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Alcohol, Oxidative Stress, and

Free Radical Damage

Defeng Wu, Ph.D., and Arthur I. Cederbaum, Ph.D.

Reactive oxygen species (ROS) are small, highly reactive, oxygen-containing molecules that are
naturally generated in small amounts during the body’s metabolic reactions and can react with
and damage complex cellular molecules such as fats, proteins, or DNA. Alcohol promotes the
generation of ROS and/or interferes with the body’s normal defense mechanisms against these
compounds through numerous processes, particularly in the liver. For example, alcohol
breakdown in the liver results in the formation of molecules whose further metabolism in the
cell leads to ROS production. Alcohol also stimulates the activity of enzymes called cytochrome
P450s, which contribute to ROS production. Further, alcohol can alter the levels of certain
metals in the body, thereby facilitating ROS production. Finally, alcohol reduces the levels of
agents that can eliminate ROS (i.e., antioxidants). The resulting state of the cell, known as
oxidative stress, can lead to cell injury. ROS production and oxidative stress in liver cells play a
central role in the development of alcoholic liver disease. KEY WORDS: alcoholic liver disorder;
oxidative stress; free radicals; reactive oxygen species; chronic AODE (alcohol and other drug effects);
NAD; NADH oxidoreductases; cytochrome P450; peroxidation; metals; proteins; DNA; lipids;
glutathione peroxidase; biochemical mechanism; survey of research

s described throughout the terms and concepts will be defined and radicals, ROS, and oxidative stress is
articles in this issue of Alcohol explained in more detail in the follow- followed by a review of the alcohol-related
Research & Health, alcohol acts ing sections.) Particularly important are cellular systems involved in ROS pro-
through numerous pathways to affect the actions of a class of oxygen-containing duction. Next, the article explains why
the liver and other organs and to lead free radicals known as reactive oxygen ROS are toxic to cells and what systems
to the development of alcoholic liver species (ROS). ROS can damage or have evolved to help cells protect them-
disease (ALD) (for summaries of many cause complete degradation (i.e., perox- selves against ROS. Finally, the role of
of these pathways, see Cederbaum 2001; idation) of essential complex molecules ROS and oxidative stress in alcohol-
Bondy 1992; Nordmann et al. 1992). in the cells, including fat molecules induced cell injury is discussed, with
No single process or underlying mecha- (i.e., lipids), proteins, and DNA. Both suggestions about future directions for
nism can account for all the effects of acute and chronic alcohol exposure research in this field. Although this dis-
alcohol on an organism or even on one can increase production of ROS and cussion focuses on the role of oxidative
specific organ; instead, many mechanisms enhance peroxidation of lipids, protein, stress in alcoholic liver disease, alcohol-
act in concert, reflecting the spectrum and DNA, as has been demonstrated in induced oxidative stress also occurs in
of the organism’s response to a myriad a variety of systems, cells, and species, and damages other tissues (e.g., muscle,
of direct and indirect actions of alcohol. including humans. pancreas, and nerve cells).
One factor that has been suggested as Researchers have learned much about
playing a central role in many pathways alcohol metabolism and the various DEFENG WU, PH.D., is a research associate
of alcohol-induced damage, and which enzymes and pathways involved, as well professor, and ARTHUR I. CEDERBAUM,
has been the focus of much research, is as about the role of lipid peroxidation PH.D., is a professor, both in the Department
the excessive generation of molecules and oxidative stress in alcohol toxicity. of Pharmacology and Biological Chemistry,
called free radicals, which can result in This article summarizes some of these Mount Sinai School of Medicine, New
a state called oxidative stress. (These findings. A detailed description of free York, New York.

