Donor-specific cell-free DNA as a biomarker in liver transplantation:A review

Due to advances in modern medicine,liver transplantation has revolutionised the prognosis of many previously incurable liver diseases.This progress has largely been due to advances in immunosuppressant therapy.However,despite the judicious use of immunosuppression,many liver transplant recipients still experience complications such as rejection,which necessitates diagnosis via invasive liver biopsy.There is a clear need for novel,minimally-invasive tests to optimise immunosuppression and improve patient outcomes.An emerging biomarker in this‘‘precision medicine’‘liver transplantation field is that of donorspecific cell free DNA.In this review,we detail the background and methods of detecting this biomarker,examine its utility in liver transplantation and discuss future research directions that may be most impactful.

Non-invasive Prenatal Gene Diagnosis: Progress through Cell-free Fetal DNA and RNA in Maternal Plasma and Urine

Non-invasive prenatal gene diagnosis has been developed rapidly in the recent years, and numerous medical researchers are focusing on it. Such techniques could not only achieve prenatal diagnosis accurately, but also prevent tangential illness in fetuses and thus, reduce the incidence of diseases. Moreover, it is non-invasive prenatal gene diagnosis that prevents potential threaten and danger to both mothers and fetuses. Therefore, it is welcomed by clinical gynecologist and obstetrian, researchers of medical genetics, and especially, pregnancies. This review article touches briefly on the advanced development of using cell-free DNA, RNA in maternal plasma and urine for non-invasive prenatal gene diagnosis.

Hepatocytic differentiation of mesenchymal stem cells in cocultures with fetal liver cells

AIM： To investigate the hepatocytic differentiation of mesenchymal stem cells （MSCs） in co-cultures with fetal liver cells （FLC） and the possibility to expand differentiated hepatocytic cells. METHODS： MSCs were marked with green fluorescent protein （GFP） by retroviral gene transduction. Clonal marked MSCs were either cultured under liver stimulating conditions using fibronectin-coated culture dishes and medium supplemented with stem cell factor （SCF）, hepatocyte growth factor （HGF）, epidermal growth factor （EGF）, and fibroblast growth factor 4 （FGF-4） alone, or in presence of freshly isolated FLC. Cells in co-cultures were harvested, and GFP＋ or GFP- cells were separated using fluorescence activated cell sorting. Reverse transcription-polymerase chain reaction （RT-PCR） for the liver specific markers cytokeratin-18 （CK-18）, albumin, and alpha-fetoprotein （AFP） was performed in different cell populations. RESULTS- Under the specified culture conditions, rat MSCs co-cultured with FLC expressed albumin, CK-18, and AFP-RNA over two weeks. At wk 3, MSCs lost hepatocytic gene expression, probably due to overgrowth of the cocultured FLC. FLC also showed a stable liver specific gene expression in the co-cultures and a very high growth potential. CONCLUSION： The rat MSCs from bone marrow can differentiate hepatocytic cells in the presence of FLC in vitro and the presence of MSCs in co-cultures also prorides a beneficial environment for expansion and differentiation of FLC.

Effects of restrictions on maternal feed intake on the immune indexes of umbilical cord blood and liver Toll-like receptor signaling pathways in fetal goats during pregnancy

Background: Liver has important immune function during fetal development and after birth.However,the effect of maternal malnutrition on immune function of the fetal liver is rarely reported.In this study,twelve pregnant goats(Xiangdong black goat,at d 45 of gestation) were assigned to the control group(fed 100% of nutritional requirements) and the restriction group(fed 60% of the intake of the control group) during gestation from d 55 to100.Fetal goats were harvested at d 100 of gestation and immune indexes and amino acid profiles of the umbilical cord blood and liver Toll-like receptors(TLRs) signaling pathways were measured.Results: Maternal body weight in the restriction group was lower than the control group(P < 0.05).Maternal feed intake restriction decreased(P < 0.05) heart weight,heart index,alkaline phosphatase and serum amyloid protein A in the umbilical cord blood(UCB).Moreover,only histidine was decreased in the restricted group(P = 0.084),and there were no differences in other amino acids contents in the UCB between the two groups(P > 0.05).The TLR2 and TLR4 mRNA expression in the fetal liver in the restriction group was greater(P < 0.05) than that in the control group.Furthermore,the mRNA expression levels of myeloid differentiation primary response 88(MyD88),TNF receptor associated factor 6,nuclear factor kappa B subunit 1,NFKB inhibitor alpha,IFN-β,TGF-β,TNF-α and IL-1β in the restricted group were upregulated(P < 0.05),and the expression of TLR3(P = 0.099) tended to be higher in the restricted group.However,protein levels of TLR2,TLR4,IκBα,phosphorylated IκBα,phosphorylated IκBα/total IκBα,TRIF and MyD88 were not affected(P > 0.05) by maternal intake restriction.Conclusions: These results revealed that the restriction of maternal feed intake influenced the development of heart and hepatic protein synthesis at the acute phase of fetal goats and upregulated the mRNA expression of genes involved in MyD88-dependent signaling pathways and of target cytokines.

