Hepatic kinome atlas: An in-depth identification of kinase pathways in liver fibrosis of humans and rodents.

BACKGROUND AND AIMS: Resolution of pathways that converge to induce deleterious effects in hepatic diseases, such as in the later stages, have potential antifibrotic effects that may improve outcomes. We aimed to explore whether humans and rodents display similar fibrotic signaling networks. APPROACH AND RESULTS: We assiduously mapped kinase pathways using 340 substrate targets, upstream bioinformatic analysis of kinase pathways, and over 2000 random sampling iterations using the PamGene PamStation kinome microarray chip technology. Using this technology, we characterized a large number of kinases with altered activity in liver fibrosis of both species. Gene expression and immunostaining analyses validated many of these kinases as bona fide signaling events. Surprisingly, the insulin receptor emerged as a considerable protein tyrosine kinase that is hyperactive in fibrotic liver disease in humans and rodents. Discoidin domain receptor tyrosine kinase, activated by collagen that increases during fibrosis, was another hyperactive protein tyrosine kinase in humans and rodents with fibrosis. The serine/threonine kinases found to be the most active in fibrosis were dystrophy type 1 protein kinase and members of the protein kinase family of kinases. We compared the fibrotic events over four models: humans with cirrhosis and three murine models with differing levels of fibrosis, including two models of fatty liver disease with emerging fibrosis. The data demonstrate a high concordance between human and rodent hepatic kinome signaling that focalizes, as shown by our network analysis of detrimental pathways. CONCLUSIONS: Our findings establish a comprehensive kinase atlas for liver fibrosis, which identifies analogous signaling events conserved among humans and rodents.

Strangulation of intraperitoneal kidney transplant by fallopian tube.

Renal allograft strangulation is a rare complication following simultaneous kidney pancreas transplant, often causing graft loss. This case report represents the first documented case of a 35-year-old female who developed renal graft strangulation around the left fallopian tube. Our case outlines a new complication that contributes to graft loss concerning iliac fossa anatomy and variations in female patients, as well as surgical considerations that need to be made prior to transplantation. We recommend measurement of the grafted renal vessels within the iliac fossa and respective surroundings structures to allow for the ideal positioning of the grafted organ.

Incarceration of transplanted kidney through incisional hernia.

Transplanted allograft kidney herniation through an incisional hernia resulting in incarceration is a rare condition with only one other similar case reported in the literature. The primary imaging modalities used to diagnose kidney herniation are graft ultrasound, abdominal computed tomography and abdominal magnetic resonance imaging [Sugi et al. (Imaging of renal transplant complications throughout the life of the allograft: comprehensive multimodality review. Radiographics 2019;39:1327-1355)]. Treatment should be based on patient's symptoms. This case report highlights the initial presentation of hematuria in a 57-year-old male that eventually led to the diagnosis of a right-sided incarcerated grafted kidney through an incisional hernia. Subsequently, the patient underwent transplant nephrectomy.

Lymphangiography with lipiodol as a diagnostic and therapeutic approach for Chyle Leak ascites following Simultaneous Pancreas-Kidney Transplant.

Chylous ascites (CA) is the leakage of triglyceride-rich fluid into the peritoneal cavity. This most commonly occurs due to trauma of the lymphatic system. Recently, lymphangiography with lipiodol have been used with promising results in managing refractory postoperative CA. We present the case of a 35-year-old man who developed massive refractory CA post simultaneous pancreas-kidney (SPK) transplant. After conservative management with diet modifications failed, the patient underwent lymphangiography and lymph angioembolization using lipiodol. In this case report, we describe the use of lymphangiography as both a diagnostic and therapeutic approach to successfully manage large volume CA following SPK.

Surgical management of a massive choledochal cyst.

Choledochal cysts (CC) are congenital bile duct anomalies, typically present in children. The size of CC vary, but they rarely exceed 9 cm. Surgical resection is the mainstay of treatment. This case report presents 18-year-old female with jaundice and abdominal pain. On imaging she was found to have a type I CC versus a type IVa CC. She was taken to the operating room where she was found to have a 20 cm type I CC. The patient experienced complete recovery after total resection of the extrahepatic cyst with reconstruction with a Roux-en-Y hepaticojejunostomy. Preoperative diagnosis of the type of CCs can be challenging. Proper imaging preoperatively can aid in diagnosis of these cysts, but delineation of anatomy and type may not always be possible. If treated in a timely manner, it can help prevent both long- and short-term complications.