Vol. 27, No. 4, 2003 277

What Are Free Radicals several molecules of ATP for each electron such as acute or chronic alcohol expo­
and ROS? that passes through the respiratory chain. sure, ROS production is enhanced
Molecular oxygen can accept a total and/or the level or activity of antioxi­
A free radical is an atom, molecule, or of four electrons, one at a time, and the dants is reduced. The resulting state—
compound that is highly unstable because corresponding number of protons to which is characterized by a disturbance
of its atomic or molecular structure (i.e., generate two molecules of water. During in the balance between ROS produc­
the distribution of electrons within the this process, different oxygen radicals tion on one hand and ROS removal
molecule). As a result, free radicals are are successively formed as intermediate and repair of damaged complex
very reactive as they attempt to pair up products, including superoxide (O2• – ); molecules (such as proteins or DNA)
with other molecules, atoms, or even peroxide (O2=), which normally exists on the other—is called oxidative stress
individual electrons to create a stable in cells as hydrogen peroxide (H2O2); (Halliwell 1999). Oxidative stress is
compound. To achieve a more stable and the hydroxyl radical (•OH). Super­ associated with numerous deleterious
state, free radicals can “steal” a hydro­ oxide, peroxide, and the hydroxyl radi­
consequences for the cell (e.g., lipid
gen atom from another molecule, bind cal are considered the primary ROS
to another molecule, or interact in vari­ and have sparked major research on
ous ways with other free radicals (see the role of free radicals in biology and
medicine.3 However, because they are Reactions Involving
the textbox).
One chemical element frequently unstable and rapidly react with addi­ Free Radicals
involved in free radical formation is oxy­ tional electrons and protons, most of
these ROS are converted to water Free radicals are highly unstable
gen. Molecular oxygen (O2) is essential molecules that attempt to
for cell function because it plays a piv­ before they can damage cells. It has
been estimated that only about 2 to 3 achieve a more stable state by
otal role in a series of biochemical reac­ reacting with other atoms or
tions occurring in the respiratory chain, percent of the O2 consumed by the res­
piratory chain is converted to ROS molecules in the cell. The
which is responsible for most of the four primary types of chemical
production of adenosine triphosphate (Chance et al. 1979). Nevertheless,
the toxic effects of oxygen in biological reactions that free radicals
(ATP), which provides the energy required undergo are:
for a multitude of cellular reactions and systems—such as the breakdown (i.e.,
oxidation) of lipids, inactivation of
functions. (For more information on
enzymes, introduction of changes (i.e., • Hydrogen abstraction, in
the respiratory chain and ATP produc­
mutations) in the DNA, and destruc­ which a radical interacts with
tion, see the article by Cunningham
tion of cell membranes and, ultimately, another molecule that has a
and Van Horn in this issue.) cells—are attributable to the reduction
In the respiratory chain, which takes free hydrogen atom (i.e., a
of O2 to ROS (Toykuni 1999; de hydrogen donor). As a result,
place in membrane-enclosed cell struc­ Groot 1994; Nakazawa et al. 1996).
tures called mitochondria, an electron the radical binds to the hydro­
and a proton (H+) are removed from a gen atom and becomes stable,
helper molecule (i.e., cofactor) called whereas the hydrogen donor
What Is Oxidative Stress? is converted to a free radical.
reduced nicotinamide adenine dinu­
cleotide (NADH).1 The electron is Because ROS form naturally during
transferred to the first component of • Addition, in which the radical
many metabolic processes, cells have binds to another, originally
the respiratory chain, and the proton is developed several protective mecha­
released into the surrounding fluid. stable molecule, converting
nisms to prevent ROS formation or to the combined molecule into
Chemically speaking, NADH is oxidized detoxify the ROS. These mechanisms
to NAD+ in this reaction, whereas the a radical.
employ molecules called antioxidants,
respiratory chain, component that accepts which will be discussed in more detail
the electron is reduced.2 The NAD+ • Termination, in which two
in the section “Protection Against ROS radicals react with each other
subsequently can be used again to accept Toxicity.” Under certain conditions,
new hydrogen atoms that are generated to form a stable compound.
during the metabolism of sugars (e.g., 1
NADH is generated in the fluid filling the cell (i.e., the
glucose) and other nutrients. The reduced cytosol) and then moves to the mitochondria.
• Disproportionation, in which
respiratory chain component, in turn, two identical radicals react

passes the electron on to other molecules

Oxidation reactions are those that add oxygen to a
molecule or remove hydrogen or an electron from a
with each other, with one of
in the respiratory chain until it is finally molecule. The reverse reactions (i.e., removal of oxygen the radicals donating an elec­
transferred to O2, which then interacts
or addition of hydrogen or electrons) are called reductions. tron to the other so that two
3 different molecules are formed,
with protons in cells to generate water. Superoxide can react with itself to produce H2O2. Thus,
systems producing superoxide also will result in formation each of which is stable.
This series of electron transfer reactions of H2O2. Technically, H2O2 is not a free radical, but it is
generates sufficient energy to produce commonly included among the ROS.