Promoted differentiation of cynomolgus monkey ES cells into hepatocyte-like cells by co-culture with mouse fetal liver-derived cells

AIM: To explore whether a co-culture of cynomolgus monkey embryonic stem (cES) cells with embryonic liver cells could promote their differentiation into hepatocytes. METHODS: Mouse fetal liver-derived cells (MFLCs) were prepared as adherent cells from mouse embryos on embryonic d (ED) 14, after which undifferentiated cES cells were co-cultured with MFLCs. The induction of cES cells along a hepatic lineage was examined in MFLC- assisted differentiation, spontaneous differentiation, and growth factors (GF) and chemicals-induced differentiations (GF-induced differentiation) using retinoic acid, leukemia inhibitory factor (LIF), FGF2, FGF4, hepatocyte growth factor (HGF), oncostatin M (OSM), and dexamethasone. RESULTS: The mRNA expression of α-fetoprotein, albumin (ALB), α-1-antitrypsin, and hepatocyte nuclear factor 4α was observed earlier in the differentiating cES cells co-cultured with MFLCs, as compared to cES cells undergoing spontaneous differentiation and those subjected to GF-induced differentiation. The expression of cytochrome P450 7a1, a possible marker for embryonic endoderm-derived mature hepatocytes, was only observed in cES cells that had differentiated in a co-culture with MFLCs. Further, the disappearance of Oct3/4, a representative marker of an undifferentiated state, was noted in cells co-cultured with MFLCs, but not in those undergoing spontaneous or GF-induced differentiation. Immunocytochemical analysis revealed an increased ratio of ALB-immunopositive cells among cES cells co-cultured with MFLCs, while glycogen storageand urea synthesis were also demonstrated. CONCLUSION: MFLCs showed an ability to induce cES cells to differentiate toward hepatocytes. The co-culture system with MFLCs is a useful method for induction of hepatocyte-like cells from undifferentiated cES cells.

Characterization of hepatic progenitors from human fetal liver using CD34 as a hepatic progenitor marker

AIM: To enrich putative hepatic progenitors from the developing human fetal liver using CD34 as a marker. METHODS: Aborted fetuses of 13-20 wk were used for the isolation of liver cells. The cells were labeled with anti CD34; a marker used for isolating progenitor population and the cells were sorted using magnetic cell sorting. The positive fractions of cells were assessed for specific hepatic markers. Further, these cells were cultured in vitro for long term investigation. RESULTS: Flow cytometric and immunocytochemical analysis for alphafetoprotein (AFP) showed that the majority of the enriched CD34 positive cells were positive for AFP. Furthermore, these enriched cells proliferated in the long term and maintained hepatic characteristics in in vitro culture. CONCLUSION: The study shows that aborted human fetal liver is a potential source for isolation of hepatic progenitors for clinical applications. The study also demonstrates that CD34 can be a good marker for the enrichment of progenitor populations.