Small bowel obstruction due to retroperitoneal hernia following renal transplant: a case report.

Para duodenal hernias, the most common type of retroperitoneal hernias, are thought to occur naturally from abnormal gut rotation because of fusion folds within the peritoneum. Retroperitoneal hernias are a rare postoperative complication and have not been described after renal transplantation via a retroperitoneal approach. This case report presents a 48-year-old male with intestinal obstruction after renal transplant due to herniation into the retroperitoneum via an incidentally created peritoneal defect. We suggest computed tomography with oral contrast be used in the early postoperative phase to assess for obstruction in patients with prolonged ileus of unclear etiology who have undergone retroperitoneal dissection. Small peritoneal defects should be closed during dissection. Larger, or multiple peritoneal defects should be extended to make a single, large defect to decrease the possibility of bowel herniating and becoming incarcerated.

Nonoperative management of gastrointestinal bleeding after a simultaneous pancreas and kidney transplant.

With a shift toward enteric drainage techniques, the complications associated with simultaneous pancreas and kidney (SPK) transplant have also changed. Gastrointestinal (GI) bleeding is one of the most common complications associated with SPK. This case report describes the treatment of a postoperative GI hemorrhage using the push endoscopy technique. A 48-year-old male underwent an uneventful SPK transplant with entero-systemic drainage and developed hematochezia. The push enteroscopy technique was utilized to treat the bleeding ulcer. Historically, the use of the push enteroscopy technique to treat GI bleeding from the small bowel is not described in the literature. One of the limitations of duodenojejunostomy is that standard endoscopy cannot be readily used to visualize the duodenojejunostomy. However, the use of push enteroscopy may prove to be a minimal invasive and cost-effective intervention for GI bleeding after SPK.

Surgical approach for kidney transplantation under spinal anesthesia.

Kidney transplantation is the treatment of choice for patients with end-stage renal disease (ESRD). It has been shown to improve quality of life as well as extending life of patients with ESRD as compared to renal replacement therapy (5-year survival rate of 68% after transplant vs 36% dialysis) (Hart A, Smith JM, Skeans MA. OPTN/SRTR 2015 annual data report: kidney. Am J Transplant 2017;17:21-116). Traditionally, patients undergo general endotracheal tube anesthesia for this surgery. During the COVID-19 pandemic, general anesthesia drugs and airway equipment were in short supply. Additionally, airway manipulation was avoided when possible due to concern for virus spread from aerosolizing procedures (i.e. intubation/extubation). In this case report, we review a 65-year-old female with an ESRD due to hypertension and diabetes that underwent deceased donor kidney transplant under spinal anesthesia. We will further discuss the benefits of spinal anesthesia in renal transplant operations.

The presence of donor liver granuloma requiring further workup to rule out parasitic disease.

A shortage of donor organs is a major limitation to liver transplantation. Expansion of donor pool criteria to include patients with schistosomiasis diagnosed on liver biopsy might allow the allocation of more transplant livers. Schistosomiasis is a chronic parasitic disease affecting millions in endemic areas including sub-Sahara Africa that might lead to the development of granulomas as a response to the parasite's ova and might cause chronic liver disease and portal hypertension. Due to increased mobility globally, schistosomiasis may be encountered in non-endemic areas. Currently, the usage of donor livers with known Schistosomiasis is not universally defined.

Donor-specific antibodies present at the time of kidney transplantation in immunologically unmodified patients increase the risk of acute rejection.

BACKGROUND: Human leukocyte antigens (HLA) class II donor-specific antibodies (DSAs) are associated with microcirculation inflammation, transplant glomerulopathy and ultimately graft loss. There is however no data on allograft outcomes in deceased donor kidney transplant recipients who have not received any desensitization prior to transplantation. METHODS: We prospectively evaluated the association of HLA DR and DQ DSAs on rejection and short-term graft survival in patients who did not receive desensitization prior to transplantation. On the basis of their cumulative strength of HLA DR and/or DQ DSA, the patients were dichotomized into: 1) median fluorescence intensity (MFI)<1000 and 2) MFI≥1000. RESULTS: In the two year study period, 50 consecutive patients with HLA DR and/or DQ sensitization were transplanted in our two centers. Post-transplantation, the incidence of acute rejection was significantly greater in the MFI≥1000 group (35%; 8/22) compared to the MFI<1000 group (7%; 2/28) (p<0.001). There were two graft losses, both in the MFI≥1000 group. CONCLUSION: The strength of DR and/or DQ DSA at the time of renal transplantation influences the risk of rejection in non-desensitized recipients with HLA class II DSA.