278 Alcohol Research & Health

Alcohol, Oxidative Stress, and Free Radical Damage

peroxidation or even cell death), and tion of certain signaling molecules

Systems Producing ROS
alcohol-induced oxidative stress may called cytokines, which in turn lead

play a significant role in the develop­ to the activation of an array of bio­

As implied in the previous section,
ment of ALD. chemical processes. (For more infor­
numerous cellular systems can produce
Many processes and factors are mation on alcohol’s effect on cytokine
ROS. The major source of ROS pro­
involved in causing alcohol-induced duction in the cell is the mitochondrial
oxidative stress, including: production and its consequences,
respiratory chain, which, as described
see the article in this issue by Neuman.)
earlier, utilizes approximately 80 to 90
• Changes in the NAD+/NADH ratio percent of the O2 a person consumes.
in the cell as a result of alcohol • Alcohol-induced increase in the Thus, even though only a small per­
metabolism. Alcohol is metabolized ability of the bacterial molecule centage of that oxygen is converted to
in two steps. First, the enzyme alco­ endotoxin to enter the bloodstream ROS, the mitochondrial respiratory
hol dehydrogenase converts alcohol and liver, where it can activate cer­ chain in all cells generates most of the
to acetaldehyde, a toxic and reactive tain immune cells. (For more infor­ ROS produced in the body.
molecule. Next, the enzyme aldehyde mation on the role of endotoxin in Another major source of ROS, espe­
dehydrogenase converts the acetalde­ liver damage, see the article by
cially in the liver, is a group of enzymes
hyde to acetate. Each of these reac­ called the cytochrome P450 mixed-
tions leads to formation of one Wheeler in this issue.) function oxidases. Many different variants
molecule of NADH, thereby pro­ of these iron-containing enzymes exist,
viding more starting material and • Alcohol-induced increases in the some of which are responsible for
thus enhanced activity of the respi­ activity of the enzyme cytochrome removing or detoxifying a variety of
ratory chain, including heightened P450 2E1 (CYP2E1), which (as compounds present in our environment
O2 use and ROS formation. described in the section “Systems and ingested (e.g., foods or drugs),
Producing ROS”) metabolizes alco­ including alcohol. Some cytochrome
• Production of acetaldehyde during hol and other molecules and gener­ P450 enzymes also are important for
alcohol metabolism, which through ates ROS in the process. metabolizing substances that naturally
its interactions with proteins and occur in the body, such as fatty acids,
lipids also can lead to radical forma­ cholesterol, steroids, or bile acids. The
• Alcohol-induced increases in the
tion and cell damage. (For informa­ biochemical reactions spurred (i.e.,
tion on acetaldehyde and its detri­ levels of free iron in the cell (i.e., catalyzed) by the cytochrome P450
mental effects, see the article in this iron that is not bound to various molecules use molecular oxygen, and
issue by Tuma and Casey.) proteins), which can promote ROS during these reactions small amounts
generation, as described in the sec­ of ROS are generated. The extent of
• Damage to the mitochondria result­ tion “Role of Metals.” ROS generation may vary considerably
ing in decreased ATP production. depending on the compound to be
• Effects on antioxidant enzymes and degraded and on the cytochrome
• Effects on cell structure (e.g., the chemicals, particularly a molecule P450 molecule involved. One type of
membranes) and function caused by called glutathione (GSH), as described cytochrome molecule that is especially
alcohol’s interactions with either mem­ active in producing ROS is known as
brane components (i.e., phosphate- in the section “Protection Against CYP2E1. This enzyme is of particular
containing lipids [phospholipids]) ROS Toxicity.” interest when investigating alcohol-
or enzymes and other protein com­ induced oxidative stress because its
ponents of the cells. • Biochemical reactions generating activity increases after heavy alcohol
an alcohol-derived radical (i.e., the exposure and because CYP2E1 itself
• Alcohol-induced oxygen deficiency 1-hydroxyethyl radical). also metabolizes alcohol (Lieber 1997).
(i.e., hypoxia) in tissues, especially ROS also are produced by a variety
in certain areas of the liver lobules • Conversion of the enzyme xanthine of oxidative enzymes present in cells,
(i.e., the pericentral region), where dehydrogenase into a form called such as the previously mentioned xan­
extra oxygen is required to metabolize xanthine oxidase, which can gener­ thine oxidase. Under normal physiolog­
the alcohol. (For more information ate ROS. ical conditions, xanthine oxidase acts
on alcohol-induced hypoxia in the as a dehydrogenase—that is, it removes
liver and its consequences, see the hydrogen from xanthine or hypoxanthine
article by Cunningham and Van Many of these processes operate and attaches it to NAD, thereby gener­
Horn in this issue.) concurrently, and it is likely that sev­ ating NADH. However, under certain
eral, indeed many, systems contribute conditions, such as the disruption of blood
• Alcohol’s effects on the immune sys­ to the ability of alcohol to induce a flow to a tissue, xanthine dehydroge­
tem, which lead to altered produc- state of oxidative stress. nase is converted to a ROS-producing

