Korean J Physiol Pharmacol 2021; 25(1): 69-77
Published online January 1, 2021 https://doi.org/10.4196/kjpp.2021.25.1.69
Copyright © Korean J Physiol Pharmacol.
Kezban Tuna Ozkaloglu Erdem1, Zehra Bedir2, Irem Ates3, Ufuk Kuyrukluyildiz4, Taha Abdulkadir Coban5, Gulce Naz Yazici6, Yusuf Kemal Arslan7, Zeynep Suleyman8, and Halis Suleyman9,*
1Balikesir Ataturk City Hospital Anesthesiology and Reanimation Clinic, Balikesir 10010, 2Department of Anesthesiology and Reanimation, Erzurum Nenehatun Maternity Hospital, Erzurum 25000, 3Department of Anesthesiology and Reanimation, Faculty of Medicine, Ataturk University, Erzurum 25000, Departments of 4Anesthesiology and Reanimation, 5Medical Biochemistry, 6Histology and Embryology, 7Biostatistics, Faculty of Medicine, Erzincan Binali Yildirim University, Erzincan 24100, 8Department of Nursing, Faculty of Health Sciences, Erzincan Binali Yildirim University, 9Department of Pharmacology, Faculty of Medicine, Erzincan Binali Yildirim University, Erzincan 24100, Turkey
Correspondence to:Halis Suleyman
E-mail: halis.suleyman@gmail.com
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Propofol infusion syndrome characterized by rhabdomyolysis, metabolic acidosis, kidney, and heart failure has been reported in long-term propofol use for sedation. It has been reported that intracellular adenosine triphosphate (ATP) is reduced in rhabdomyolysis. The study aims to investigate the protective effect of ATP against possible skeletal muscle damage of propofol in albino Wistar male rats biochemically and histopathologically. PA-50 (n = 6) and PA-100 (n = 6) groups of animals was injected intraperitoneally to 4 mg/kg ATP. An equal volume (0.5 ml) of distilled water was administered intraperitoneally to the P-50, P-100, and HG groups. One hour after the administration of ATP and distilled water, 50 mg/kg propofol was injected intraperitoneally to the P-50 and PA-50 groups. This procedure was repeated once a day for 30 days. The dose of 100 mg/kg propofol was injected intraperitoneally to the P-100 and PA-100 groups. This procedure was performed three times with an interval of 1 days. Our experimental results showed that propofol increased serum CK, CK-MB, creatinine, BUN, TP I, ALT, AST levels, and muscle tissue MDA levels at 100 mg/kg compared to 50 mg/kg and decreased tGSH levels. At a dose of 100 mg/ kg, propofol caused more severe histopathological damage compared to 50 mg/ kg. It was found that ATP prevented propofol-induced muscle damage and organ dysfunction at a dose of 50 mg/kg at a higher level compared to 100 mg/kg. ATP may be useful in the treatment of propofol-induced rhabdomyolysis and multiple organ damage.
