Immunology of hepatic diseases during pregnancy. Semin Immunopathol. 2016; Jun 20. [Epub ahead of print]. [PMID: 27324237 DOI: 10.1007/s00281-016-0573-1]

Altered placental macrophage numbers and subsets in pregnancies complicated with intrahepatic cholestasis of pregnancy (ICP) compared to healthy pregnancies

INTRODUCTION

Intrahepatic cholestasis of pregnancy (ICP) can result in adverse outcomes for both mother and fetus. Inflammatory (M1 subset) or anti-inflammatory (M2 subset) macrophage polarisation is associated with various complications of pregnancy. However, the influence of ICP on macrophage numbers and polarisation remains unknown. This study analyses macrophage density and distribution in placentas of patients with ICP compared to controls. Clinical parameters were correlated to macrophage distribution and ursodeoxycholic acid use (UDCA).

METHODS

This study included routinely collected placental tissue samples of 42 women diagnosed with ICP and of 50 control pregnancies. Immunohistochemical staining was performed on placental tissue using CD68 antibody as a pan-macrophage marker, CD206 antibody as an M2 and HLA-DR antibody as an M1 macrophage marker. Macrophage density (cells/mm2) and distribution (CD206+/CD68+ or CD206+/CD68+HLA-DR+) in both decidua (maternal tissue) and villous parenchyma (fetal tissue) were compared between groups. Macrophage density and distribution were correlated to clinical parameters for ICP patients.

RESULTS

The density of CD68+ macrophages differed significantly between groups in villous parenchyma. In both decidua and villous parenchyma, CD206+/CD68+ ratio was significantly lower in ICP patients compared to controls (p = 0.003 and p=<0.001, respectively). No difference was found based on UDCA use or in CD68+HLA-DR+ cell density. Significant correlations were found between macrophage density and peak serum bile acids and liver enzymes.

DISCUSSION

In ICP patients, an immune shift was observed in both decidual and villous tissue, indicated by a lower CD206+/CD68+ ratio. ICP seems to affect placental tissue, however more research is required to understand its consequences.

Maternal hepatic immunology during pregnancy

The liver plays pivotal roles in immunologic responses, and correct hepatic adaptations in maternal immunology are required during pregnancy. In this review, we focus on anatomical and immunological maternal hepatic adaptations during pregnancy, including our recent reports in this area. Moreover, we summarize maternal pregnancy-associated liver diseases, including hyperemesis gravidarum; intrahepatic cholestasis of pregnancy; preeclampsia, specifically hemolysis, elevated liver enzymes, and low platelet count syndrome; and acute fatty liver of pregnancy. In addition, the latest information about the factors that regulate hepatic immunology during pregnancy are reviewed for the first time, including human chorionic gonadotropin, estrogen, progesterone, growth hormone, insulin like growth factor 1, oxytocin, adrenocorticotropic hormone, adrenal hormone, prolactin, melatonin and prostaglandins. In summary, the latest progress on maternal hepatic anatomy and immunological adaptations, maternal pregnancy-associated diseases and the factors that regulate hepatic immunology during pregnancy are discussed, which may be used to prevent embryo loss and abortion, as well as pregnancy-associated liver diseases.

Autoimmune hepatitis in pregnancy: Pearls and pitfalls

Autoimmune hepatitis (AIH) in pregnancy has many unique considerations. Evidence provided from single center studies with patient level data and nationwide population studies provide valuable insight into this complex situation. Because a planned pregnancy is a safer pregnancy, preconception counseling is a crucial opportunity to optimize care and risk stratify women with AIH. Women with chronic liver disease who receive preconception advice and counseling are more likely to achieve stable liver disease at conception and undergo appropriate variceal surveillance. Loss of biochemical response in pregnancy is associated with adverse outcomes in unstable disease. New onset AIH in pregnancy should be managed with classical treatment regimens. The continued use of immunosuppression in pregnancy, with the exception of mycophenolate mofetil, has not shown to adversely affect the rates of stillbirth or congenital malformation. Previously adopted immunosuppression withdrawal paradigms in pregnancy should no longer be considered advantageous, because remission loss postdelivery is likely (12%-86%). Population studies, report improved outcomes with preterm birth rates falling from 20% to 9%-13% in AIH pregnancies over a 20-year period. Newer data have also demonstrated an increased risk of gestational diabetes and hypertensive complications in AIH pregnancy, which has implications for management and preeclampsia prevention with aspirin use. This review aims to provide the framework to guide and manage pregnancy in AIH outlining pearls and pitfalls to ensure optimal outcomes for mother, baby and to reduce variation in practice.

Increased serum delta neutrophil index levels are associated with intrahepatic cholestasis of pregnancy

OBJECTIVE

This study aims to compare the maternal serum delta neutrophil index (DNI) levels in intrahepatic cholestasis of pregnancy (ICP) and healthy pregnancies.