Vol. 27, No. 4, 2003 279

oxidase form. Alcohol consumption also Role of Metals Why Are ROS Toxic?
may promote the conversion of xanthine
Most of the systems for the production ROS are toxic to cells because they can
dehydrogenase to xanthine oxidase of ROS described above produce super­
(Sultatos 1988), which can generate react with most cellular macro­
oxide radicals or hydrogen peroxide. molecules, including proteins, lipids,
ROS, thereby enhancing oxidative stress. Earlier studies suggested the possibility
Other sources of ROS in the body and DNA.
that these two radicals could interact Proteins perform numerous crucial
are two types of immune cells called with each other to produce the most
macrophages and neutrophils, which functions in the cell, primarily in the
reactive ROS, the hydroxyl radical (•OH). form of enzymes that mediate most
help defend the body against invading Under normal physiological condi­ biochemical reactions required for cel­
microorganisms. In this case, however, tions, direct interaction between these lular functions. Proteins are made up of
ROS production is beneficial and even two radicals is not likely to play a sig­ approximately 20 different building
essential to the organism because it nificant role in generating hydroxyl blocks called amino acids, which differ
plays a central role in destroying for­ radicals. However, in the presence of in their sensitivity to interactions with
eign pathogens (Rosen et al. 1995). certain metals, particularly free iron or ROS. For example, the amino acids
Macrophages and neutrophils contain copper ions, a sequence of two reaction cysteine, methionine, and histidine are
a group of enzymes called the NADPH steps can occur that results in hydroxyl especially sensitive to attack and oxidation
oxidase complex, which, when activated, radical generation. In the first step, by the hydroxyl radical. Accordingly,
generates superoxide radicals and hydro­ hydrogen peroxide can produce the enzymes in which these amino acids
gen peroxide. Hydrogen peroxide then hydroxyl radical by removing an elec­ are located at positions that are critical
interacts with chloride ions present in tron from the participating metal ion.4 to the enzyme’s activity will become
the cells to produce hypochlorite (the inactivated by the interaction with ROS.
In the second step, involving the super­
Alternatively, the ROS-induced oxida­
active ingredient in bleach), which in oxide radical (O2• – ), the original metal tion of proteins can lead to changes in
turn destroys the pathogen. The NADPH ions are regenerated so that they are again the proteins’ three-dimensional structure
oxidase complex and the resulting ROS available for reaction with the hydrogen as well as to fragmentation, aggregation,
production are critical to the body’s peroxide. This combination of two or cross-linking of the proteins. Finally,
defense against all kinds of diseases, as chemical reactions appears to account protein oxidation often will make the
is evident in patients with a condition for most of the hydroxyl radical pro­ marked protein more susceptible to
called chronic granulomatous disease, duction in biological systems and explains, degradation by cellular systems respon­
in which ROS production by the at least in part, why metals such as iron sible for eliminating damaged proteins
NADPH oxidase complex is drastically and copper produce oxidative stress from the cell.
reduced. Patients with this condition and ROS-induced injury in cells. Lipids that contain phosphate groups
are highly sensitive to infections and Because of iron’s critical contribution (i.e., phospholipids) are essential com­
usually die at an early age. to hydroxyl radical formation, anything ponents of the membranes that sur­
Besides the ROS generation that that increases the levels of free iron in round the cells as well as other cellular
occurs naturally in the body, humans the cells promotes ROS generation and structures, such as the nucleus and
are constantly exposed to environmen­ oxidative stress. Chronic alcohol con­ mitochondria. Consequently, damage
tal free radicals, including ROS, in the sumption has been shown to increase to the phospholipids will compromise
form of radiation, UV light, smog, iron levels in the body not only when the viability of the cells. The complete
iron-rich alcoholic beverages, such as red degradation (i.e., peroxidation) of lipids
tobacco smoke, and certain compounds
wine, are consumed, but also because is a hallmark of oxidative damage. The
referred to as redox cycling agents, polyunsaturated fatty acids5 present in
which include some pesticides, but also chronic alcohol consumption enhances
the membranes’ phospholipids are par­
certain medications used for cancer iron absorption from food (see Nanji ticularly sensitive to attack by hydroxyl
treatment. The toxicity of these medi­ and Hiller-Sturmhöfel 1997). Similarly, radicals and other oxidants. A single
cations against tumor cells (as well as adding iron to alcohol-containing diets hydroxyl radical can result in the perox­
normal body cells) results from the fact has been shown to exacerbate liver idation of many polyunsaturated fatty
that the compounds are modified by injury in animal studies (Tsukamoto et acid molecules because the reactions
cellular enzymes to an unstable inter­ al. 1995), whereas administration of involved in this process are part of a
mediate, which then reacts with molec­ agents that capture free iron can pre­
ular oxygen to produce the original vent or ameliorate alcohol’s toxic effects 5
Unsaturated fatty acids are those that contain a double

