Clinical Case Summary

This case report describes the clinical history of a 59 years-old female with a delayed diagnosis of primary biliary cholangitis (PBC) and celiac disease (CeD), ultimately requiring orthotopic liver transplantation (OLT). In June 2021 the patient developed weight loss, fatigue, anorexia, diarrhea, and generalized itching. As the patient showed progressive worsening of symptoms, an ultrasound scan was performed in May 2022 revealing hepato-splenomegaly, ascites and cholelithiasis, which required hospitalization. Laboratory tests showed hyperbilirubinemia, elevated liver enzymes with a cholestatic pattern, thrombocytopenia, and anemia; serology was positive for antimitochondrial (AMA) and antinuclear antibodies (ANA) and abdominal MRI confirmed intrahepatic bile duct alterations consistent with PBC. Persistent diarrhea and weight loss despite treatment with ursodeoxycholic acid and cholestyramine, required further evaluation for CeD. High tissue transglutaminase antibody levels and duodenal villous atrophy (3B according to Marsh-Oberhuber Classification) confirmed the diagnosis. A gluten-free diet (GFD) was started with incomplete adherence; the patient’s liver function further deteriorated, leading, in October 2023, to an acute on chronic decompensation with ascites and jaundice (Child-Pugh C13 and MELD 32). She eventually underwent successful OLT via piggyback technique. One year after transplant, the patient showed a significant clinical improvement, resolution of diarrhea and itching associated with better adherence to a GFD, although sarcopenia and nutritional deficiencies persisted. This report underscores the critical need for early diagnosis, screening for other autoimmune diseases, strict dietary adherence, regular follow-up, as well as a multidisciplinary management, in patients with PBC and CeD to prevent severe liver dysfunction and improve outcomes.

Figure 1. Trend of liver function markers (AST, ALT, GGT, ALP), MELD, Child-Pugh since PBC diagnosis

References

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2. Jena A et al. Liver abnormalities in celiac disease and response to gluten free diet: A systematic review and meta-analysis. J Gastroenterol Hepatol. 2023 Jan;38(1):11-22. doi: 10.1111/jgh.16039.

3. Yang J et al.. Prevalence and effect on prognosis of sarcopenia in patients with primary biliary cholangitis. Front Med (Lausanne). 2024 Feb 29;11:1346165. doi: 10.3389/fmed.2024.1346165

4. Al-Toma et al. European Society for the Study of Coeliac Disease (ESsCD) guideline for coeliac disease and other gluten-related disorders. United European Gastroenterol J. 2019 Jun;7(5):583-613. doi: 10.1177/2050640619844125.

5. European Association for the Study of the Liver, EASL Clinical Practice Guidelines: The diagnosis and management of patients with primary biliary cholangitis. J Hepatol. 2017 Jul;67(1):145-172. doi: 10.1016/j.jhep.2017.03.022. Epub 2017 Apr 18. PMID: 28427765.

Introduction

Biliary leaks are a well-recognized complication following liver transplantation (LT). Despite advancements in ERCP techniques, there remains variability in treatment success, Considering the peculiarities of this patient group, characterized by specific post-surgical anatomy, variations in endoductal pressure, and immunosuppressive therapy. This study was conducted to identify predictive factors influencing the healing of biliary leaks and the development of post-leak strictures, with the goal of refining management strategies and enhancing patient outcomes.

Aims & Methods

A retrospective analysis was performed on 34 LT patients who developed biliary leaks and were managed with ERCP within 24 hours from diagnosis. Variables included: the type of biliary stricture (anastomotic vs. non-anastomotic), presence of clinical symptoms (pain, fever, jaundice), time interval between multiple ERCPs to reach leak healing, characteristics of the stents (number, diameter in French, and length in cm), and leak parameters (high-grade vs. low-grade, early vs. late leak onset). Statistical analyses included Chi-square and Fisher's exact tests for categorical variables, Student's t-test and Mann-Whitney U test were used for continuous variables. The significance threshold was p<0.05.

Results

Among 34 patients with post-liver transplant biliary leaks, the overall healing rate was 94.1% (32/34). Early leaks (≤4 weeks) had longer healing times than late leaks (>4 weeks) (21.1 vs. 13.0 days). Strictures developed in 54.5% of patients (18/33). All strictures occurred in high-grade leaks: 66.7% in early high-grade and 60.0% in late high-grade groups. No strictures were observed in any low-grade leak, regardless of timing.
Based on cholangiographic appearance, high-grade leaks (visible before full biliary opacification) accounted for all strictures and often required multiple ERCPs. Low-grade leaks (visible only after full opacification) never led to strictures and typically healed after a single procedure. Notably, no strictures occurred in low-grade leaks, regardless of timing, while all strictures developed in patients with high-grade leaks, both early and late.
Shorter healing times were associated with the presence of symptoms, use of 10 Fr vs. 7 Fr stents, and intervals <1 month between ERCPs. In contrast, use of multiple stents, pre-existing NAS, and early high-grade leaks were linked to prolonged healing courses or non-resolution with standard ERCP strategy. The Kehr tube showed no significant impact.

Conclusion

Leak grade and timing are key predictors of post-transplant biliary leak healing. High-grade leaks, especially when early, were associated with delayed recovery and the need for multiple ERCPs, while low-grade leaks followed a consistently favorable course. Faster healing was also observed in symptomatic patients, with the use of 10 Fr stents and short ERCP intervals (<1 month). Strictures occurred exclusively in high-grade leaks, further supporting the prognostic relevance of cholangiographic grading. Incorporating leak grade and timing into early ERCP decision-making can accelerate healing, reduce complications, and significantly improve post-transplant outcomes.

