Address correspondence to Michael Wong, MD, PhD, Department of Neurology, Washington University School of Medicine PO Box 8111, 660 South Euclid Avenue, St. Louis, MO 63110, U.S.A. E-mail: email@example.com
The ketogenic diet (KD) is an effective treatment for epilepsy, but its mechanisms of action are poorly understood. We investigated the hypothesis that the KD inhibits mammalian target of rapamycin (mTOR) pathway signaling. The expression of pS6 and pAkt, markers of mTOR pathway activation, was reduced in hippocampus and liver of rats fed KD. In the kainate model of epilepsy, KD blocked the hippocampal pS6 elevation that occurs after status epilepticus. Because mTOR signaling has been implicated in epileptogenesis, these results suggest that the KD may have anticonvulsant or antiepileptogenic actions via mTOR pathway inhibition.
The ketogenic diet (KD) is an effective treatment for intractable epilepsy that appears to possess not only traditional anticonvulsant effects, but also disease-modifying and antiepileptogenic properties in humans and animal models. Patients treated with the KD often have improvement in seizure control that persists long after the diet has been discontinued (Marsh et al., 2006, Patel et al., 2010). In the kainic acid (KA)–induced status epilepticus (SE) animal model of temporal lobe epilepsy, injection of KA results in SE, followed by a latent period of epileptogenesis and later development of spontaneous recurrent seizures. Early treatment with KD prevents mossy fiber sprouting and spontaneous seizures in this model, suggesting that KD can prevent epileptogenesis (Muller-Schwarze et al., 1999; Su et al., 2000). A better understanding of the mechanisms of KD could help elucidate the cascade of events involved in epileptogenesis and identify potential therapeutic targets for more effective antiepileptic agents.
The mammalian target of rapamycin (mTOR) signaling pathway has recently generated interest as an important regulator of cellular changes involved in epileptogenesis. mTOR is a protein kinase that integrates energy, nutrient, and growth factor signals to regulate numerous cellular functions. mTOR is activated by phosphoinositide-3 kinase (PI3K)/Akt signaling in the presence of nutrients and growth factors, and inhibited by AMP-activated protein kinase (AMPK) in the setting of energy deprivation (Fig. 1A). Dysregulated mTOR signaling has been observed in a variety of models of genetic and acquired epilepsy, including tuberous sclerosis complex (TSC) and other cortical malformations, traumatic brain injury, and pilocarpine- and KA-induced SE (Wong, 2010). Furthermore, the mTOR inhibitor rapamycin prevents the development of epilepsy and underlying pathophysiologic mechanisms that cause epileptogenesis in animal models of TSC and KA-induced SE (Zeng et al., 2008, 2009). The ability of mTOR to integrate nutrient and energy signals makes it a plausible candidate for modulation by KD, which has widespread metabolic and nutritional effects on the brain and body. We, therefore, investigated the effects of KD on mTOR pathway signaling in normal rats, and in the KA epilepsy model.
Materials and Methods
Animals and dietary protocols
All experimental protocols were in compliance with National Institutes of Health (NIH) and Washington University Animal Studies Committee guidelines. For normal animal experiments, Sprague-Dawley rats (Charles River Laboratories, Wilmington, MA, U.S.A.) were given ad libitum access to KD (F3666; Bioserv Bio-Serve, Frenchtown, NJ, U.S.A.) or standard diet (SD) beginning at P21. By weight, the KD had a 6:1 ratio of fat to carbohydrate + protein. For the KA model, Sprague-Dawley rats were injected with KA (15 mg/kg, i.p., Sigma Sigma-Aldrich, St. Louis, MO, U.S.A.) at P35 to induce SE, and started on KD or SD after resolution of SE. Acute KA-induced seizures were monitored behaviorally using a modified Racine scale, and animals that developed stage 4 or 5 seizures for at least 3 h were included (Zeng et al., 2009). Serum beta-hydroxybutyrate levels were assayed using KetoSite reflectance photometry (Stanbio Laboratory, Boerne, TX, U.S.A.). For methods on western blotting, immunohistochemistry, and statistics see (Data S1).
In normal rats, western blot analysis demonstrated that KD reduced pS6 and pAkt expression in the hippocampus (24% and 14%, respectively, p < 0.05 for both, n = 7 per group) and liver (45% and 54%, respectively, p < 0.05 for both; Fig. 1B–E). There was a similar trend toward decreased pS6 and pAkt with KD in neocortex, but this was not statistically significant (Fig. S1). KD increased pAMPK in liver (44%, p < 0.001), but not in brain. Immunohistochemistry also demonstrated a reduction in hippocampal and neocortical pS6 expression in KD-fed rats fed (Fig. 1F–K). Baseline weights were similar in KD and SD groups at P21 (57.6 ± 0.8 and 59.1 ± 1.4 g, respectively), but after 2 weeks on their respective diets, KD-fed rats had significantly lower body weight (81.0 ± 3.1 and 174.4 ± 9.2 g, respectively, p < 0.001).