product plus a superoxide radical. Thus, on the liver (Sadrzadeh et al. 1994). bond between two of the carbon atoms making up the
backbone of the fatty acid molecule. These double bonds
a vicious cycle of chemical reactions can easily be opened in chemical reactions and interact
4 with other substances. Fatty acids containing only one
This reaction can generate other products as well, but
involving these compounds continually the hydroxyl radical appears to be the primary oxidant such double bond are called monounsaturated; fatty acids
produces ROS. generated (McCord 1998). with two or more double bonds are called polyunsaturated.

280 Alcohol Research & Health

Alcohol, Oxidative Stress, and Free Radical Damage

cyclic chain reaction. In addition to (SODs), catalase, and glutathione per­ tors glutathione (GSH) and reduced
damaging cells by destroying mem­ oxidase. SODs catalyze the rapid removal nicotinamide adenosine dinucleotide
branes, lipid peroxidation can result in of superoxide radicals. In mammals phosphate (NADPH).7 Together, these
the formation of reactive products that there are several types of SODs, which molecules effectively remove hydrogen
themselves can react with and damage differ with respect to their location in peroxide. GSH, which consists of three
proteins and DNA. (For more infor­ the cells and the metal ions they require amino acids, is an essential component
mation regarding the actions of such for their function. For example, a copper– of this system and serves as a cofactor
reactive products, see the article by Tuma zinc SOD is present in the fluid filling for an enzyme called glutathione trans­
and Casey in this issue.) the cell (i.e., the cytosol) and in the ferase, which helps remove certain drugs
DNA is the cell’s genetic material, and space between the two membranes and chemicals as well as other reactive
any permanent damage to the DNA surrounding the mitochondria. Further­ molecules from the cells. Moreover,
can result in changes (i.e., mutations) more, a manganese-containing SOD GSH can interact directly with certain
in the proteins encoded in the DNA, is present in the mitochondrial interior ROS (e.g., the hydroxyl radical) to
which may lead to malfunctions or (i.e., matrix). Both of these enzymes are detoxify them, as well as performing
complete inactivation of the affected critical for prevention of ROS-induced other critical activities in the cell.
proteins. Thus it is essential for the toxicity (Fridovich 1997).6 The effects
viability of individual cells or even the of chronic alcohol exposure on the cellu­
entire organism that the DNA remain lar content or activity of SODs are con­
Nonenzymatic Mechanisms
intact. The building blocks of DNA troversial, with reports of increases, no Because of all its functions, GSH is
molecules are called nucleotides; they changes, or decreases, depending on probably the most important antioxi­
consist of a sugar component and an the model, diet, amount, and time of dant present in cells. Therefore, enzymes
organic base. Each DNA molecule con­ alcohol feeding. Studies employing a that help generate GSH are critical to
sists of two strands of nucleotides held commonly used model in which alcohol the body’s ability to protect itself against
together by weak chemical bonds. Changes is administered directly into the stom­ oxidative stress. Alcohol has been shown