Fibrin deposition following bile duct injury limits fibrosis through an αMß2-dependent mechanism.

Coagulation cascade activation and fibrin deposits have been implicated or observed in diverse forms of liver damage. Given that fibrin amplifies pathological inflammation in several diseases through the integrin receptor αMß2, we tested the hypothesis that disruption of the fibrin(ogen)-αMß2 interaction in Fibγ(390-396A) mice would reduce hepatic inflammation and fibrosis in an experimental setting of chemical liver injury. Contrary to our hypothesis, α-naphthylisothiocyanate (ANIT)-induced liver fibrosis increased in Fibγ(390-396A) mice, whereas inflammatory cytokine expression and hepatic necrosis were similar to ANIT-challenged wild-type (WT) mice. Increased fibrosis in Fibγ(390-396A) mice appeared to be independent of coagulation factor 13 (FXIII) transglutaminase, as ANIT challenge in FXIII-deficient mice resulted in a distinct pathological phenotype characterized by increased hepatic necrosis. Rather, bile duct proliferation underpinned the increased fibrosis in ANIT-exposed Fibγ(390-396A) mice. The mechanism of fibrin-mediated fibrosis was linked to interferon (IFN)γ induction of inducible nitric oxide synthase (iNOS), a gene linked to bile duct hyperplasia and liver fibrosis. Expression of iNOS messenger RNA was significantly increased in livers of ANIT-exposed Fibγ(390-396A) mice. Fibrin(ogen)-αMß2 interaction inhibited iNOS induction in macrophages stimulated with IFNγ in vitro and ANIT-challenged IFNγ-deficient mice had reduced iNOS induction, bile duct hyperplasia, and liver fibrosis. Further, ANIT-induced iNOS expression, liver fibrosis, and bile duct hyperplasia were significantly reduced in WT mice administered leukadherin-1, a small molecule that allosterically enhances αMß2-dependent cell adhesion to fibrin. These studies characterize a novel mechanism whereby the fibrin(ogen)-integrin-αMß2 interaction reduces biliary fibrosis and suggests a novel putative therapeutic target for this difficult-to-treat fibrotic disease.

Increased hepatic receptor interacting protein kinase 3 expression due to impaired proteasomal functions contributes to alcohol-induced steatosis and liver injury.

Chronic alcohol exposure increased hepatic receptor-interacting protein kinase (RIP) 3 expression and necroptosis in the liver but its mechanisms are unclear. In the present study, we demonstrated that chronic alcohol feeding plus binge (Gao-binge) increased RIP3 but not RIP1 protein levels in mouse livers. RIP3 knockout mice had decreased serum alanine amino transferase activity and hepatic steatosis but had no effect on hepatic neutrophil infiltration compared with wild type mice after Gao-binge alcohol treatment. The hepatic mRNA levels of RIP3 did not change between Gao-binge and control mice, suggesting that alcohol-induced hepatic RIP3 proteins are regulated at the posttranslational level. We found that Gao-binge treatment decreased the levels of proteasome subunit alpha type-2 (PSMA2) and proteasome 26S subunit, ATPase 1 (PSMC1) and impaired hepatic proteasome function. Pharmacological or genetic inhibition of proteasome resulted in the accumulation of RIP3 in mouse livers. More importantly, human alcoholics had decreased expression of PSMA2 and PSMC1 but increased protein levels of RIP3 compared with healthy human livers. Moreover, pharmacological inhibition of RIP1 decreased Gao-binge-induced hepatic inflammation, neutrophil infiltration and NF-κB subunit (p65) nuclear translocation but failed to protect against steatosis and liver injury induced by Gao-binge alcohol. In conclusion, results from this study suggest that impaired hepatic proteasome function by alcohol exposure may contribute to hepatic accumulation of RIP3 resulting in necroptosis and steatosis while RIP1 kinase activity is important for alcohol-induced inflammation.