Keywords: Adenosine triphosphate, Muscle, Myopathy, Propofol, Rat, Rhabdomyolysis
Propofol (2,6-diisopropylphenol) is a short-acting drug used in anesthesia induction and maintenance in short procedures and outpatient procedures [1]. When administered intravenously, it induces anesthesia at a rate similar to barbiturates, but post-operative recovery is much faster [2]. Propofol is one of the most preferred drugs in intensive care units because it is a strong anesthetic and effective sedative [3,4]. However, multiple organs and system damage known as propofol infusion syndrome (PIS) have been reported in those using propofol for a long time for sedation [5]. Retrospective studies have shown that the risk of PIS is high in all patients receiving short-term infusions at high doses or long-term infusions at different doses [5]. The literature has revealed that PIS progresses with severe metabolic acidosis, rhabdomyolysis, kidney, and heart failure, and can even lead to death [6]. One of the causes of mortality, rhabdomyolysis is a serious muscle injury characterized by the breakdown of skeletal muscle cells. It has been reported that skeletal muscle and myocardial cell damage markers such as creatine kinase (CK), creatine kinase MB (CK-MB), and troponin-I (TP I) levels are increased in PIS [7,8]. It has also been reported that markers of liver damage such as lactate dehydrogenase (LDH), aspartate aminotransferase (AST), alanine aminotransferase (ALT) are also increased in PIS [8]. It has been explained that one of the important clinical signs of PIS in literature is renal failure [9]. In histopathological examination, necrosis was observed in the renal tubules [10]. This event is followed by progressive increases in serum creatinine and blood urea nitrogen (BUN) concentrations [11]. Serum creatinine and BUN are used to evaluate oxidative kidney damage. The increase in creatinine and BUN has been associated with an increase in malondialdehyde (MDA), an oxidant parameter, and a decrease in endogenous antioxidant levels such as glutathione (GSH) [12]. A decrease in intracellular adenosine triphosphate (ATP) levels has been noted as the underlying cause of all forms of rhabdomyolysis [13]. Cray
No data was found in the literature indicating oxidative stress in the pathogenesis of propofol-induced rhabdomyolysis. However, the pathophysiological process has been reported to include oxidative stress and inflammation in the glycerol-induced rhabdomyolysis (animal) model [17]. It has been noted that the damage caused by reactive oxygen species (ROS) such as hydrogen peroxide is associated with the loss of mitochondrial membrane potential and a decrease in ATP levels [18]. It has been reported that drugs increasing ATP levels restore mitochondrial damage and protect cells from ROS damage [19]. ATP to be examined in the present study for its possible protective effect against propofol-induced muscle damage is an organic compound involved in energy transformations in all living cells and contains carbon (C), hydrogen (H), oxygen (O), nitrogen (N) and phosphate (P). More than 95% of the molecular oxygen is used by mitochondria for energy generation in the form of ATP [20]. The energy released from ATP degradation is the primary energy source for muscle contraction [21]. Kumbasar
A total of 30 male albino Wistar rats weighing 245–257 grams were used in the experiment. The animals were obtained from Ataturk University Medical Experimental Application and Research Center. The animals were housed and fed in groups in normal laboratory conditions (22˚C) before the experiment. Animal experiments were performed by the National Guidelines for the Use and Care of Laboratory Animals and were approved by the local animal ethics committee of Ataturk University, Erzurum, Turkey (Ethics Committee [Dated: 28/10/2019, Meeting no:88012460-840.01-E50907]).
Propofol (1%-20 ml ampoule) was obtained from Fresenius Kabi Pharmaceutical San-Turkey, thiopental sodium was provided by IE Ulagay-Turkey, and ATP was supplied by Zdorove Narodu Ukraine.
Experimental animals were divided into five groups as healthy controls (HG), 50 mg/kg propofol (P-50), 50 mg/kg propofol + 4 mg/kg ATP (PA-50), 100 mg/kg propofol (P-100), and 100 mg/kg propofol + 4 mg/kg ATP (PA-100).
ATP was injected into the PA-50 (n = 6) group at a dose of 4 mg/kg intraperitoneally (IP) to experiment. An equal volume (0.5 ml) of distilled water was administered to the P-50 (n = 6) and HG (n = 6) groups simultaneously. One hour after the administration of ATP and distilled water, 50 mg/kg propofol was injected IP to P-50 and PA-50 groups. This procedure was performed once a day for 30 days.
Furthermore, 4 mg/kg ATP was IP injected to the PA-100 (n = 6) group and an equal volume of distilled water was administered to the P-100 (n = 6) group. After one hour, 100 mg/kg propofol was intraperitoneally injected into both groups. This procedure was performed three times with an interval of 1 days. At the end of this period, CK, CK-MB, creatinine, BUN, TP I, AST, ALT, and LDH were measured in blood samples taken from all animal groups. Also, MDA and total glutathione (tGSH) levels were measured in skeletal muscle tissue samples of animals killed by decapitation. Some of the skeletal muscle tissues were examined histopathologically. Biochemical and histopathological results obtained from all experimental groups were compared and evaluated.
