Ammonia level and Alzheimer type 2 astrocytes in the brain of deceased patients with liver cirrhosis of the varying degree




liver cirrhosis, ammonia, hepatic encephalopathy, histocytochemistry, optical density, Alzheimer type 2 astrocytes, bilirubin


The aim of the study – comparative analysis of the ammonia level and Alzheimer type 2 astrocytes in the brain cortex and white matter of cerebral hemispheres, hippocampus, thalamus, striatum and cerebellum in the deceased patients with liver cirrhosis of classes A, B and C according to Child–Pugh.

Materials and methods. The study was performed on the brain of deceased 90 patients (65 ± 3 years) suffered from non-alcoholic liver cirrhosis (LC) of classes A (n = 30, group “A”), B (n = 30, group “B”) and C (n = 30, group “C”) according to Child–Pugh score, among which 59 (65.55 %) patients had clinical symptoms of hepatic encephalopathy of I–IV grades. The control group included postmortem brains of 30 patients (59.0 ± 2.5 years) who died from acute cardiovascular insufficiency and did not suffer from liver diseases or intoxication. A retrospective analysis of clinical and laboratory data from case histories was carried out. For histochemical (HC) determination of the ammonia in paraffin sections of the cerebral cortex and white matter, hippocampus, thalamus, striatum and cerebellum we used the protocol with Nessler’s reagent proposed by Gutierrez-de-Juan et al. (2017). In the noted brain regions, the analysis of HC ammonia optical density was performed in five standardized fields of view (×200) of the microscope scope A1 “Carl Zeiss” (Germany) with Jenoptik camera progress Gryphax 60 N-C1ꞌꞌ1.0x426114 (Germany) using ImageJ software; in each noted brain region the number of Alzheimer’s type 2 astrocytes (AA2) was counted per twenty standardized fields of view at magnification ×400.

Results. HC method for ammonia detection with Nessler’s reagent according to V. Gutiérrez-de-Juan et al. (2017) reveals region-dependent fine-grained expression of ammonia in the brain neuropil of deceased patients in control and cirrhotic groups. In control patients, a very low HC ammonia expression is observed with higher values in cerebellum, thalamus, and striatum, while still ranked as negative. Increased HC ammonia expression (compared to control) is observed in deceased patients with compensated LC of “A” group in the cortex, thalamus, striatum and cerebellum; in subcompensated LC of “B” group – as well in the white matter and hippocampus. In deceased patients with decompensated LC of “C” group, in cerebellum, thalamus and striatum HC ammonia expression is maximally increased (by 6.18, 5.72, and 5.50 folds, respectively). Significant correlations are present between patients’ postmortem brain HC ammonia expression and the last intravital indicators of the blood total bilirubin, AST, ALT, albumin, leukocytic intoxication index. In compensated cirrhosis, increase in AA2 numbers compared to control is found in thalamus, striatum and cerebellum, which corresponds to AA2-astrocytosis of I degree. In subcompensated cirrhosis, AA2-astrocytosis of moderate II degree is found in the cortex, thalamus and cerebellum; AA2-astrocytosis of I degree – in striatum. In decompensated cirrhosis, pronounced AA2-astrocytosis of III degree is determined in the cortex, thalamus, striatum and cerebellum; moderate AA2-astrocytosis of II degree – in cerebral white matter, and mild AA2-astrocytosis of I degree – in the hippocampus. There is a moderate, strong, and very strong positive relationship between the levels of AA2-astrocytosis and HC ammonia expression in the thalamus, striatum, and cerebellum.

Conclusions. In deceased patients with LC, the neuropil HC ammonia expression in cerebellum, thalamus, striatum, and cerebral cortex directly correlates with the severity of LC according to Child–Pugh, reaching a maximum in LC of class C, and has significant correlations with intravital blood levels of total bilirubin, AST, ALT, albumin, leukocytic intoxication index. With LC progression, AA2-astrocytosis increases significantly in thalamus, cerebellum, striatum and cerebral cortex, which positively correlates with HC ammonia expression in these brain regions.

Author Biographies

T. V. Shulyatnikova, Zaporizhzhia State Medical University, Ukraine

MD, PhD, Associate Professor of the Department of Pathological Anatomy and Forensic Medicine

V. O. Tumanskyi, Zaporizhzhia State Medical University, Ukraine

MD, PhD, DSc, Professor of the Department of Pathological Anatomy and Forensic Medicine, Vice-Rector for Research, Honorary Scientist and Engineering Worker of Ukraine


Bohra, A., Worland, T., Hui, S., Terbah, R., Farrell, A., & Robertson, M. (2020). Prognostic significance of hepatic encephalopathy in patients with cirrhosis treated with current standards of care. World journal of gastroenterology, 26(18), 2221-2231.