METHODS

This study consisted of a group of patients (n = 40) diagnosed with isolated ICP who gave birth in our hospital and a control group (n = 60) between December 1, 2015, and June 30, 2018. The diagnosis of ICP was made based on pruritus and elevated fasting serum bile acids and liver enzymes. Laboratory tests of both groups in the hospitalization process were retrospectively examined. Maternal and neonatal characteristics, pregnancy outcomes, and DNI values of the two groups were compared. Statistical analyses were performed using SPSS version 20.

RESULTS

Mean maternal serum DNI levels were significantly higher in women with ICP than in the control group (0.49 ± 4.8 vs -3.99 ± 3.02, p = <0.01). Receiver operating characteristic (ROC) curve analysis was used to define the DNI value where ICP can be best predicted.

CONCLUSION

DNI, a new inflammatory marker, was found to be higher in women with ICP than in normal pregnancies.

Transforming growth factor-beta and liver injury in an arginine vasopressin-induced pregnant rat model

Objective

Approximately 30% of preeclamptic pregnancies exhibit abnormal liver function tests. We assessed liver injury-associated enzyme levels and circulating transforming growth factor beta (TGF-β) levels in an arginine vasopressin (AVP)-induced pregnant Sprague-Dawley rat model.

Methods

Pregnant and non-pregnant Sprague-Dawley rats (n=24) received AVP (150 ng/hr) subcutaneously via mini-osmotic pumps for 18 days. Blood pressure was measured, urine samples were collected, and all animals were euthanized via isoflurane. Blood was collected to measure circulating levels of TGF-β1-3 isomers and liver injury enzymes in pregnant AVP (PAVP), pregnant saline (PS), non-pregnant AVP (NAVP), and non-pregnant saline (NS) rats.

Results

The PAVP group showed significantly higher systolic and diastolic blood pressure than both saline-treated groups. The weight per pup was significantly lower in the AVP-treated group than in the saline group (p<0.05). Circulating TGF-β1-3 isomer levels were significantly higher in the PAVP rats than in the NS rats. However, similar TGF-β1 and TGF-β3 levels were noted in the PS and PAVP rats, while TGF-β2 levels were significantly higher in the PAVP rats. Circulating liver-type arginase-1 and 5'-nucleotidase levels were higher in the PAVP rats than in the saline group.

Conclusion

This is the first study to demonstrate higher levels of TGF-β2, arginase, and 5'-nucleotidase activity in PAVP than in PS rats. AVP may cause vasoconstriction and increase peripheral resistance and blood pressure, thereby elevating TGF-β and inducing the preeclampsia-associated inflammatory response. Future studies should explore the mechanisms through which AVP dysregulates liver injury enzymes and TGF-β in pregnant rats.

Liver disease in pregnancy

Development of liver diseases during pregnancy is not uncommon. They are caused by either a disorder that is unique to pregnancy or an acute or chronic liver disease that already exists or coincidentally develops as a comorbidity of pregnancy. Liver diseases unique to pregnancy include hyperemesis gravidarum; hypertensive disorders of pregnancy, such as pre-eclampsia/eclampsia; hemolysis, elevated liver enzymes, and low platelet count syndrome; intrahepatic cholestasis of pregnancy; and acute fatty liver of pregnancy. Chronic liver diseases that affect pregnancy, or are affected by pregnancy, mainly include autoimmune liver diseases and non-alcoholic fatty liver disease. Prompt diagnosis and management of liver diseases in pregnancy, while very challenging, is extremely important, as they might cause adverse maternal and fetal outcomes. Therefore, a multidisciplinary, collaborative approach involving both hepatologists and obstetricians is required. In this review article, the up-to-date epidemiology, etiology, clinical features, and outcomes of liver diseases in pregnancy are discussed, to promote a deeper understanding among physicians, and subsequently improved outcomes.

The Effects of Androgens on T Cells: Clues to Female Predominance in Autoimmune Liver Diseases?

The immune system responds differently in women and in men. Generally speaking, adult females show stronger innate and adaptive immune responses than males. This results in lower risk of developing most of the infectious diseases and a better ability to clear viral infection in women (1–5). On the other hand, women are at increased risk of developing autoimmune diseases (AID) such as rheumatoid arthritis, multiple sclerosis (MS), systemic lupus erythematosus (SLE), Sjögren's syndrome, and the autoimmune liver diseases autoimmune hepatitis (AIH) and primary biliary cholangitis (PBC) (6). Factors contributing to the female sex bias in autoimmune diseases include environmental exposure, e.g., microbiome, behavior, and genetics including X chromosomal inactivation of genes. Several lines of evidence and clinical observations clearly indicate that sex hormones contribute significantly to disease pathogenesis, and the role of estrogen in autoimmune diseases has been extensively studied. In many of these diseases, including the autoimmune liver diseases, T cells are thought to play an important pathogenetic role. We will use this mini-review to focus on the effects of androgens on T cells and how the two major androgens, testosterone and dihydrotestosterone, potentially contribute to the pathogenesis of autoimmune liver diseases (AILD).