in the nucleotides in one strand can ach of laboratory animals (i.e., the to deplete GSH levels, particularly in
result in mismatches with the nucleotides intragastric infusion model, used most the mitochondria, which normally are
in the other strand, yielding subsequent commonly with rats and mice) found characterized by high levels of GSH
mutations. ROS are a major source of decreases in SOD activity in the liver needed to eliminate the ROS generated
DNA damage, causing strand breaks, (Polavarapu et al. 1998) (see the article during activity of the respiratory chain.
removal of nucleotides, and a variety of by Nanji and French in this issue). Mitochondria cannot synthesize
modifications of the organic bases of the Catalase and the glutathione peroxi­ GSH but import it from the cytosol
nucleotides. Although cells have devel­ dase system both help to remove hydrogen using a carrier protein embedded in the
oped repair mechanisms to correct nat­ peroxide. Catalase is an iron-containing membrane surrounding the mitochon­
urally occurring changes in the DNA, enzyme found primarily in the small dria. Alcohol appears to interfere with
additional or excessive changes caused membrane-enclosed cell components the function of this carrier protein,
by ROS or other agents can lead to called peroxisomes; it serves to detoxify thereby leading to the depletion of
permanent changes or damage to the hydrogen peroxide and various other mitochondrial GSH (Fernandez-Checa
DNA, with potentially detrimental effects molecules. One way that catalase elimi­ et al. 1997).
for the cell. nates hydrogen peroxide is by catalyz­ NADPH is involved in a much
ing a reaction between two hydrogen more diverse range of reactions in the
peroxide molecules, resulting in the cell than GSH. Nevertheless, because
Protection Against ROS formation of water and O2. In addition, of its role in the glutathione peroxidase
Toxicity catalase can promote the interaction of system, NADPH or the enzymes that
hydrogen peroxide with compounds generate this compound are sometimes
Because ROS production is a naturally that can serve as hydrogen donors so considered antioxidants.
occurring process, a variety of enzymatic that the hydrogen peroxide can be con­ In addition to GSH and NADPH,
and nonenzymatic mechanisms have verted to one molecule of water, and numerous other nonenzymatic anti­
evolved to protect cells against ROS (Yu the reduced donor becomes oxidized oxidants are present in the cells, most
1994). At least some of these mechanisms (a process sometimes called the peroxi­ prominently vitamin E (α-tocopherol)
are impaired after long-term alcohol datic activity of catalase). Compounds and vitamin C (ascorbate). Vitamin E
consumption and may therefore contribute that can provide these hydrogen atoms is a major antioxidant found in the lipid
to damage to the liver and other organs. include beverage alcohol (i.e., ethanol)
and methanol. 6
Another type of SOD (EC–SOD) is found outside the cells.
The glutathione peroxidase system
Protective Enzymes consists of several components, includ­ 7
Glutathione peroxidase contains an amino acid that is
modified by addition of a molecule of the metal selenium;
Enzymes involved in the elimination ing the enzymes glutathione peroxidase therefore, low amounts of selenium are critical for the
of ROS include superoxide dismutases and glutathione reductase and the cofac­ body’s antioxidant defense.