Shulyatnikova, T. V., & Shavrin, V. A. (2017). Modern view on hepatic encephalopathy: basic terms and concepts of pathogenesis. Pathologia, 14(3), 371-380.

Ferenci, P. (2017). Hepatic encephalopathy. Gastroenterology report, 5(2), 138-147.

Wan, S. Z., Nie, Y., Zhang, Y., Liu, C., & Zhu, X. (2020). Assessing the Prognostic Performance of the Child-Pugh, Model for End-Stage Liver Disease, and Albumin-Bilirubin Scores in Patients with Decompensated Cirrhosis: A Large Asian Cohort from Gastroenterology Department. Disease markers, 2020, 5193028.

Butterworth, R. F. (2019). Hepatic Encephalopathy in Cirrhosis: Pathology and Pathophysiology. Drugs, 79(Suppl 1), 17-21.

Adlimoghaddam, A., Sabbir, M. G., & Albensi, B. C. (2016). Ammonia as a Potential Neurotoxic Factor in Alzheimer’s Disease. Frontiers in molecular neuroscience, 9, 57.

Xie, G., Wang, X., Jiang, R., Zhao, A., Yan, J., Zheng, X., Huang, F., Liu, X., Panee, J., Rajani, C., Yao, C., Yu, H., Jia, W., Sun, B., Liu, P., & Jia, W. (2018). Dysregulated bile acid signaling contributes to the neurological impairment in murine models of acute and chronic liver failure. EBioMedicine, 37, 294-306.

Jayakumar, A. R., & Norenberg, M. D. (2018). Hyperammonemia in Hepatic Encephalopathy. Journal of clinical and experimental hepatology, 8(3), 272-280.

Lu, K. (2023). Cellular Pathogenesis of Hepatic Encephalopathy: An Update. Biomolecules, 13(2), 396.

Görg, B., Karababa, A., Schütz, E., Paluschinski, M., Schrimpf, A., Shafigullina, A., Castoldi, M., Bidmon, H. J., & Häussinger, D. (2019). O-GlcNAcylation-dependent upregulation of HO1 triggers ammonia-induced oxidative stress and senescence in hepatic encephalopathy. Journal of hepatology, 71(5), 930-941.

Angelova, P. R., Kerbert, A. J. C., Habtesion, A., Hall, A., Abramov, A. Y., & Jalan, R. (2022). Hyperammonaemia induces mitochondrial dysfunction and neuronal cell death. JHEP reports: innovation in hepatology, 4(8), 100510.

Deutsch-Link, S., Moon, A. M., Jiang, Y., Barritt, A. S., 4th, & Tapper, E. B. (2022). Serum Ammonia in Cirrhosis: Clinical Impact of Hyperammonemia, Utility of Testing, and National Testing Trends. Clinical therapeutics, 44(3), e45-e57.

Ma, K. C. (2001). Alzheimer-type I astrogliopathy (AIA) and its implications for dynamic plasticity of astroglia: a historical review of the significance of AIA. Journal of neuropathology and experimental neurology, 60(2), 121-131.

Gelpi, E., Rahimi, J., Klotz, S., Schmid, S., Ricken, G., Forcen-Vega, S., Budka, H., & Kovacs, G. G. (2020). The autophagic marker p62 highlights Alzheimer type II astrocytes in metabolic/hepatic encephalopathy. Neuropathology, 40(4), 358-366.

Norenberg, M., Tong, X., Shamaladevi, N., Ahmad, A., Arcuri, J., Mehran, T., & Jayakumar, A. (2019). P: 78 Mechanism of Alzheimer Type II Astrocyte Development: Implication for the Defective Neuronal Integrity and Neurobehavioral Deficits Associated With Chronic Hepatic Encephalopathy. American Journal of Gastroenterology, 114(1), S38-S39.

Agarwal, A. N., & Mais, D. D. (2019). Sensitivity and Specificity of Alzheimer Type II Astrocytes in Hepatic Encephalopathy. Archives of pathology & laboratory medicine, 143(10), 1256-1258.

Gutiérrez-de-Juan, V., López de Davalillo, S., Fernández-Ramos, D., Barbier-Torres, L., Zubiete-Franco, I., Fernández-Tussy, P., Simon, J., Lopitz-Otsoa, F., de Las Heras, J., Iruzubieta, P., Arias-Loste, M. T., Villa, E., Crespo, J., Andrade, R., Lucena, M. I., Varela-Rey, M., Lu, S. C., Mato, J. M., Delgado, T. C., & Martínez-Chantar, M. L. (2017). A morphological method for ammonia detection in liver. PloS one, 12(3), e0173914.

