ype) we e classi-
ied as high isk o HE de elopmen (48%; 24/50) and he es
(52%; 26/50) as low isk o o e HE.
Expe imen al S udy
We pe o med an expe imen al s udy in i o (chemical assay
and cells assay) o in es iga e he glu aminase ac i i y inhibi ion,
acco ding o di e en me o min concen a ions.
Fi s , in an enzyma ic assay, we es ed di e en me o min doses
(0, 10, 25, 50 and 100 mM) wi h a cons an glu amine
concen a ion (100 mM). Ammonia p oduc ion was measu ed o
de e mine he glu aminase ac i i y.
On he o he hand, human colonic epi helial mammalian cell
line o Caco2 (Ame ican Type Cul u e Collec ion, ATCC) was
main ained in DMEM medium pH 7.4 supplemen ed wi h 10%
e al bo ine se um, 2.2 g/L HCO
3
Na, 100 mM sodium py u a e,
Figu e 1. Kaplan Meie cu e showing he impac o me o min use on hepa ic encephalopa hy (n = 82; log Rank: 9.45; p = 0.002).
doi:10.1371/jou nal.pone.0049279.g001
Table 3. Mul i a ia e analysis acco ding o o e HE.
Hepa ic encephalopa hy Mul i a ia e
Me o min use [H.R. 11.4 (95% CI: 1.2–108.8); p = 0.034]
Age a diagnosis [H.R. 1.12 (95% CI: 1.04–1.2); p = 0.002]
Female sex [H.R. 10.4 (95% CI: 1.5–71.6); p = 0.017]
HE isk [H.R. 21.3 (95% CI: 2.8–163.4); p = 0.003]
doi:10.1371/jou nal.pone.0049279. 003
Me o min Inhibi s Glu aminase Ac i i y
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0.292 g /L glu amine, 100 U/mL penicillin, 100 mg/mL s ep o-
mycin and 0.25 mg/mL ampho e icin in 5% CO
2
a 37uC. Cell
assay was ini ia ed 24 h a e seeding. Caco2 cells (10000 cells/
cm
2
) we e cul u ed in p esence o di e en me o min doses (0, 20,
50, 100 and 200 mM) and samples (cell pelle and cul u ed
medium) we e collec ed a e 0, 24, 48 and 72 h pos - ea men .
Glu aminase ac i i y was de e mined by he measu emen o
ammonia p oduc ion.
S a is ical Analysis
Resul s a e exp essed as mean6SD o 3 independen expe i-
men s. Da a we e compa ed using ANOVA wi h he Leas
Signi ican Di e ence (LSD) es as pos hoc mul iple compa ison
analysis. We used he Kaplan-Meie me hod (log ank es o
compa e cu es), Chi-squa e and T-s uden . Cox’s eg ession was
used o uni a ia e analysis and hose a iables wi h p,0.150 we e
en e ed in o he mul i a ia e analysis. The s a is ical di e ences
we e placed a p#0.05.
Resul s
E ec o Me o min Use on Hepa ic Encephalopa hy
Baseline epidemiological, biochemical and li e unc ion es
om bo h g oups o pa ien s a e shown in Table 1. No di e ences
we e ound in sex, age, e iology o ci hosis and li e unc ion
(including Child-Pugh sco e and MELD). The e iology o ci hosis
was alcoholic ci hosis (n = 46; 56.1%), HCV- ela ed (n = 22;
26.8%), HBV- ela ed (n = 2; 2.4%), c yp ogenic (n = 10; 12.3%) o
au oimmune (n = 2; 2.4%). Gende dis ibu ion was 75.6% men
(62/82) and 24.4% emales (20/82), wi h mean age o 60.369.5
yea s. Li e unc ion acco ding o Child-Pugh s age was: 57
pa ien s (69.5%) a Child-Pugh S age A; 24 pa ien s (29.3%) a
S age B and 1 pa ien (1.2%) a s age C. Mean Child-Pugh sco e
was 6.161.4 and MELD sco e was 9.563.5. A e age ollow-up
was 42.5627.4 mon hs. Nine een pa ien s (23.2%) de eloped
episodes o o e HE du ing ollow-up. These bou s we e ela ed
o diu e ics (31.6%; 6/19), a iceal bleeding (26.2%; 5/19) and
in ec ions (15.8%; 3/19), being 26.4% (5/19) spon aneous.