Characterization of hepatic progenitors from human fetal liver during second trimester

AIM： To enrich hepatic progenitors using epithelial cell adhesion molecule （EpCAM） as a marker from human fetal liver and investigate the expression of human leukocyte antigen （HLA） and their markers associated with hepatic progenitor cells. METHODS： EpCAM ＋ve cells were isolated using magnetic cell sorting （MACS） from human fetuses （n = 10） at 15-25 wk gestation. Expression of markers for hepatic progenitors such as albumin, alpha-fetoprotein （AFP）, CD29 （integrin ~1）, CD49f （integrin c^6） and CD90 （Thy 1） was studied by using flow cytometry, immunocytochemistry and RT-PCR; HLA class Ⅰ （A, B, C） and class Ⅱ （DR） expression was studied by flow cytometry only. RESULTS： FACS analysis indicated that EpCAM ＋ve cells were positive for CD29, CD49f, CD90, CD34, HLA class I, albumin and AFP but negative for HLA class Ⅱ （DR） and CD45. RT PCR showed that EpCAM ＋ve cells expressed liver epithelial markers （CK18）, biliary specific marker （CK19） and hepatic markers （albumin, AFP）. On immunocytochemical staining, EpCAM ＋ve cells were shown positive signals for CK18 and albumin. CONCLUSION： Our study suggests that these EpCAM ＋ve cells can be used as hepatic progenitors for cell transplantation with a minimum risk of alloreactivity and these cells may serve as a potential source for enrichment of hepatic progenitor.

Transplantation of fetal liver epithelial progenitor cells ameliorates experimental liver fibrosis in mice

AIM： To investigate the effect of transplanted fetal liver epithelial progenitor （FLEP） cells on liver fibrosis in mice. METHODS： FLEP cells were isolated from embryonal day （ED） 14 BALB/c mice and transplanted into female syngenic BALB/c mice （n = 60）. After partial hepatectomy （PH）, diethylnitrosamine （DEN） was administered to induce liver fibrosis. Controls received FLEP cells and non-supplemented drinking water, the model group received DEN-spiked water, and the experimental group received FLEP cells and DEN. Mice were killed after 1, 2, and 3 mo, and alanine aminotransferase （ALT）, aspartate aminotransferase （AST）, hyaluronic acid （HA）, and laminin （LN） in serum, and hydroxyproline （Hyp） content in liver were assessed. Alpha-smooth muscle actin （α-SMA） of liver was tested by immunohistochemistry. Transplanted male mice FLEP cells were identified by immunocytochemistry for sty （sex determination region for Y chromosome） protein. RESULTS： Serum ALT, AST, HA, and LN were markedly reduced by transplanted FLEP cells. Liver Hyp content and （α-SMA staining in mice receiving FLEP cells were lower than that of the model group, which was consistent with altered liver pathology. Transplanted cells proliferated and differentiated into hepatocytes and bile duct epithelial cells with 30%-50% repopulation in the liver fibrosis induced by DEN after 3 mo. CONCLUSION： Transplanted FLEP cells proliferate and differentiate into hepatocytes and bile duct epithelial cells with high repopulation capacity in the fiberized liver induced by DEN, which restores liver function and reduces liver fibrosis.

Isolation, characterization and culture of Thy1-positive cells from fetal rat livers

AIM： To investigate whether Thyl recognizes oval cells in the fetal liver and to characterize the cultured Thy1 selected cells from E14 rat livers. METHODS： Thyl populations were analyzed by fluorescence activated cell sorter analysis. Thyl positive cells were isolated using magnetic beads. Hepatic markers were detected by Western blotting, immunocytochemistry and RT-PCR. RESULTS： The percentage of Thyl-positive cells decreased during early development of fetal rat liver （E13-E16）. E14 fetal livers contained 7.8% Thy1 positive cells, of which 61% were positive for α-fetoprotein （AFP） and 25% expressed albumin. The Thy1＋ population expressed oval cell markers c-Kit and CXCR4, liver enriched-transcription factors HNF1α and HNF6, hepatocytic markers albumin, AFP and cytokeratin 18, and biliary marker cytokeratin 19. Thy1- selected cells formed only mesenchymal colonies when plated on collagen and in serum-containing media. Thyl selected cells were able to form hepatic colonies positive for HNF1α, HNF6, albumin, AFP, cytokeratin 18, cytokeratin 19 and glycogen, when grown on STO feeder layers in serum free-media. CONCLUSION： Oval cells positive for Thyl are present in early liver embryonic stages.