Groove Pancreatitis: A Rare form of Chronic Pancreatitis.

CONTEXT: Groove pancreatitis is a rare form of chronic pancreatitis affecting the "groove" of the pancreas among the pancreatic head, duodenum, and common bile duct. The exact cause is unknown, although there are associations with long-term alcohol abuse, smoking, peptic ulcer disease, heterotopic pancreas, gastric resection, biliary disease, and anatomical or functional obstruction of the minor papilla. The diagnosis can be challenging. Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography are the preferred imaging modalities. The treatment of choice is conservative although surgical intervention can sometimes be required. CASE REPORT: A 57-year-old male with a history of human immunodeficiency virus and hepatitis B presented with 4 days of epigastric pain. Abdominal exam revealed absent bowel sounds and epigastric tenderness. He had a creatinine of 1.72 mg/dL, potassium of 2.9 mmol/L, and a normal lipase level of 86 U/L. Liver enzymes and total bilirubin were normal. Computed tomography abdomen showed high-grade obstruction of the second portion of the duodenum without any obvious mass. An esophagogastroduodenoscopy showed a mass at the duodenal bulb causing luminal narrowing, with biopsies negative for malignancy. Magnetic resonance imaging revealed a mass in the region of the pancreatic head and descending duodenum. EUS revealed a 3 cm mass in the region of pancreatic head with irregular borders and no vascular invasion. Fine needle aspiration (FNA) was nondiagnostic. The patient then underwent a Whipple's procedure. Pathology of these specimens was negative for malignancy but was consistent with para-duodenal or groove pancreatitis. CONCLUSION: The low incidence of groove pancreatitis is partly due to lack of familiarity with the disease. Groove pancreatitis should be considered in the differential for patients presenting with pancreatic head lesions and no cholestatic jaundice, especially when a duodenal obstruction is present, and neither duodenal biopsies nor pancreatic head FNA confirm adenocarcinoma.

Dynamic Arginine Methylation of Tumor Necrosis Factor (TNF) Receptor-associated Factor 6 Regulates Toll-like Receptor Signaling.

Arginine methylation is a common post-translational modification, but its role in regulating protein function is poorly understood. This study demonstrates that, TNF receptor-associated factor 6 (TRAF6), an E3 ubiquitin ligase involved in innate immune signaling, is regulated by reversible arginine methylation in a range of primary and cultured cells. Under basal conditions, TRAF6 is methylated by the methyltransferase PRMT1, and this inhibits its ubiquitin ligase activity, reducing activation of toll-like receptor signaling. In response to toll-like receptor ligands, TRAF6 is demethylated by the Jumonji domain protein JMJD6. Demethylation is required for maximal activation of NF-κB. Loss of JMJD6 leads to reduced response, and loss of PRMT1 leads to basal pathway activation with subsequent desensitization to ligands. In human primary cells, variations in the PRMT1/JMJD6 ratio significantly correlate with TRAF6 methylation, basal activation of NF-κB, and magnitude of response to LPS. Reversible arginine methylation of TRAF6 by the opposing effects of PRMT1 and JMJD6 is, therefore, a novel mechanism for regulation of innate immune pathways.

Late-onset renal vein thrombosis: A case report and review of the literature.

INTRODUCTION: Renal vein thrombosis, a rare complication of renal transplantation, often causes graft loss. Diagnosis includes ultrasound with Doppler, and it is often treated with anticoagulation or mechanical thrombectomy. Success is improved with early diagnosis and institution of treatment. PRESENTATION OF CASE: We report here the case of a 29 year-old female with sudden development of very late-onset renal vein thrombosis after simultaneous kidney pancreas transplant. This resolved initially with thrombectomy, stenting and anticoagulation, but thrombosis recurred, necessitating operative intervention. Intraoperatively the renal vein was discovered to be compressed by a large ovarian cyst. DISCUSSION: Compression of the renal vein by a lymphocele or hematoma is a known cause of thrombosis, but this is the first documented case of compression and thrombosis due to an ovarian cyst. CONCLUSION: Early detection and treatment of renal vein thrombosis is paramount to restoring renal allograft function. Any woman of childbearing age may have thrombosis due to compression by an ovarian cyst, and screening for this possibility may improve long-term graft function in this population.