Vol. 27, No. 4, 2003 281

phase of membranes and, like other with ALD commonly exhibit reduced a variety of human diseases (see the
chemically related molecules, acts as a vitamin E levels (see Nanji and Hiller- sidebar). What is the evidence that
powerful terminator of lipid peroxidation. Sturmhöfel 1997). alcohol-induced oxidative stress plays a
During the reaction between vitamin E role in cell injury, particularly damage
and a lipid radical, the vitamin E radical to the liver cells? Many studies have
is formed, from which vitamin E can Alcohol, Oxidative Stress, demonstrated that alcohol increases
be regenerated in a reaction involving and Cell Injury lipid peroxidation as well as the modifi­
GSH and ascorbate. Alcohol also appears cation of proteins; however, it is not
to interfere with the body’s normal Excess levels of ROS and the resulting always clear if these changes are the
vitamin E content because patients oxidative stress have been implicated in causes rather than consequences of

Diseases Involving Excessive ROS Levels

In addition to contributing to the development of Finally, increasing evidence suggests that aging may
ALD, ROS have been implicated in many other major be a consequence of the normal, long-term exposure
diseases that plague humans. A partial listing of these to ROS and the accumulation of oxidized, damaged
conditions (Knight 1998; Kehrer 1993) includes: molecules within the cell—a process that could be
likened to a lifetime of “rusting away.”
• The toxic effects of O2 itself, such as the oxidation of Accordingly, the health benefits of administering
lipids and proteins, generation of mutations in the antioxidants such as vitamins E and C or other com­
DNA, and destruction of cell membranes.
pounds are the subject of much current research, and
• Cardiovascular diseases. clinical trials employing antioxidants in the treatment
of various conditions are under way. For example, some
• Atherosclerosis. therapeutic interventions with antioxidants have shown
success or promise in the treatment of Parkinson’s dis­
• Various types of cancer. ease and in reducing the toxicity of the cancer medi­
cation adriamycin.
• Diabetes. Not all instances of ROS production are detrimen­
tal to the organism, however. One beneficial effect, as
• Neurodegenerative diseases, including Parkinson’s the main article describes, is the production of ROS by
disease and Alzheimer’s disease.
certain immune cells in order to destroy invading foreign
• Toxicity of heavy metals (e.g., iron). organisms (Rosen et al. 1995). Furthermore, recent
evidence suggests that ROS, especially hydrogen perox­
• Radiation injury. ide, may be important in signal transduction mecha­
nisms in cells and thus may be an integral component
• Vitamin deficiency. of cellular physiology and metabolism (Lander 1997).
• Toxicity of certain medications. —Defeng Wu and Arthur I. Cederbaum

• Inflammation, such as the destruction of joints, the References

synovial fluid that lubricates joints and one of its
components (i.e., hyaluronic acid), as well as activa­ KEHRER, J.P. Free radicals as mediators of tissue injury and disease.
tion of inflammation-promoting signaling molecules Critical Reviews in Toxicology 23:21–48, 1993.
called cytokines.
KNIGHT, J.A. Free radicals: Their history and current status in aging
• Toxic effects of tobacco smoke. and disease. Annals of Clinical and Laboratory Science 28:331–346, 1998.

LANDER, H.M. An essential role for free radicals and derived species in
• Emphysema. signal transduction. FASEB Journal 11:118–124, 1997.

ROSEN, G.M.; POU, S.; RAMOS, C.L.; ET AL. Free radicals and phago­
• Cataracts. cytic cells. FASEB Journal 9:200–209, 1995.