Hepatic reconstruction from fetal porcine liver cells using a radial flow bioreactor

AIM： To examine the efficacy of the radial flow bioreactor （RFB） as an extracorporeal bioartificial liver （BAL） and the reconstruction of liver organoids using embryonic pig liver cells. METHODS： We reconstructed the liver organoids using embryonic porcine liver cells in the RFB. We also determined the gestational time window for the optimum growth of embryonic porcine liver cells. Five weeks of gestation was designated as embryonic day （E） 35 and 8 wk of gestation was designated as E56. These cells were cultured for one week before morphological and functional examinations. Moreover, the efficacy of pulsed adminisbation of a high concentration hepatocyte growth factor （HGF） was examined. RESULTS： Both cell growth and function were excellent after harvesting on E35. The pulsed administration of a high concentration of HGF promoted the differentiation and maturation of these fetal hepatic cells. Microscopic examination of organoids in the RFB revealed palisading and showed that bile duct-like structures were well developed, indicating that the organoids were mini livers. Transmission electron microscopy revealed microvilli on the luminal surfaces of bile duct-like structures and junctional complexes, which form the basis of the cytoskeleton of epithelial tissues. Furthermore, strong expression of connexin （Cx） 32, which is the main protein of hepatocyte gap junctions, was observed. With respect to liver function, ammonia detoxification and urea synthesis were shown to be performed effectively. CONCLUSION： Our system can potentially be applied in the fields of BAL and transplantation medicine.

Partial isolation and identification of hepatic stimulator substance mRNA extracted from human fetal liver

IM To partially isolate and identify hepatic stimulator substance mRNA from human fetal liver tissues.METHODS The poly (A)mRNA was extracted from human fetal liver tissues of 4-5 month gestation, fractionated by size on sucrose gradient centrifugation, translated into protein from each fraction in vitro and then its products were tested for HSS activity.RESULTS Twentytwo 500μg total RNA was obtained from human fetal liver tissues and pooled. mRNA of 420μg was yielded, processed by oligo(dT)cellulose column chromatography, then was sizefractionated by ultracentrifution on a continuous sucrose density gradient (5%-25%), and separated into 18 fractions. Translated products of mRNA in fraction 8 and 9 could produce a twofold increase in the incorporation of 3HTdR into DNA of SMMC7721 hepatoma cells and in a heatresistant and organspecific way.CONCLUSION The partially purified HSS mRNA was obtained and this would facilitate the cloning of HSS using expression vectors.

A New Hematopoietic Stimulating Activity Produced by Fetal Liver Cells

Human fetal liver cells were cultured in vitro for 12h and the supernatant(Fetal liver cell conditioned medium,FLCM)was collected.The effects of FLCM ongranulopoiesis were studied.The results show that when combined with colonystimulating factor(CSF),FLCM could significantly stimulate the proliferation of normalmyctoid progenitor cells(CFU-e),and increase ~3H-TdR incorporation into bone mar-row cells.The data suggest that FLCM contains a CSF synergistic activity.

EFFECT OF HEPATIC STIMULATOR SUBSTANCE (HSS) EXTRACTED FROM FETAL LIVER ON THE PROLIFERATION OF HUMAN ALEXENDER HEPATOMA CELLS

It's reported that hepatic stimulator substance (HSS) was extracte from the fetal liver of 4 - 6 months of fetus, and that the effect of HSS on the proliferation of human Alexender hepatoma cells was studied in this paper. The results showed that proliferation of Alexender cells varied with the amount of HSS in the culture medium, and the former was positively correlated with the latter significantly (P<0. 01). The study indicated that HSS from the fetal liver can stimulate the proliferation of human Alexender hepatoma cells.

