Reduced urinary 6β-hydroxycortisol to cortisol ratios in patients with liver cirrhosis

https://doi.org/10.1016/S1386-6346(03)00005-6Get rights and content

Abstract

While the urinary concentration ratio of 6β-hydroxycortisol (6β-HC) to cortisol (C) in 24-h urine samples is an established parameter for the induction of hepatic cytochrome P450 (CYP) 3A activity, it remains unclear whether it would be reduced in association with chronic liver damages. To clarify this issue we measured this parameter in 12 patients with chronic hepatitis, 15 patients with liver cirrhosis and 12 healthy subjects. Urinary 6β-HC and C were assayed with high-performance liquid chromatography with ultraviolet absorption. Multiple regression analysis was performed to search for which biochemical or demographic parameter(s) would be associated with the overall variability of urinary 6β-HC/C ratios. Results showed that the mean (±S.D.) 6β-HC/C ratio obtained from the patients with liver cirrhosis (4.3±2.6), but not that from patients with chronic hepatitis (7.4±7.2), was significantly (P<0.05) lower than that obtained from the healthy controls (11.8±8.3). It was also revealed that among the clinical parameters examined (e.g. serum transaminases concentrations) only serum albumin concentrations were correlated significantly (R=0.61, P<0.05) with the urinary 6β-HC/C ratio. In conclusion, the present study implies that that the reduced urinary 6β-HC/C ratios in patients with liver cirrhosis may be associated with attenuated hepatic CYP3A activity in these patients.

Introduction

Urinary 6β-hydroxycortisol (6β-HC) to free cortisol (C) ratio may be a useful non-invasive parameter of the hepatic cytochrome P450 (CYP) activity in humans [1], [2]. Earlier studies [3], [4] demonstrated that the urinary 6β-HC/C ratios (or 6β-HC excretion) is a good index for the enzyme induction of CYP isoforms by concomitant medications: several CYP inducers (e.g. rifampicin, phenobarbital) produced a substantial increase in the urinary 6β-HC/C ratios (or 6β-HC excretion) in patients and healthy subjects as compared with their respective pretreatment values. Subsequently, Ged et al. [5] reported that the in vitro metabolism of C to 6β-HC with human liver microsomes is mediated mainly by CYP3A and that there was a highly significant (r=0.81, P<0.001) correlation between the urinary 6β-HC/C ratio and CYP3A levels quantitated immunologically in liver biopsy specimens. Thus, the urinary 6β-HC/C ratio has been considered as a useful parameter of in vivo CYP3A induction [2].

However, debate continues whether the urinary 6β-HC/C ratio would also be a useful parameter for detecting reduction of hepatic CYP3A4 activity. Watkins et al. [6] showed that there was a highly significant correlation between the results obtained from erythromycin breath tests (an established marker of the hepatic CYP3A4 activity) and urinary 6β-HC/C ratios in healthy subjects. In addition, several studies [7], [8], [9], [10] demonstrated that a single or repeated administration of competitive or mixed-type CYP3A4 inhibitors (i.e. cimetidine, methadone, fluconazole, nelfinavir and nelfinavir plus ketoconazole, clarithromycin) significantly reduced the 6β-HC/C ratio and/or 6β-HC excretion measured in 4- or 24-h urine samples in healthy subjects. In addition, we have recently reported that clarithromycin, a potent CYP3A4 inhibitor, significantly inhibits the partial cortisol clearance by 6β-hydroxycortisol formation in a dose-dependent manner during Helicobacter pylori eradication therapy with a combination of clarithromycin–lansoprazole–amoxicillin in patients with H. pylori-positive peptic ulcer diseases [11]. In contrast to these data, Watkins et al. [6] found only inconsistent changes in the urinary 6β-HC/C ratio in four healthy subjects who were given a single oral dose (250 mg) of another CYP3A inhibitor, troleandomycin.

Another approach for clarifying the contribution of the hepatic CYP3A4 activity to urinary 6β-HC/C ratios is to compare this parameter between patients with liver diseases and healthy subjects. Watkins et al. [6] reported that a recipient of liver transplantation exhibited a 50% reduction in the urinary 6β-HC/C ratio during the anhepatic period of the surgery, indicating that at least some 50% of 6β-HC in urine sample was associated with the hepatic CYP3A metabolism. In contrast, Ng et al. [12] showed that the mean urinary 6β-HC/C ratio obtained from patients with liver cirrhosis differs insignificantly from that obtained from liver disease-free controls. They also reported that the mean 6β-HC/C ratio obtained from patients with unresectable hepatocellular carcinoma was significantly greater than that obtained from the controls. At present, their data have not been confirmed by others. Because they employed an immunoassay method that might have been less specific to urinary 6β-HC and C than currently employed HPLC methods [13], [14], we considered that a reappraisal of urinary 6β-HC/C ratios in patients with liver diseases as compared with healthy subjects is to be warranted. Here, we present the data that support a significant association of hepatic CYP3A activity with the urinary 6β-HC/C ratio.