Effects of resveratrol on autophagy and the expression of inflammasomes in a placental trophoblast oxidative stress model

OBJECTIVE

We aim to investigate whether there is activation of NLRP1 and autophagy in trophoblast oxidative stress model. Resveratrol was taken to clarify its role in oxidative damage of placental trophoblasts.

METHODS

H₂O₂ was added to HTR-8/SVneo cell for 3 h, then the ROS level and apoptosis panel was performed. The levels of IL-1β, caspase-1, NLRP1, LC3 and Beclin-1 were detected. Resveratrol was added after 8 h, the ROS level and apoptosis rate were detected, the expression of IL-1β, caspase-1, NLRP1, LC3 and Beclin-1 were detected.

RESULTS

300 μmol/L H₂O₂ for 3 h is the optimum combination in establishing the oxidative stress injury model (P < 0.01). LDH, ROS and MDA level was increased, the activity of SOD, CAT were declined (P < 0.01). Apoptosis rate increased (P < 0.01). The expression of IL-1β, caspase-1, NLRP1, LC3 and Beclin-1 protein was higher (P < .01). Resveratrol (50 μmol/L) treatment for 8 h could improve the changes caused by H₂O₂, increase the survival rate of cells (P < 0.01), reduce the release of LDH, decrease the level of MDA, increase the level of SOD and CAT (P < 0.01). The expression of IL-1β, caspase-1, NLRP1, LC3 and Beclin-1 protein decreased (P < 0.01).

CONCLUSION

Trophoblast oxidative damage model can be established under 300 μmol/L H₂O₂ for 3 h, the expression of NLRP1and autophagy after H₂O₂ treatment were detected. Resveratrol reduces apoptotic cells, thus ensuring the normal biological functions of trophoblasts.

CAPSULE

H₂O₂-induced oxidative stress damage model in HTR-8/SVneo cells can be successfully established under 300 μmol/L H₂O₂ for 3 h, resveratrol alleviates of H₂O₂-induced damage by its antioxidant and autophagy regulation function.

The outcomes of transient elevation of maternal liver enzymes preceding laser treatment for twin-twin transfusion syndrome

BACKGROUND

A proportion of twin-twin transfusion syndrome (TTTS) patients may have elevated liver enzymes (ELEzs) before fetoscopic laser therapy, but the incidence of ELEzs before laser therapy and the association with the perinatal outcomes after laser therapy remain unclear.

METHODS

From October 2008 to April 2015, 93 patients with TTTS who received fetoscopic laser therapy at our hospital were included in this study, and aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were measured within 24 h before therapy. If ELEzs (AST > 34 U/L or ALT > 36 U/L) were observed before therapy, the AST and ALT levels were evaluated within 24 h after therapy. The pre-operative characteristics and post-therapy outcomes were compared between patients with and without ELEzs.

RESULTS

Among 93 TTTS patients before laser operation, 18 patients (were found with ELEzs (19.4%) before laser therapy. In 17 (94.4%) of the 18 cases, their liver enzymes values dropped after laser surgery. Maternal body mass index, age, gestational age of laser therapy, hemoglobin level before laser therapy and survival rates after laser therapy were not significantly different between TTTS with and without ELEzs. The maternal hemoglobin dropped significantly from 10.8 [1.6] g/dL before surgery to 9.6 [1.5] g/dL after laser therapy in TTTS with ELEzs (p < 0.001).

CONCLUSION

An elevated liver enzyme was not associated with poor perinatal outcomes in patients with TTTS after laser therapy. The authors suspected that the reduced liver enzymes values after laser therapy could partly arise from the hemo-dilution effect.

The role of hepatic sinusoidal obstruction in the pathogenesis of the hepatic involvement in HELLP syndrome: Exploring the literature

AIM

This study aims to determine, based on existing data, whether the mechanism resulting in liver dysfunction in HELLP syndrome resembles that in Sinusoidal Obstruction Syndrome (SOS).

BACKGROUND

HELLP syndrome is a serious pregnancy disorder with high maternal and perinatal morbidity and mortality rates. Because of poor insight in its pathophysiology, particularly that of the liver involvement, clinical management is limited to symptomatic treatment, often followed by termination of pregnancy. SOS is a rare, potentially life-threatening complication of radio and/ or chemotherapy in the preparation of hematopoietic cell transplantation. The etiology of liver dysfunction in SOS is - unlike that in HELLP syndrome - better-understood and seems to be initiated by direct toxic damage and demise of endothelial cells, causing hepatic sinusoidal obstruction and ischemia.

