Laurence J. Britton

Iron and non-alcoholic fatty liver disease

The mechanisms that promote liver injury in non-alcoholic fatty liver disease (NAFLD) are yet to be thoroughly elucidated. As such, effective treatment strategies are lacking and novel therapeutic targets are required. Iron has been widely implicated in the pathogenesis of NAFLD and represents a potential target for treatment. Relationships between serum ferritin concentration and NAFLD are noted in a majority of studies, although serum ferritin is an imprecise measure of iron loading. Numerous mechanisms for a pathogenic role of hepatic iron in NAFLD have been demonstrated in animal and cell culture models. However, the human data linking hepatic iron to liver injury in NAFLD is less clear, with seemingly conflicting evidence, supporting either an effect of iron in hepatocytes or within reticulo-endothelial cells. Adipose tissue has emerged as a key site at which iron may have a pathogenic role in NAFLD. Evidence for this comes indirectly from studies that have evaluated the role of adipose tissue iron with respect to insulin resistance. Adding further complexity, multiple strands of evidence support an effect of NAFLD itself on iron metabolism. In this review, we summarise the human and basic science data that has evaluated the role of iron in NAFLD pathogenesis.

Urea production during normothermic machine perfusion: Price of success?

Oxygenated normothermic machine perfusion (NMP) has been proposed as a technique that may provide the means to preserve organ function and, moreover, accurately predict clinical outcomes because graft function can be analyzed before the transplant procedure. Promising results have been obtained in several animal models, and a recent pilot study of discarded human donor livers showed that NMP was feasible and that graft viability could be assessed. We have successfully established an ex vivo normothermic oxygenated perfusion circuit using only a single centrifugal pump. We perfused 4 human donor livers that were currently deemed unsuitable for transplantation on the basis of local criteria. Interestingly, we observed high levels of calculated osmolality in the perfusate; we believe this problem should be addressed in order to implement this new technique in clinical practice.

Ferroportin expression in adipocytes does not contribute to iron homeostasis or metabolic responses to a high calorie diet

Background & Aims Iron has an increasingly recognized role in the regulation of adipose tissue function, including the expression of adipokines involved in the pathogenesis of nonalcoholic fatty liver disease. The cellular iron exporter, ferroportin, has been proposed as being a key determinant of adipocyte iron homeostasis. Methods We studied an adipocyte-specific ferroportin (Fpn1) knockout mouse model, using an Adipoq-Cre recombinase driven Fpn1 deletion and fed mice according to the fast food diet model of nonalcoholic steatohepatitis. Results We showed successful selective deletion of Fpn1 in adipocytes, but found that this did not lead to increased adipocyte iron stores as measured by atomic absorption spectroscopy or histologically quantified iron granules after staining with 3,3’-diaminobenzidine–enhanced Perls’ stain. Mice with adipocyte-specific Fpn1 deletion did not show dysregulation of adiponectin, leptin, resistin, or retinol-binding protein-4 expression. Similarly, adipocyte-specific Fpn1 deletion did not affect insulin sensitivity during hyperinsulinemic–euglycemic clamp studies or lead to histologic evidence of increased liver injury. We have shown, however, that the fast food diet model of nonalcoholic steatohepatitis generates an increase in adipose tissue macrophage infiltration with crown-like structures, as seen in human beings, further validating the utility of this model. Conclusions Ferroportin may not be a key determinant of adipocyte iron homeostasis in this knockout model. Further studies are needed to determine the mechanisms of iron metabolism in adipocytes and adipose tissue.

Low dose lipopolysaccharide causes biliary injury by blood biliary barrier impairment in a rat hepatic ischemia‐reperfusion model

This study explored whether bacterial endotoxins, in the form of lipopolysaccharides (LPS), could have an injurious effect on the biliary tract in conjunction with ischemia. A total of 64 rats were randomly assigned to 4 groups: sham operation (sham group), 1 mg/kg LPS intraperitoneal (LPS group), hepatic ischemia/reperfusion (IR; IR group), and IR combined with LPS (IR+LPS group). Following 1 or 6 hours of reperfusion, serum liver tests, bile duct histology, immunofluorescence microscopy (zonula occludens‐1 [ZO‐1]), bile composition (bile salts, phospholipids, lactate dehydrogenase), hepatic gene expression (bile salt transporters and inflammatory mediators), as well as serum and biliary cytokine concentrations were quantified and compared between the study groups. In addition, the integrity of the blood biliary barrier (BBB) was assayed in vivo using horseradish peroxidase (HRP). LPS administration induced severe small bile duct injury following 6 hours of reperfusion. Furthermore, total bile salts and bilirubin concentrations in serum were increased in the LPS groups compared with sham controls (LPS, + 3.3‐fold and +1.9‐fold; IR+LPS, + 3.8‐fold and +1.7‐fold, respectively). The BBB was impaired in the LPS groups as evidenced by elevated levels of HRP in bile (+4.9‐fold), and decreased expression of claudin 1 (–6.7‐fold) and claudin 3 (–3.6‐fold). LPS was found to be a potent inducer of small bile duct injury following hepatic ischemia and 6 hours of reperfusion. This injury was associated with increased permeability of the BBB and impaired hepatic bile salt clearance. Liver Transplantation 23 194–206 2017 AASLD