For statistical analysis IBM SPSS 22 was used (released 2013. IBM SPSS Statistics for Windows, Version 22.0; IBM Corp., Armonk, NY, USA). The results were presented as mean ± standard deviation (SD). The distribution of variables was confirmed with the Shapiro–Wilk test. For biochemical measurements except CK-MB and Creatinine were compared with ANOVA. According to the homogeneity of variances, Tukey's HSD or Games-Howell tests were used as
Similarly, 50 mg/kg propofol increased CK-MB level compared to the healthy group (p = 0.005) and the ATP group (p = 0.02), while at 100 mg/kg the difference was even more compared to the healthy group (p < 0.001) and the ATP group (p = 0.014). No difference was found in CK-MB activity between the 50 mg/kg propofol + ATP group and the healthy group (p = 0.25). Furthermore, there was no difference in CK-MB activity between the 100 mg/kg propofol + ATP group and the healthy group (p = 0.28).
Compared to the healthy group (p < 0.001) and the ATP group (p < 0.001), 50 mg/kg propofol administration increased BUN level significantly. BUN level increased even more significantly by 100 mg/kg propofol administration compared to the healthy group (p < 0.0001) and the ATP group (p < 0.0001). The difference in the BUN level between the 50 mg/kg propofol + ATP group and the healthy group was statistically insignificant (p = 0.45). However, the difference in the BUN level between the 100 mg/kg propofol + ATP group and the healthy group was statistically significant (p < 0.001).
Also, 100 mg/kg propofol administration increased serum TPI levels of animals more significantly compared to the dose of 50 mg/kg (p < 0.001). The difference in TPI levels between the healthy group and 50 mg/kg propofol + ATP group was statistically insignificant (p = 0.12). The difference in the TPI level between the 100 mg/kg propofol + ATP group and the healthy group was not found statistically significant (p = 0.07).
Similarly, 100 mg/kg propofol administration increased AST activity further (p < 0.001) compared to 50 mg/kg propofol administration. ATP significantly inhibited the propofol-related increase in AST activity at 50 mg/kg (p < 0.0001) and 100 mg/kg (p < 0.0001) doses. There was a significant difference in AST activity between the 50 mg/kg propofol + ATP group and the healthy group (p < 0.05). A higher difference was observed in AST activity between the 100 mg/kg propofol + ATP group and the healthy group (p < 0.01).
Propofol caused an increase in LDH activity in the blood serum of animals. 100 mg/kg propofol administration caused a higher increase in LDH activity compared to 50 mg/kg (p < 0.001). No difference was found between the 50 mg/kg propofol + ATP group and the healthy group (p = 0.26). The difference between the 100 mg/kg propofol + ATP group and the healthy group was statistically significant (p = 0.002).
The 50 and 100 mg/kg doses of propofol increasing MDA caused a decrease in tGSH in muscle tissue. Propofol further reduced the amount of tGSH at a dose of 100 mg/kg compared to 50 mg/kg (p < 0.001). There was a significant difference between the amount of tGSH in the muscle tissue of the 50 mg/kg propofol + ATP group and the healthy group (p = 0.009). This difference was more pronounced between the 100 mg/kg propofol + ATP group and the healthy group (p < 0.001).
Normal muscle cell nuclei, muscle fibers, and blood vessels in the skeletal muscle tissue of the healthy animal group are shown in Fig. 4. In the 50 mg/kg propofol group, pale muscle fibers having a marked swelling and irregular appearance, conjunctive blood vessels, and polymorphonuclear cell infiltration were observed (Fig. 5A). Significant recovery and improvement were observed in the group treated with 50 mg/kg propofol + ATP. In this group, the muscle fibers were regularly aligned and their color was normal. The degenerative disruption in muscle fibers decreased and blood vessels were normal (Fig. 5B). Furthermore, irregularity in adjacent muscle fibers, degeneration coupled with disruptions in transverse lines of the muscle fibers, and some torn fibers were observed in the 100 mg/kg propofol group. When the overall tissue was evaluated, dilated and conjunctive blood vessels were observed and numerous polymorphonuclear cell infiltrations were seen around the blood vessels (Fig. 5C). In the 100 mg/kg propofol + ATP group, muscle fiber nuclei and the alignment of muscle fibers showed normal appearance, mild confirmation in the blood vessels, and very few polymorphonuclear cells around the vessels were observed (Fig. 5D).