Age-related changes in cerebral angiogenesis and fetal liver kinase-1 expression after cerebral ischemia/reperfusion

Cerebral angiogenesis in the early stages after cerebral ischemia injury is essential for the recovery of nerve function,in which fetal liver kinase-1（Flk-1）,as a major regulator of vasculogenesis and angiogenesis,plays a very important role.Microvessel density（MVD）was greater in an aged model group compared with the young sham operated group（P 〈 0.01）.MVD and the sum of the lumen area were decreased in the aged group at 1,3,6 and 12 days following ischemia/reperfusion（I/R）injury compared with the young model group（P 〈 0.05 and P 〈 0.01,respectively）.Flk-1 protein and mRNA expression was greater in the aged model group when compared with the young sham operated group（P 〈 0.01）.Flk-1 protein and mRNA expression was lower in the aged group at 1,3,6 and 12 days after I/R compared with the young model group（P 〈 0.01）.Flk-1 expression in aged rats attenuated rapidly,but was still maintained at relatively higher levels at 12 days following I/R in younger rats.The results suggest that angiogenesis was weakened after cerebral I/R in aged rats,and the mechanism of which might be correlated with attenuated expression of Flk-1 protein and mRNA.

Universal RNA editing in a human liver at the fetal stage

It is known that RNA editing occurs in human cells, which can change the information transmission from DNA to RNA and proteins. Most previous studies have focused on editing of the mRNAs. Here we reported that several kinds of RNAs, including miRNA, rRNA, mRNA, miscRNA and unknown RNA, exhibited base editing in a human fetal liver. Several editing types are displayed. Our data reveals that RNA editing may occur in different species of RNAs.

Hematopoietic Stem Cell Niche in Foetal Liver and Production of Pluripotent Stem Cell-Derived Liver Organoids

There is a considerable demand but limited supply for hematopoietic stem cells (HSCs) in clinics. To meet clinical needs of HSCs, new efforts focus on de novo HSCs generation from pluripotent stem cells (PSCs). Although previous attempts have yielded precursors and progenitors of HSCs, the production of fully functional HSCs has largely been unsuccessful. The failure of PSC-derived HSCs to mature to foetal liver stage is not surprising, as most methods are trying to generate hemogenic endothelium resembling that found in the aorta-gonad-mesonephros (AGM) region, highlighting the importance of understanding human foetal liver niche and developing protocols to mimic this environment. This paper investigates the diverse cellular interactions within the fetal liver niche that contribute to HSC maturation and explores the potential for generating human fetal liver organoids that can recreate these supportive environments in vitro. Such organoids could provide a groundbreaking model for studying HSC maturation and potentially offer a scalable solution for the ex vivo production of functional HSCs, paving the way for advances in both regenerative medicine and hematopoietic stem cell transplantation.

Liver disease in pregnancy

Liver diseases in pregnancy may be categorized into liver disorders that occur only in the setting of pregnancy and liver diseases that occur coincidentally with pregnancy. Hyperemesis gravidarum, preeclampsia/eclampsia, syndrome of hemolysis, elevated liver tests and low platelets (HELLP), acute fatty liver of pregnancy, and intrahepatic cholestasis of pregnancy are pregnancy-specific disorders that may cause elevations in liver tests and hepatic dysfunction. Chronic liver diseases, including cholestatic liver disease, autoimmune hepatitis, Wilson disease, and viral hepatitis may also be seen in pregnancy. Management of liver disease in pregnancy requires collaboration between obstetricians and gastroenterologists/hepatologists. Treatment of pregnancy-specific liver disorders usually involves delivery of the fetus and supportive care, whereas management of chronic liver disease in pregnancy is directed toward optimizing control of the liver disorder. Cirrhosis in the setting of pregnancy is less commonly observed but offers unique challenges for patients and practitioners. This article reviews the epidemiology, pathophysiology, diagnosis, and management of liver diseases seen in pregnancy.

Effect of Bushen Yiqi Huoxue Recipe on Placental Vasculature in Pregnant Rats with Fetal Growth Restriction Induced by Passive Smoking