The role of macrophages in the development of biliary injury in a lipopolysaccharide-aggravated hepatic ischaemia-reperfusion model

INTRODUCTION Endotoxins, in the form of lipopolysaccharides (LPS), are potent inducers of biliary injury. However the mechanism by which injury develops remains unclear. We hypothesized that hepatic macrophages are pivotal in the development of endotoxin-induced biliary injury and that no injury would occur in their absence. MATERIAL AND METHODS Clodronate liposomes were used to deplete macrophages from the liver. Forty-eight rats were equally divided across six study groups: sham operation (sham), liposome treatment and sham operation (liposomes+sham), 1mg/kg LPS i.p. (LPS), liposome treatment and LPS administration (liposomes+LPS), hepatic ischaemia-reperfusion injury with LPS administration (IRI+LPS) and liposome treatment followed by IRI+LPS (liposomes+IRI+LPS). Following 6h of reperfusion, blood, bile, and liver tissue was collected for further analysis. Small bile duct injury was assessed, serum liver tests were performed and bile composition was evaluated. The permeability of the blood-biliary barrier (BBB) was assessed using intravenously administered horseradish peroxidase (HRP). RESULTS The presence of hepatic macrophages was reduced by 90% in LPS and IRI+LPS groups pre-treated with clodronate liposomes (P<0.001). Severe small bile duct injury was not affected by macrophage depletion, and persisted in the liposomes+IRI+LPS group (50% of animals) and liposomes+LPS group (75% of animals). Likewise, BBB impairment persisted following macrophage depletion. LPS-induced elevation of the chemokine Mcp-1 in bile was not affected by macrophage depletion. CONCLUSIONS Depletion of hepatic macrophages did not prevent development of biliary injury following LPS or LPS-enhanced IRI. Cholangiocyte activation rather than macrophage activation may underlie this injury. This article is part of a Special Issue entitled: Cholangiocytes in Health and Diseaseedited by Jesus Banales, Marco Marzioni, Nicholas LaRusso and Peter Jansen.

Iron Inhibits the Secretion of Apolipoprotein E in Cultured Human Adipocytes

Nonalcoholic steatohepatitis (NASH) is characterized by adipose tissue dysfunction with insulin resistance and the dysregulation of adipokines.1 Recent data indicate repartitioning of iron from the liver to adipocytes in obesity and a role for iron in the development of adipose tissue dysfunction.2, 3 However, the molecular mechanisms have not been established. To test the hypothesis that iron modulates adipokine release, we performed a quantitative proteomics analysis of the human Simpson-Golabi-Behmel Syndrome (SGBS) adipocyte secretome after 48 hours of treatment with ferric ammonium citrate (FAC). We used stable isotope-labeled amino acids in cell culture (SILAC) to characterize changes in the adipocyte secretome in response to iron. This technique has enabled direct comparison of quantities of individual proteins in the adipocyte secretome in response to iron using a proteomics approach as a tool for the identification of novel treatment targets in NASH. Detailed methodology is described in Supplementary Methods...

Hepatic iron concentration correlates with insulin sensitivity in nonalcoholic fatty liver disease

Rodent and cell‐culture models support a role for iron‐related adipokine dysregulation and insulin resistance in the pathogenesis of nonalcoholic fatty liver disease (NAFLD); however, substantial human data are lacking. We examined the relationship between measures of iron status, adipokines, and insulin resistance in patients with NAFLD in the presence and absence of venesection. This study forms part of the Impact of Iron on Insulin Resistance and Liver Histology in Nonalcoholic Steatohepatitis (IIRON2) study, a prospective randomized controlled trial of venesection for adults with NAFLD. Paired serum samples at baseline and 6 months (end of treatment) in controls (n = 28) and patients who had venesection (n = 23) were assayed for adiponectin, leptin, resistin, retinol binding protein‐4, tumor necrosis factor α, and interleukin‐6, using a Quantibody, customized, multiplexed enzyme‐linked immunosorbent assay array. Hepatic iron concentration (HIC) was determined using MR FerriScan. Unexpectedly, analysis revealed a significant positive correlation between baseline serum adiponectin concentration and HIC, which strengthened after correction for age, sex, and body mass index (rho = 0.36; P = 0.007). In addition, there were significant inverse correlations between HIC and measures of insulin resistance (adipose tissue insulin resistance (Adipo‐IR), serum insulin, serum glucose, homeostasis model assessment of insulin resistance, hemoglobin A1c, and hepatic steatosis), whereas a positive correlation was noted with the insulin sensitivity index. Changes in serum adipokines over 6 months did not differ between the control and venesection groups. Conclusion: HIC positively correlates with serum adiponectin and insulin sensitivity in patients with NAFLD. Further study is required to establish causality and mechanistic explanations for these associations and their relevance in the pathogenesis of insulin resistance and NAFLD. (Hepatology Communications 2018;2:644‐653)