Protein expression profiling of nuclear membrane protein reveals potential biomarker of human hepatocellular carcinoma.

BACKGROUND: Complex molecular events lead to development and progression of liver cirrhosis to HCC. Differentially expressed nuclear membrane associated proteins are responsible for the functional and structural alteration during the progression from cirrhosis to carcinoma. Although alterations/ post translational modifications in protein expression have been extensively quantified, complementary analysis of nuclear membrane proteome changes have been limited. Deciphering the molecular mechanism that differentiate between normal and disease state may lead to identification of biomarkers for carcinoma. RESULTS: Many proteins displayed differential expression when nuclear membrane proteome of hepatocellular carcinoma (HCC), fibrotic liver, and HepG2 cell line were assessed using 2-DE and ESI-Q-TOF MS/MS. From the down regulated set in HCC, we have identified for the first time a 15 KDa cytochrome b5A (CYB5A), ATP synthase subunit delta (ATPD) and Hemoglobin subunit beta (HBB) with 11, 5 and 22 peptide matches respectively. Furthermore, nitrosylation studies with S-nitrosocysteine followed by immunoblotting with anti SNO-cysteine demonstrated a novel and biologically relevant post translational modification of thiols of CYB5A in HCC specimens only. Immunofluorescence images demonstrated increased protein S-nitrosylation signals in the tumor cells and fibrotic region of HCC tissues. The two other nuclear membrane proteins which were only found to be nitrosylated in case of HCC were up regulated ATP synthase subunit beta (ATPB) and down regulated HBB. The decrease in expression of CYB5A in HCC suggests their possible role in disease progression. Further insight of the functional association of the identified proteins was obtained through KEGG/ REACTOME pathway analysis databases. String 8.3 interaction network shows strong interactions with proteins at high confidence score, which is helpful in characterization of functional abnormalities that may be a causative factor of liver pathology. CONCLUSION: These findings may have broader implications for understanding the mechanism of development of carcinoma. However, large scale studies will be required for further verification of their critical role in development and progression of HCC.

Completely laparoscopic nonanatomic hepatic resection using saline-cooled cautery and hydrodissection.

The technical aspects of laparoscopic hepatic resection have evolved rapidly. The key to any approach is establishing a reliable method to prevent or control hemorrhage during parenchymal transection. Although combining a hand-assist technique with laparoscopy allows improved control of bleeding risk, this requires the addition of a hand-port incision. The development of novel devices that can be used to safely divide liver parenchyma laparoscopically may lessen the need for hand-assist. Here, we report a series of laparoscopic hepatic resections that were attempted without the use of hand-assistance (completely laparoscopic). Resections were performed using saline-cooled cautery (Tissue-Link Endohook) and/or hydrodissection (Erbe Helix Hydrojet). Fifteen laparoscopic hepatic resections were attempted by a single surgeon from 2002 to 2006. In each case, a nonanatomic, completely laparoscopic approach was attempted. Patients with lesions at the hepatic dome or those requiring lobectomy or hilar dissection were excluded. Fourteen of 15 cases (93%) were accomplished completely laparoscopically, while one patient required placement of a hand port. Resected tumors averaged 3.9 cm diameter. There were no bile leaks and no patient required transfusion. Average length of stay was 4.1 days (range 1-5). Complications included ileus (1) and atrial fibrillation (1). In six patients with malignancies, margins were negative and there have been no local or port recurrences. This report demonstrates the feasibility of completely laparoscopic hepatic resection using novel devices for parenchymal transaction. Hand-assist techniques remain useful as a salvage strategy or for larger resections.

Pretransplant bilateral hand-assisted laparoscopic nephrectomy in adult patients with polycystic kidney disease.

Laparoscopic procedures continue to gain popularity over traditional open procedures for a number of abdominal and pelvic surgeries. With increasing experience, the application of this technique is rising because it provides an alternative, less invasive, approach to various surgical procedures. Herein, we report our experience with adult patients with polycystic kidney disease, requiring bilateral laparoscopic nephrectomy before renal transplantation.