Interactions of vascular endothelial growth factor （VEGF） with receptors VEGFR1/Fltl and VEGFR2/Flk1, and those of angiopoietins （Ang-1, Ang-2） with receptor Tie2 play important roles in placental angiogenesis. This study investigated vascular morphology and expression of these angiogenic factors in rat placenta on the day 15, 18, 21 of gestation （D 15, D 18 and D21）. The rats were randomly assigned into 3 groups： normal group, model group [fetal growth restriction （FGR） model], and Bushen Tqi Huoxue （BYHR） recipe treatment group （BYHR group, the pregnant rats with FGR were treated with BYHR recipe）. Morphological analysis indicated that during initial villous formation, fetal nucle- ated erythrocytes （FNEs） appeared in maternal blood sinus （MBS）. Subsequently, FNEs were sur- rounded by endothelial cells to form fetal capillary （FC） and then by trophoblast cells to form villi. As pregnancy proceeded, FC density increased progressively with increasing endothelial identification staining （EIS） in normal and BYHR groups. Whereas, villous formation was suppressed, normal in- crease in FC density was impaired and EIS was weakened in model group. Quantitative PCR analysis showed that VEGF and Flkl mRNA increased over gestation in all groups, indicating that VEGF might play a pivotal role in FC growth during late gestation. VEGF mRNA was increased on D15, while de- creased on D21 in model group as compared with normal group and BYHR group. Immunohistochemi- cally, Ang-2 protein was highly expressed in FNEs, gradually disappeared as villi matured, and decreased over gestation in all groups, indicating that Ang-2 might play a pivotal role in villous formation, which was further supported by decreased Ang-2 mRNA and protein expression in model group on D 15. Ang-1 mRNA, Tie2 mRNA and Ang-1/Ang-2 ratio increased from D15 to D18 in all groups as placenta matured. Ang-1 mRNA, Tie2 mRNA and Ang-1/Ang-2 ratio were decreased on D18 in model group as compared with normal and BYHR groups, indicating delayed maturity of FGR placenta. Alterations in angiogenic factors may result in altered placental vasculature and cause placental insufficiency. BYHR recipe could balance the angiogenic factors to promote the formation and maturation of FGR placental vasculature.

Noninvasive Prenatal Testing for Fetal Chromosomal Abnormalities Using Massively Parallel Sequencing: Clinical Experience from 7910 Korean Pregnancies

Objective: The purpose of this study is to review the clinical experience and performance of noninvasive prenatal testing (NIPT) method, using cell-free DNAto detect chromosomes 21, 18, 13, X, and Y abnormalities in over 7910 clinical samples from South Korean population. Method: Pregnant women between 1st of November 2015 to 18th of February 2018, with obstetric clinical findings participated in the study. NIPT was performed based on masivelly parallel sequencing with 0.3× low coverage paired-end sequencing using cell-free DNA in maternal plasma. Further invasive prenatal testing was recommended for pregnant women with positive NIPT results. Results: Of the total 7910 participants, 7890 (99.75%) were tested for NIPT and the remaining 20 (0.25%) were below the Quality Control (QC) standards. T13, T18, XXX, XXY and XYY had 100% of sensitivity, specificity, positive predictive values (PPV) and accuracy. The overall sensitivity was 100% and specificity, PPV and accuracy of all chromosomal abnormalities with further validation were 99.92%, 94.25%, and, 99.92% respectively. Conclusion: Our NIPT results showed high positive predictive value for the detection of autosomal trisomies and sex chromosome aneuploidies in our sample cohort.

Obstetrical and gynecologic challenges in the liver transplant patient

An increasing number of childbearing agewomen undergo liver transplantation(LT)in the United States.Transplantation in this patient subgroup poses a significant challenge regarding the plans for future fertility,particularly in terms of immunosuppression and optimal timing of conception.Intrapartum LT is only rarely performed as the outcome is commonly dismal for the mother or more commonly the fetus.On the other hand,the outcomes of pregnancy in LT recipients are favorable,and children born to LT recipients are relatively healthy.Counseling on pregnancy should start before LT and continue after LT up until pregnancy,while all pregnant LT recipients must be managed by amultidisciplinary team,including both an obstetrician and a transplant hepatologist.Additionally,an interval of at least 1-2 years after successful LT is recommended before considering pregnancy.Pregnancy-induced hypertension,pre-eclampsia,and gestational diabetes mellitus are reported more commonly during the pregnancies of LT recipients than in the pregnancies of non-transplant patients.As adverse fetal outcomes,such asmiscarriage,abortion,stillbirth,or ectopic pregnancy,may occur more often than in the non-transplant population,early planning or delivery either through a planned induction of labor or cesarean section is critical to minimize the risk of complications.No significant long-term physical or phycological abnormalities have been reported in children born to LT recipients.