Heterozygous Hfe gene deletion leads to impaired glucose homeostasis, but not liver injury in mice fed a high‐calorie diet

Heterozygous mutations of the Hfe gene have been proposed as cofactors in the development and progression of nonalcoholic fatty liver disease (NAFLD). Homozygous Hfe deletion previously has been shown to lead to dysregulated hepatic lipid metabolism and accentuated liver injury in a dietary mouse model of NAFLD. We sought to establish whether heterozygous deletion of Hfe is sufficient to promote liver injury when mice are exposed to a high‐calorie diet (HCD). Eight‐week‐old wild‐type and Hfe+/− mice received 8 weeks of a control diet or HCD. Liver histology and pathways of lipid and iron metabolism were analyzed. Liver histology demonstrated that mice fed a HCD had increased NAFLD activity score (NAS), steatosis, and hepatocyte ballooning. However, liver injury was unaffected by Hfe genotype. Hepatic iron concentration (HIC) was increased in Hfe+/− mice of both dietary groups. HCD resulted in a hepcidin‐independent reduction in HIC. Hfe+/− mice demonstrated raised fasting serum glucose concentrations and HOMA‐IR score, despite unaltered serum adiponectin concentrations. Downstream regulators of hepatic de novo lipogenesis (pAKT, SREBP‐1, Fas, Scd1) and fatty acid oxidation (AdipoR2, Pparα, Cpt1) were largely unaffected by genotype. In summary, heterozygous Hfe gene deletion is associated with impaired iron and glucose metabolism. However, unlike homozygous Hfe deletion, heterozygous gene deletion did not affect lipid metabolism pathways or liver injury in this model.

Comparable Levels of Inflammatory Mediators in Portal Venous Blood Collected from Organ Donors Donating after Circulatory Death and those Donating after Brain Death

Introduction Extended criteria donors, such as those who donate after cardiac death (DCD) are increasingly considered for transplantation. Biliary stricture formation often complicates the use of these grafts and the aetiology remains largely unknown. We have previously shown that endotoxins, in the form of lipopolysaccharides (LPS), are potent inducers of biliary injury. However, it remains unclear if endotoxaemia occurs during DCD organ donation. The aim of this study was to determine the inflammatory propensity of portal blood collected from DCD donors compared to those donating after brain death (DBD). Materials and Methods Serial portal venous as well as hepatic venous blood samples were collected from adult DBD and DCD organ donors. An NF-&kgr;B-dependent cell-based assay was used to detect endotoxins and/or other inflammatory stimuli in the portal blood samples. &bgr;-galactosidase activity in hepatic venous samples was assessed as a marker for hepatic Kupffer cell activation. In addition, bile and bile duct tissue was collection for assessment of biliary injury. Results and Discussion Thirty patients (nine DCD, 21 DBD) were included in this study. Compared to DBD donors, portal samples of DCD donors did not have an enhanced propensity for triggering inflammatory responses. However, Kupffer cell activation was enhanced and prolonged in DCD donors. Lactate dehydrogenase as a biomarker of biliary injury was increased in bile collected from DCD donors and histological scoring showed evidence of increased injury of peri-luminal peribiliary glands. Conclusion In this study no evidence was found of endotoxaemia or increased propensity to produce an inflammatory response in portal blood collected from DCD donors. Despite this, hepatic Kupffer cell activation was increased and there was evidence of biliary injury. Liver Transplant Bequest, PA Research Foundation, Princess Alexandra Hospital, Brisbane, Australia. Gallipoli Medical Research Foundation, Greenslopes Private Hospital, Brisbane, Australia.

The Implications of the Shift Toward Donation After Circulatory Death in Australia

Background In recent years, an increasing number of donor livers are being declined for transplantation in Australia. The aim of this study was to evaluate the impact of donation after cardiac death and other factors associated with organ quality on liver utilization rates in Australia. Methods Data on organ donors who donated at least 1 organ between 2005 and 2014 were obtained from the Australia and New Zealand organ donation registry. Temporal changes in donor characteristics were assessed and a logistical regression analysis was performed to evaluate their association with liver nonuse. Results The number of organ donors increased from 175 in 2005 to 344 in 2014, with overall 19% being donation after cardiac death donors (P < 0.001). The percentage of livers deemed unsuitable for transplantation increased from 24% in 2005 to 41% in 2014 (P < 0.001). Donation after cardiac death was identified as the most important risk factor for nonuse with an odds ratio of 25.88 (95% confidence interval, 18.84-35.56), P < 0.001) followed by donor age, obesity, and diabetes. Discussion This study shows that livers donated after circulatory death are an underused resource in Australia. Better use of these currently available organs would be a highly cost-effective way of reducing waiting list mortality in liver transplantation.