282 Alcohol Research & Health

Alcohol, Oxidative Stress, and Free Radical Damage

alcohol-induced tissue injury. Nevertheless, continuously had been fed alcohol humans will be a difficult task because
numerous investigations have found indicated that alcohol metabolism via ROS production and antioxidant status
that administering antioxidants, agents the enzyme alcohol dehydrogenase in humans are affected by numerous
that reduce the levels of free iron, or results in increased ROS production, nutritional, environmental, and drug
agents that replenish GSH levels can hepatocyte injury, and a type of cell influences that are difficult to repro­
prevent or ameliorate the toxic actions death known as apoptosis. Moreover, duce in animals. To date, scattered data
of alcohol. For example, in the intra- all of these reactions could be blocked suggest that the blood of human alco­
gastric infusion model, the antioxidant by the administration of antioxidants holics can contain lipids modified by
vitamin E; the chemical ebselen, which (Adachi and Ishii 2002; Bailey and radicals and other reactive molecules as
mimics the actions of glutathione per­ Cunningham 2002). Finally, studies well as immune molecules targeted at
oxidase; the copper–zinc or manganese using an established hepatocyte cell line such modified lipids and proteins.
SODs; or a GSH precursor—all pre­ that contains the alcohol-metabolizing These data indicate that ROS and
vented ALD (Iimuro et al. 2000; Nanji and ROS-producing enzyme CYP2E1 other reactive molecules are indeed
et al. 1996; Kono et al. 2001; Wheeler demonstrated that adding alcohol, formed in human alcoholics. (For more
et al. 2001a,b). polyunsaturated fatty acids, or iron, as information on the presence of such
The most convincing data indicat­ well as reducing GSH, resulted in cell compounds in humans, see the article
ing that oxidative stress contributes to toxicity, increased oxidative stress, and by Tuma and Casey in this issue.)
ALD come from studies using the intra- mitochondrial damage (Wu and Other questions that should be
gastric infusion model. In these studies, Cederbaum 1999). Furthermore, all of addressed in future research include
ALD was associated with enhanced these reactions could be prevented by the following:
lipid peroxidation, protein modification, administering antioxidants. Taken
formation of the 1-hydroxyethyl radical together, these findings indicate that • Do reactive nitrogen species (e.g.,
and lipid radicals, and decreases in the alcohol-induced oxidative stress is a nitric oxide) play a role in alcohol-
hepatic antioxidant defense, particularly pivotal factor in the development of ALD. induced oxidative stress in addition
GSH levels (Knecht et al. 1995; Tsuka­ to ROS?
moto and Lu 2001; Iimuro et al. 2000;
Nanji et al. 1994; Morimoto et al. 1994). Future Directions for • What is the impact of possible interac­
Moreover, changes in the animals’ diets Research tions between alcohol and environ­
that helped promote or reduce oxidative mental influences such as smoking,
stress led to corresponding changes in Although researchers already have gained use of other drugs or medications,
the extent of liver injury. For example, substantial insight into the mechanisms and viral infections (e.g., hepatitis C)
when polyunsaturated fats (which are and consequences of alcohol-induced on ROS production, oxidative stress,
required for lipid peroxidation to occur) oxidative stress, additional studies are and tissue injury? These interactions
were replaced with saturated fats or required to further clarify how alcohol must be better defined because most
other types of fats (i.e., medium-chain produces oxidative stress in various tis­ alcoholics are exposed to one or
triglycerides), lipid peroxidation as sues. For example, more detailed infor­ more of these influences in addition
well as ALD were reduced or prevented mation is needed on the mechanisms to alcohol.
completely, indicating that both alcohol involved in some of the major proposed
and polyunsaturated fats must be pre­ pathways (e.g., how alcohol-derived • How is oxidative stress affected by
sent for ALD to occur. The extent of NADH leads to ROS production either interactions between alcohol and
the ALD was further exacerbated when directly or during the passage of NADH- nutritional factors, such as the levels
iron—which, as mentioned earlier, is derived electrons through the mito­ and specific types of fats ingested?
required for the generation of the chondrial respiratory chain). Other And how much iron is “safe” in a
hydroxyl radical and therefore pro­ mechanisms remain highly controver­ heavy drinker?
motes oxidative stress—was added to sial, such as the role of CYP2E1 or of
these diets (Tsukamoto et al. 1995). various cytokines in alcohol-induced • What are the effects of antioxidants
Conversely, the addition of antioxidants oxidative stress. Additional analyses (e.g., vitamin E, vitamin C, or
such as vitamin E, SOD, or GSH pre­ need to determine the role of alcohol carotenoids) in heavy drinkers? This
cursors prevented the development of metabolism and its byproducts (e.g., question is important because some
ALD, as mentioned above. acetaldehyde) in the production of antioxidants can be toxic under cer­
In addition to these studies conducted ROS. Finally, it still is unclear how tain conditions.
with intact animals (i.e., in vivo), studies alcohol-induced oxidative stress is pro­
with liver cells (i.e., hepatocytes) grown duced in tissues where only limited The ability of alcohol to promote
in culture also showed that alcohol can alcohol metabolism occurs. oxidative stress and the role of free radi­
produce oxidative stress and hepatocyte Many of these issues can be studied cals in alcohol-induced tissue injury
toxicity. Studies with hepatocytes iso­ using animal models; however, extrapo­ clearly are important areas of research
lated from control rats or from rats that lation of findings from animals to in the alcohol field, particularly because

Vol. 27, No. 4, 2003 283

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