Mehta, R., GP trainee, Chinthapalli, K., & consultant neurologist (2019). Glasgow coma scale explained. BMJ (Clinical research ed.), 365, l1296.

Zhu, L., Zhang, W., Chen, L., Ren, Y., Cao, Y., Sun, T., Sun, B., Liu, J., Wang, J., & Zheng, C. (2022). Brain Gray Matter Alterations in Hepatic Encephalopathy: A Voxel-Based Meta-Analysis of Whole-Brain Studies. Frontiers in human neuroscience, 16, 838666.

Wang, M., Cui, J., Liu, Y., Zhou, Y., Wang, H., Wang, Y., Zhu, Y., Nguchu, B. A., Qiu, B., Wang, X., & Yu, Y. (2019). Structural and functional abnormalities of vision-related brain regions in cirrhotic patients: a MRI study. Neuroradiology, 61(6), 695-702.

Lu, C. Q., Jiao, Y., Meng, X. P., Cai, Y., Luan, Y., Xu, X. M., & Ju, S. (2018). Structural change of thalamus in cirrhotic patients with or without minimal hepatic encephalopathy and the relationship between thalamus volume and clinical indexes related to cirrhosis. NeuroImage. Clinical, 20, 800-807.

Norenberg, M. D. (1987). The role of astrocytes in hepatic encephalopathy. Neurochemical pathology, 6(1-2), 13-33.

Swaminathan, M., Ellul, M. A., & Cross, T. J. (2018). Hepatic encephalopathy: current challenges and future prospects. Hepatic medicine: evidence and research, 10, 1-11.

Tapper, E. B., Henderson, J. B., Parikh, N. D., Ioannou, G. N., & Lok, A. S. (2019). Incidence of and Risk Factors for Hepatic Encephalopathy in a Population-Based Cohort of Americans With Cirrhosis. Hepatology communications, 3(11), 1510-1519.

Goldstein, B. N., Wesler, J., Nowacki, A. S., Reineks, E., & Natowicz, M. R. (2017). Investigations of blood ammonia analysis: Test matrices, storage, and stability. Clinical biochemistry, 50(9), 537-539.

Haj, M., & Rockey, D. C. (2020). Ammonia Levels Do Not Guide Clinical Management of Patients With Hepatic Encephalopathy Caused by Cirrhosis. The American journal of gastroenterology, 115(5), 723-728.

Vierling, J. M., Mokhtarani, M., Brown, R. S., Jr, Mantry, P., Rockey, D. C., Ghabril, M., Rowell, R., Jurek, M., Coakley, D. F., & Scharschmidt, B. F. (2016). Fasting Blood Ammonia Predicts Risk and Frequency of Hepatic Encephalopathy Episodes in Patients With Cirrhosis. Clinical gastroenterology and hepatology, 14(6), 903-906.e1.

Jaeger, V., DeMorrow, S., & McMillin, M. (2019). The Direct Contribution of Astrocytes and Microglia to the Pathogenesis of Hepatic Encephalopathy. Journal of clinical and translational hepatology, 7(4), 352-361.

Chen J. R., Wang B. N., Tseng G. F., Wang Y. J., Huang Y. S., & Wang T. J. (2014). Morphological changes of cortical pyramidal neurons in hepatic encephalopathy. BMC Neurosci, 15, 15.

Finnie, J. W., Blumbergs, P. C., & Williamson, M. M. (2010). Alzheimer type II astrocytes in the brains of pigs with salt poisoning (water deprivation/intoxication). Australian veterinary journal, 88(10), 405-407.

Hough, S., Jennings, S. H., & Almond, G. W. (2015). Thiamine-responsive neurological disorder of swine. Journal of Swine Health and Production, 23, 143-151.

Cabrera-Pastor, A., Llansola, M., Montoliu, C., Malaguarnera, M., Balzano, T., Taoro-Gonzalez, L., García-García, R., Mangas-Losada, A., Izquierdo-Altarejos, P., Arenas, Y. M., Leone, P., & Felipo, V. (2019). Peripheral inflammation induces neuroinflammation that alters neurotransmission and cognitive and motor function in hepatic encephalopathy: Underlying mechanisms and therapeutic implications. Acta physiologica (Oxford, England), 226(2), e13270.




How to Cite

Shulyatnikova TV, Tumanskyi VO. Ammonia level and Alzheimer type 2 astrocytes in the brain of deceased patients with liver cirrhosis of the varying degree. Pathologia [Internet]. 2023Apr.28 [cited 2024Apr.21];20(1):36-44. Available from:



Original research