Section snippets

Materials and methods

Urine samples were collected for 24 h in 12 patients with chronic hepatitis, 15 patients with liver cirrhosis and 12 healthy subjects. Urine collection was begun at 07:00 h on the study day and was continued until 07:00 h on the next day. The diagnosis of liver cirrhosis was made based upon a combination of cardinal clinical symptoms (e.g. ascites and esophageal varices), laboratory findings (e.g. hypoalbuminemia, hyperbilirubinemia, abnormal coagulation profiles) and a preceding history of

Discussion

We revealed that the mean urinary 6β-HC/C ratio obtained from the patients with liver cirrhosis was significantly (P<0.05) lower than that obtained from healthy subjects (Fig. 1C). In addition, using the multiple regression analysis we demonstrated that only serum albumin concentrations would significantly (P<0.05) associated with the overall variability of 6β-HC/C ratios in the patients with chronic liver diseases and healthy subjects (Fig. 2). Because hypoalbuminemia in patients with liver

Acknowledgments

The authors thank S. Kurihara and N. Komada for their excellent technical assistance.

References (24)

  • J.P. Desager et al.

    The urinary 6β-hydroxycortisol excretion in man on inducers and inhibitors of the hepatic mixed function oxidase

    Pharmacol. Ther.

    (1987)
  • E.G. Schuetz et al.

    Expression of cytochrome P450 3A in amphibian, rat and human kidney

    Arch. Biochem. Biophys.

    (1992)
  • J. Nakamura et al.

    Age- and sex-related differences in urinary excretion of 6β-hydroxycortisol in humans

    Clin. Chim. Acta

    (1985)
  • P.B. Watkins

    Noninvasive tests of CYP3A enzymes

    Pharmacogenetics

    (1994)
  • S.J. Kovacs et al.

    Urinary excretion of 6β-hydroxycortisol as an in vivo marker for CYP3A induction: applications and recommendations

    Clin. Pharmacol. Ther.

    (1998)
  • E.E. Ohnhaus et al.

    Measurement of urinary 6-β-hydroxycortisol excretion as an in vivo parameter in the clinical assessment of the microsomal enzyme-inducing capacity of antipyrine, phenobarbitone and rifampicin

    Eur. J. Clin. Pharmacol.

    (1979)
  • P. Saenger

    6β-Hydroxycortisol in random urine samples as an indicator of enzyme induction

    Clin. Pharmacol. Ther.

    (1983)
  • C. Ged et al.

    The increase in urinary excretion of 6β-hydroxycortisol as a marker of human hepatic cytochrome P450IIIA induction

    Br. J. Clin. Pharmacol.

    (1989)
  • P.B. Watkins et al.

    Comparison of urinary 6-β-hydroxycortisol and the erythromycin breath test as measures of hepatic P450IIIA (CYP3A) activity

    Clin. Pharmacol. Ther.

    (1992)
  • D.W. Boulton et al.

    A single dose of methadone inhibits cytochrome P-450 3A activity in healthy volunteers as assessed by the urinary C ratio

    Br. J. Clin. Pharmacol.

    (2001)
  • J.H. Lillibridge et al.

    Characterization of the selectivity and mechanism of human cytochrome P450 inhibition by the human immunodeficiency virus-protease inhibitor nelfinavir mesylate

    Drug Metab. Dispos.

    (1998)
  • K. Morita et al.

    Fluconazole: a potent inhibitor of cytochrome P-450-dependent drug metabolism in mice and human in vivo. Comparative study with ketoconazole

    Chem. Pharm. Bull.

    (1992)
  • Cited by (12)

    • DEC1 binding to the proximal promoter of CYP3A4 ascribes to the downregulation of CYP3A4 expression by IL-6 in primary human hepatocytes

      2012, Biochemical Pharmacology
      Citation Excerpt :

      Taken together, these data clearly demonstrated that DEC1 was specifically recruited to the CCCTGC sequence. It has been reported that drug biotransformation is impaired in patients with liver conditions such as hepatitis and cirrhosis [30,31]. In those conditions, as the production of various proinflammatory cytokines (e.g., IL-6) markedly increased [32,33], the metabolisms of many drugs decreased [34–36].

    • Factors affecting pharmacokinetics of benzimidazole anthelmintics in food-producing animals: The consequences and potential risks

      2011, Research in Veterinary Science
      Citation Excerpt :

      It is hardly surprising that the major effects are observed with liver diseases as liver represents the main drug metabolizing organ. The parasitoses causing liver damage generally decrease the liver’s ability to metabolize drugs due to decreased enzyme activity and hepatic blood flow (Villeneuve and Pichette, 2004; Renton, 2001; Shibuya et al., 2003). Moreover, hypoalbuminaemia, leading to lower plasma binding, increases plasma concentration of the free drug and in this way affects drug efficacy.

    • Steroid hormone biotransformation and xenobiotic induction of hepatic steroid metabolizing enzymes

      2004, Chemico-Biological Interactions
      Citation Excerpt :

      Women taking St. John’s Wort concurrently with oral contraceptives could risk of becoming pregnant [92], presumably because of enhanced inactivation of the steroids in the contraceptives. On the other hand, chronic impairment of hepatic function, such as in patients suffering liver cirrhosis, would lead to reduction of metabolic clearance of steroids [64]. In comparison to pharmacological steroids, the effects of xenobiotic-caused hepatic enzyme induction on the inactivation and clearance of endogenous steroid hormones are less certain.

    View all citing articles on Scopus
    View full text