Uni a ia e analysis demons a ed al e ed Child-Pugh, OGC,
PHES, CFF, gene ic ac o s and me o min use we e associa ed
wi h he isk o o e hepa ic encephalopa hy (Table 2). In he
me o min g oup, we ound 4.9% o cases (2/41), while 41.5%
(17/41) occu ed in con ols (log Rank 9.81; p = 0.002) (Fig. 1). In
mul i a ia e analysis, me o min use [H.R. 11.4 (95% CI: 1.2–
108.8); p = 0.034], age a diagnosis [H.R. 1.12 (95% CI: 1.04–1.2);
p = 0.002], emale sex [H.R. 10.4 (95% CI: 1.5–71.6); p = 0.017]
and HE isk [H.R. 21.3 (95% CI: 2.8–163.4); p = 0.003] we e
ound independen ly associa ed wi h EH (Table 3). On he o he
hand, o e all su i al a e eached a end in ci ho ic pa ien s
me o min-expe ienced: 92.7% (38/41) o MET g oup su i ed
and 82.9% (34/41) o con ols.
E ec o Me o min on High Risk Pa ien s
Pa ien s wi h MHE (PHES,24 o CFF,38 Hz) and al e ed
OGC (NH3.128 mg/dl a 60 minu es) o showing gene ic p o ile
(La ge/la ge mic osa elli e o non-TACC haplo ype) we e classi-
ied as high isk o HE de elopmen . Me o min use, in hese
coho s, was associa ed wi h lowe HE bou s, bo h in high- isk and
low isk pa ien s (log Rank 7.57; p = 0.006).
E ec o Me o min on Glu aminase Ac i i y in i o
In chemical assay, 17.5% o glu aminase ac i i y inhibi ion was
ob ained wi h a me o min concen a ion o 10 mM and up o
68% inhibi ion was eached using 100 mM. The e o e, a dose-
dependen glu aminase ac i i y was obse ed wi h me o min use
(Fig. 2). In Caco2 cells, 20 mM o me o min showed 24%
inhibi ion o glu aminase ac i i y a 72 hou s compa ed wi h he
con ol a he same ime (p,0.05) (ammonia p oduc ion was
dec eased om 26.8560.74 mM o 19.962.05 mM; p,0.05)
(Fig. 3A). O he me o min concen a ions (50, 100 and
200 mM) inhibi ed also he glu aminase ac i i y, bu his e ec
was lowe han 20 mM o me o min, as e lec ed by he p esence
o ammonium in cul u ed medium (Fig. 3B).
Discussion
The majo indings om his wo k a e: i s , in he expe imen al
s udy, we ob ained a pa ial inhibi ion o glu aminase ac i i y
(abou 20%), bo h in he chemical and cells assays when compa ed
wi h con ol expe imen s. Glu aminase con e s glu amine in
glu amic acid, which is indispensable o cell unc ion, oge he
wi h ammonia and ee adicals. The e o e, his pa ial inhibi ion
Figu e 2. Glu aminase ac i i y in chemical assay (%), acco ding o me o min concen a ion. Each ba ep esen s he mean6SD (all
expe imen s we e conduc ed by iplica e).
doi:10.1371/jou nal.pone.0049279.g002
Me o min Inhibi s Glu aminase Ac i i y
PLOS ONE | www.plosone.o g 4 No embe 2012 | Volume 7 | Issue 11 | e49279
is p obably enough o p e en complica ions in ci ho ic pa ien s
(in pa icula hepa ic encephalopa hy), p ese ing he bene icial
e ec s o glu aminase. Second, we obse ed an eigh - old lowe
isk o hepa ic encephalopa hy in me o min-expe ienced pa ien s
(4.9% s 41.5%; p = 0.002), despi e bo h coho we e simila in
li e unc ion and HE isk sco e. Me o min e ec s on glu aminase
ac i i y and in lamma o y s a e (modula ed by glycemic con ol)
could explain, a leas in pa , his esul . HOMA-IR co ela es
wi h p o ein-C- eac i e ac i i y and pa ien s ecei ing me o min
showed a end o lowe ing TNF 2 le els han non-me o min
ea ed pa ien s (da a no shown). In e es ingly, in Child-Pugh A
pa ien s, HOMA index was independen ly associa ed wi h highe
a e o o e HE, suppo ing he hypo hesis ha insulin esis ance
synd ome could p omo e in lamma ion and inc eased isk o o e
HE. Indeed, ecal calp o ec in co ela ed wi h c i ical licke
equency and HE g ading [16].