METHODS

We searched Pubmed, Embase and Cochrane for reports on the etiology of HELLP and SOS. This yielded 73 articles, with 14 additional reports from the references listed in these articles.

RESULTS

The dysfunctional placenta in women developing HELLP initiates a cascade of events that eventually results in liver dysfunction. The placenta releases, besides anti-angiogenetic factors, also necrotic debris and cell-free DNA, a mixture that not only induces systemic endothelial dysfunction as in preeclampsia, but also a systemic inflammatory response. The latter aggravates the endothelio-toxic effects in the systemic cardiovascular bed, amplifying the already increased pro-thrombotic conditions. Particularly in microcirculations with extremely low shear forces, such as in the hepatic sinusoids, this will facilitate microthrombi formation and fibrin deposition eventually resulting in obstruction of the sinusoids similar as in SOS. The latter causes ischemic damage and progressive demise of hepatocytes.

CONCLUSION

The available information supports the concept that the liver damage in HELLP and SOS results from sinusoidal ischemia, presumably resulting from partially overlapping pathophysiological mechanisms.

Effect of Nanoherbal Andaliman (Zanthoxylum acanthopodium) and Extra Virgin Olive Oil Combination on Preeclamptic Rats Liver Histology

BACKGROUND

Andaliman (Zanthoxylum acanthopodium) is a spice traditional Northen Sumatera, Indonesia and these fruits contain alkaloids, steroids and terpenoids. Extra Virgin Olive Oil (EVOO) contains antioxidants. Combination of this plant have activities to reduce preeclampsia.

AIM

To know the safety of the combination of nano herbal andaliman and Extra virgin olive oil (EVOO) on preeclampsia patients' liver.

METHODS

Pregnant rats were made to have preeclampsia with 3 ml of NaCl 6% injections. This research consists of 5 groups: K- (negative control): normal pregnant rats, K+: preeclampsia rats; P1: PE rats were given nano herbal andaliman 1 ml EVOO / day / 20 gBW from the 13th to the 19th day of pregnancy, P2: PE rats were given nano herbal andaliman 100 mg/day / 200 gBW from the 13th to the 19th day of pregnancy, P3: PE was given the combination of 1 ml EVOO/day / 200 gBW and andaliman nano herbal 100 mg/day/200 gBW on the 13th day of pregnancy to the 19th day given orally. Then on the 20th day of pregnancy, the subjects were dissected.

RESULTS

There were significant differences (p < 0.05) on the value of SGOT, SGPT, and the average damage of the hepatocyte cells except parenchymatous degeneration after being given the nano herbal andaliman and EVOO. The compared mean of normal hepatocytes cell, hydropic degeneration and necrosis value between all groups were p < 0.05 and p < 0.01 compared to (K-). The non-significant difference was found in the mean of parenchymatous degeneration between the groups (p = 0.058).

CONCLUSION

The combination of nano herbal andaliman (Zanthoxylum acanthopodium) and EVOO affected the level of necrosis in hepatocyte cells on preeclampsia rats.

Effect of shikonin on concanavalin A-induced liver injury and possible mechanisms involved

AIM

To investigate the effect of shikonin on concanavalin A (Con A)-induced acute liver injury in mice and explore the underlying mechanisms.

METHODS

Acute liver injury was induced by Con A in Balb/c mice through tail injection. The mice were randomly divided into five groups of fourteen mice as follows: (1) normal group; (2) Con A-induced model group; (3) low-dose (12.5 mg/kg) shikonin + Con A group; (4) medium-dose (25 mg/kg) shikonin + Con A group; (5) high-dose (50 mg/kg) shikonin + Con A group. Histological grading and the measurement of the levels of alanine transaminase (ALT), aspartate transaminase (AST), nitric oxide (NO), inducible nitric oxide synthase (iNOS), nuclear factor-κB (NF-κB), IκBα and IκBβ were performed.

RESULTS

Compared to the normal group, the histological grade as well as the levels of ALT, AST, NO, iNOS and NF-κB significantly increased in the model group, but the levels of IκBα and IκBβ were decreased. After shikonin (50 mg/kg) treatment, the histological grade and the levels of ALT, AST, NO, iNOS and NF-κB significantly were decreased, and the levels of IκBα and IκBβ were increased. The doses of 12.5 mg/kg and 25 mg/kg worked inefficiently.

CONCLUSION

Shikonin (50 mg/kg) protects against Con A-induced liver injury by decreasing the level of NO, which may correlate with the amelioration of NF-κB activity.