To determine the potential relevance of these KD effects on mTOR signaling to epileptogenesis, the effect of KD on mTOR activation was also assessed in the KA model. In SD-fed rats, KA-induced SE increased pS6 expression in the hippocampus, but not neocortex, at 1 (77%, p < 0.001, n = 7, compared to control, n = 8) and 7 days (38%, p < 0.05, n = 10) after SE, with return to baseline by 21 days (n = 7; Fig. 2). KD initiated immediately after resolution of SE did not prevent the increased pS6 expression at 1 day seen in KA-treated rats on SD, but blocked the increase in hippocampal pS6 expression at 7 days following SE. At 7 and 21 days, KD-fed rats had lower pS6 expression in both hippocampus and neocortex compared to SD-fed rats (p < 0.05, except 7 days hippocampus p < 0.01, 7 days n = 10 per group, 21 days n = 7 per group). Correlating with the effects on pS6 expression, KD induced a significant increase in beta-hydroxybutyrate levels compared to SD at 7 (SD 0.28 ± 0.03 mm, n = 5, KD 2.24 ± 0.20 mm, n = 6, p < 0.01) and 21 days (SD 0.24 ± 0.03 mm, n = 5, KD 1.77 ± 0.25 mm, n = 6, p < 0.05), but not 1 day, following SE. Weight gain was reduced in rats fed KD compared to SD at 7 days (SD +21.7 ± 7.7 g, KD −3.5 ± 4.6 g, p = 0.01, n = 10 per group) and 21 days (SD +148.9 ± 13.2 g, KD +6.9 ± 3.2 g, p < 0.001, n = 7 per group) after SE.
These results indicate that KD inhibits mTOR pathway signaling in the brain and liver of normal rats, most likely via decreased Akt signaling in both regions, as well as increased AMPK signaling in the liver. The KD has previously been shown to decrease insulin levels in rodents (Thio et al., 2006; Yamada, 2008), and a reduction in insulin would be expected to inhibit pAkt and consequently mTOR signaling. Therefore, lower insulin levels in KD-fed animals may trigger the observed decrease in pAkt and pS6. The mechanism by which the KD increased AMPK signaling in the liver but not brain is less clear. One possibility is that the KD reduces energy and nutrient availability in liver, but not brain. Previous reports of increased brain ATP and energy stores in KD-fed animals support this explanation (Devivo et al., 1978; Bough et al., 2006). In addition, observations that KD impairs growth in animals and children may also be explained by mTOR inhibition, given the role of mTOR in cellular growth and anabolic processes (Thio et al., 2006; Patel et al., 2010).
Alternatively, the observed mTOR inhibition may be due to other effects of the KD, including poor growth, protein restriction, or low glucose levels. Although KD-fed rats have significantly reduced growth, they have relatively preserved brain weights (Thio et al., 2006) and increased brain energy stores (Devivo et al., 1978). So although protein restriction or poor growth may contribute to mTOR inhibition in liver, it is unlikely to explain effects seen in brain. Furthermore, KD-fed rats exhibit increased caloric intake per body weight (Thio et al., 2006), which may partially compensate for low protein. Low glucose levels might also trigger mTOR inhibition, as we previously documented reduced serum glucose in KD-fed rats (Thio et al., 2006). However, low glucose and protein restriction would be expected to inhibit mTOR via AMPK activation, but we observed AMPK increases only in liver, not brain.
In this study, KD also prevented mTOR hyperactivation after KA-induced SE. Our previous work demonstrated that KA-induced SE results in biphasic mTOR activation, with a peak within 24 h of SE and a second peak in the hippocampus 7 days after SE, a time which corresponds to the latent period of epileptogenesis (Zeng et al., 2009). Rapamycin treatment after SE blocked the second phase of hippocampal mTOR activation, decreased mossy fiber sprouting in the dentate gyrus, and reduced spontaneous seizures. This suggests that in the KA model, late mTOR hyperactivation plays a role in epileptogenesis and pharmacologic mTOR inhibition after SE is antiepileptogenic. Our demonstration of a similar blockade of late hippocampal mTOR activation with KD provides a possible mechanism for antiepileptogenic effects of KD. Although we did not assess the effect on spontaneous seizures in the present study, this mTOR pathway inhibition during the latent period of epileptogenesis may explain the previously reported findings that KD initiation 2 days after KA-induced SE prevents mossy fiber sprouting and reduces spontaneous recurrent seizures, whereas KD initiation 14 days after SE has no effect on seizure frequency (Muller-Schwarze et al., 1999; Su et al., 2000). However, the ability of the KD to prevent sprouting remains controversial, as other studies found no effect of the KD on mossy fiber sprouting in dentate gyrus after KA-induced SE (Xu et al., 2006).
In summary, this study demonstrates that KD inhibits mTOR pathway signaling in the brain and liver of healthy rats, and prevents late hippocampal mTOR activation after KA-induced SE. This mTOR inhibition may underlie some of the physiologic effects of KD, including growth impairment, anticonvulsant actions, and potential antiepileptogenic effects. Further studies are necessary to prove a causal relationship between mTOR inhibition and antiepileptogenic actions of the KD.
This work was supported by NIH R01 NS056872 (MW) and P30NS057105 (Washington University).
None of the authors has any conflict of interest to disclose. The authors have read the Journal’s position on issues involved in ethical publications and affirm that this report is consistent with those guidelines.