Type 2 diabe es melli us has been ound associa ed wi h hepa ic
encephalopa hy in pa ien s wi h Hepa i is C- ela ed ci hosis. The
mechanisms by which diabe es could p omo e hepa ic encepha-
lopa hy includes: a) in lamma ion s a es in ci ho ic pa ien s has
been associa ed wi h bac e ial ansloca ion, hepa ic encephalop-
a hy and isk o spon aneous bac e ial pe i oni is. Insulin esis ance
synd ome and ype 2 diabe es melli us a e conside ed as an
in lamma o y s a e due o inc eased p oduc ion o p o-in lamma-
o y cy okines, such as TNFaand IL-6 [17]; b) mo ili y
impai men has been desc ibed in diabe ic pa ien s showing
delayed duodenum-cecal ansi ime. I could p omo e small
in es ine bac e ial o e g ow h (SIBO) aising bac e ial ansloca-
ion a e. Indeed, SIBO was ound in mo e han 60% o ci ho ic
pa ien s and i was s ongly ela ed o bac e ial ansloca ion [18].
Mo eo e , lac ulose b ea h es was ound al e ed in 8 ou o 9
pa ien s wi h p e ious bou s o hepa ic encephalopa hy; c) ype 2
diabe es seems o play a ole modula ing se e al iso o ms o
glu aminase (GA). Th ee glu aminase iso o ms ha e been
desc ibed; kidney- ype (KGA), li e - ype (LGA) and ype C
(CGA). Baglie o-Va gas e al. demons a ed ha KGA and
LGA a e p esen in endoc ine panc eas (KGA in alpha cells and
pe iphe y o he isle s and LGA in be a cells) and could ha e some
Figu e 3. E ec o me o min on glu aminase ac i i y
in i o.
3A) Glu aminase ac i i y inhibi ion in cells assay (%), acco ding o me o min
concen a ion; 3B) Ammonia concen a ion in cells assay, acco ding o me o min concen a ion. Each ba ep esen s he mean 6SD (all expe imen s
we e conduc ed by iplica e). *p#0.05 s. he co esponding con ol sample. #p#0.05 s. he same g oup collec ed a he p e ious ime poin .
doi:10.1371/jou nal.pone.0049279.g003
Me o min Inhibi s Glu aminase Ac i i y
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ole in he sec e ion o insulin [19]. In addi ion, ype 2 diabe es
p omo es enal up ake o plasma glu amine o he p oduc ion o
u ina y ammonia, ac i a ing KGA. Besides, s ep ozo ocin-
induced diabe ic a s ha e demons a ed ha hepa ocy es use
glu amine mo e apidly han do hepa ocy es om no mal a s; as a
consequence o ha , glu aminase ac i i y in diabe ic a s is
inc eased leading o a highe glu amine up ake and ammonia
p oduc ion. Fu he mo e, Wa o d e al. obse ed he inc ease in
glu aminase ac i i y in he small in es ine in ype 2 diabe es a s
[20].
The e ec o me o min on hepa ic encephalopa hy was
s onge han expec ed. In spi e o all hese da a suppo an ac i e
e ec o me o min on ci ho ics, a selec ion bias could no be
excluded in a e ospec i e analysis. Mo eo e , al hough me o -
min seems o be sa e han exogenous insulin p e en ing ci hosis
complica ions, i may be di icul o main ain adequa e blood
glucose le els wi h insulin sensi ize s alone. Thus, a balance
be ween glucose con ol o a oid diabe es p og ession and insulin
sensi i i y o a oid ci hosis complica ions is equi ed. O he
ci hosis ou comes, pa icula ly asci es, we e also modi ied by
me o min use (p obably due o dec ease in lamma ion [21]) bu in
a di e en manne and we e beyond he aim o ou s udy.
In conclusion, ou esul s indica ed ha me o min use educed
he isk o hepa ic encephalopa hy in diabe ic ci ho ic pa ien s,
p obably by wo mechanisms: inhibi ing pa ially glu aminase
ac i i y and imp o ing insulin sensi i i y. A andomized con ol
ial is wa an ed o con i m o no hese da a de ining he
use ulness o me o min in he managemen o li e ci hosis.
Au ho Con ibu ions
Concei ed and designed he expe imen s: JA MRG. Pe o med he
expe imen s: IR MdMDH JAdC AR IC JDB. Analyzed he da a: JA
MRG. Con ibu ed eagen s/ma e ials/analysis ools: DN MM BF. W o e
he pape : JA MRG.
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PLOS ONE | www.plosone.o g 6 No embe 2012 | Volume 7 | Issue 11 | e49279