In this study, the effect of ATP on the propofol administration at different doses, different intervals, and different durations was investigated biochemically and histopathologically. Our biochemical results showed that CK, CK-MB, TPI, ALT, AST, LDH, creatinine, and BUN levels were significantly higher in the blood serum of animals treated with 100 mg/kg propofol compared to 50 mg/kg. Besides, muscle MDA level was higher whereas tGSH was lower in the 100 mg/kg propofol group compared to 50 mg/kg. Recent studies have reported that high-dose short-term propofol infusion causes PIS in patients. Furthermore, it has been reported that PIS develops in all patients undergoing long-term infusion at a low dose range [5]. CK enzymes are used in the clinics to determine whether there is any damage to the skeletal and cardiac muscle tissue of individuals [25]. In the literature, it is stated that an increase in CK is associated with the extent of muscle damage and the severity of the disease. Furthermore, it is emphasized that muscle cell damage is caused by CK leak from the cells into the blood serum [26]. Therefore, measuring serum CK activity is an important indicator of muscle cell necrosis and all types of muscular dystrophy [27]. Another important parameter used in the diagnosis of myocardial infarction and inflammatory skeletal muscle diseases is the CK-MB isoenzyme [28]. Chronic necrotic muscle injury can lead to an increase in CK-MB activity [29]. CK-MB increases together with CK in patients with chronic kidney disease and destructive myopathies such as Duchenne muscular dystrophy, polymyositis, and dermatomyositis [30,31].
In our study, propofol increased the amount of serum TPI as well. In a previous study, it was reported that troponin increased in propofol-associated cardiac muscle damage [32]. TPI is known to be a highly sensitive parameter in myocardial damage [33]. Studies have suggested that the increase in TPI may be the result of a defect in the myocardia membrane caused by reactive oxygen products [34]. Propofol-associated ALT and AST elevations are multifactorial processes including skeletal muscle damage and hepatocellular damage [35]. Serum ALT and AST levels usually increase in rhabdomyolysis and these enzymes are produced by skeletal muscle. On the other hand, simultaneous liver disease has been shown to elevate the levels of these enzymes [36]. ALT is generally considered as a more specific marker for hepatocyte damage. However, there is also evidence for the production of ALT outside the liver [37]. AST is found in the liver, skeletal muscle, heart, kidneys, pancreas, and erythrocytes. Therefore, both hepatic inflammation and injury of another organ should be considered in the case of elevated serum AST levels [38]. Our experimental results are consistent with the results of the previous studies [36]. LHD, as well as ALT and AST levels, were elevated in animals treated with propofol. High LDH activity has been reported in skeletal muscle, heart, lung, liver, and kidney damage associated with propofol application [10]. In the study of El-Ganainy
Kumbasar
Prolonged use of propofol at low doses may cause muscle and tissue damage in other organs, while propofol use at higher doses may cause more severe organ and tissue damage in a shorter period. Based on the results of this study, it can be concluded that ATP better prevents muscle damage and organ dysfunction caused by 50 mg/kg propofol administration compared to the dose of 100 mg/kg. These experimental results suggest that ATP may be clinically useful in the treatment of propofol-induced rhabdomyolysis and multiple organ damage.
We would like to thank the Ataturk University Medical Experimental Application and Research Center.
K.T.O.E. and Z.B. contributed to conception, design, acquisition, analysis. I.A. and U.K. contributed to interpretation, and drafted the manuscript. T.A.C. and G.N.Y. contributed to histopathological examination and revised the manuscript. Y.K.A. contributed to data analysis, Z.S. and H.S. conducted the animal experiments, writing article, critically revised the manuscript, final approval.
The authors declare no conflicts of interest.
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