References

1. Girotra, M., Soota, K., Klair, J. S., Dang, S. M., Aduli Mohit Girotra, F., Aduli, F., & Endoscopic, A. F. (2015). Endoscopic management of post-liver transplant biliary complications. World Journal of Gastrointestinal Endoscopy, 7(5), 446
2. Moy, B. T., & Birk, J. W. (2019). A Review on the Management of Biliary Complications after Orthotopic Liver Transplantation. Journal of Clinical and Translational Hepatology, 7(1), 61–71
3. Lee, H. W., Shah, N. H., & Lee, S. K. (2017). An Update on Endoscopic Management of Post-Liver Transplant Biliary Complications. Clinical Endoscopy, 50(5), 451– 463
4. Sendino, O., Fernández-Simon, A., Law, R., Abu Dayyeh, B., Leise, M., Chavez- Rivera, K., Cordova, H., Colmenero, J., Crespo, G., Rodriguez de Miguel, C., Fondevila, C., Llach, J., Navasa, M., Baron, T., & Cárdenas, A. (2018). Endoscopic management of bile leaks after liver transplantation: An analysis of two high-volume transplant centers. United European Gastroenterology Journal, 6(1), 89–96
5. Oh, D., Lee, S. K., Song, T. J., Park, D. H., Lee, S. S., Seo, D. W., & Kim, M. H. (2015). Endoscopic management of bile leakage after liver transplantation. Gut and Liver, 9(3), 417–423

Introduction

Acetaminophen-induced liver failure (AILF) has a high fatality rate and limited therapeutic approaches at present. Type 1 conventional dendritic cells (cDC1) are one of the major subgroups of cDCs in the liver, which is not only an important type in initiating adaptive immune response, but also can promote the generation, stability and function of Regulatory T (T_reg) cells through various mechanisms. cDC1 maintains liver immune homeostasis by regulating the balance between immune activation and tolerance. Nevertheless, the precise involvement and mechanistic contributions of hepatic cDCs in AILF remain to be elucidated.

Aims & Methods

Multiplex Immunohistochemistry (mIHC), flow cytometry, spatial transcriptomics (ST), single-cell RNA sequencing (scRNA-seq) and intravital 3D imaging were used to characterize the distribution and frequency of the cDC1. Bulk RNA-seq, metabolomic analyses, Cleavage Under Targets and Tagmentation (CUT&Tag) and Chromatin immunoprecipitation (ChIP)-qPCR assay were employed to explore the molecular mechanisms. CD11c^creXCR1^f/f, CD11c^creIDO1^f/f, CD11c^creP300^f/f and Foxp3^DTR mice, various mouse primary cells, human liver and serum samples were applied to verify the discoveries of bioinformatics analysis. Intravenous delivery of tolerogenic dendritic cells (tolDCs) was used to elucidate their regulatory effects on T_reg cells and roles in the AILF process.

Results

Our analyses revealed that the amount of cDC1 was significantly reduced across both clinical AILF cohorts and mouse AILF models, with the magnitude of depletion exhibiting dose- and duration-dependent associations with APAP exposure. mIHC, ST, scRNA-seq and intravital 3D imaging delineated that cDC1 depletion impaired T_reg cells priming capacity, ultimately disrupting hepatic immune homeostasis and exacerbating AILF. Intravenous tolDCs injection demonstrated therapeutic efficacy by orchestrating hepatic T_reg cells infiltration, attenuating inflammatory responses, potentiating liver regeneration, and ultimately reversing AILF-associated pathological manifestations. The therapeutic effect of intravenous tolDCs administration was abolished after diphtheria toxin-mediated T_reg cells depletion in Foxp3^DTR mice. CD11c^creXCR1^f/f mice andwild-type mice clearing cDC1 with XCL1-antibody had exacerbated liver pathology. Mechanistically, EP300-mediated histone 3 lysine 27 acetylation (H3K27ac) in IDO1 promoter region enforced stable tolerogenic states of cDC1, these epigenetically programmed cDC1 subsequently initiated tryptophan catabolism, generating kynurenine metabolites that triggered both differentiation and functional maturation of T_reg cells. Both the DC-specific knockout and inhibition of EP300 could reduce the H3k27ac levels of IDO1. And the CD11c^creIDO1^f/f mice with APAP exposure had less T_reg cells recruitment and worse phenotype.

Conclusion

This study elucidated that EP300 orchestrated tolDCs differentiation via H3K27ac/IDO1 signaling axis, this epigenetic-metabolic cascade licensed tolDCs to recruit and activate T_reg cells, thereby preserving hepatic immune homeostasis while promoting hepatocyte proliferation and tissue repair. These findings highlight novel therapeutic targets for reversing AILF pathogenesis.

Introduction

Acetaminophen (APAP) overdose is a primary cause of drug-induced liver injury (DILI). Although the inflammatory microenvironment plays a critical role in APAP-induced liver injury (AILI), its cellular interaction network and molecular regulatory mechanisms remain incompletely elucidated. Krüppel-like factor 4 (KLF4), a zinc finger transcription factor, is known to regulate monocyte differentiation, but its functional role in the AILI inflammatory microenvironment remains unclear. This study aims to investigate the regulatory effects of myeloid KLF4 deletion on the AILI microenvironment.

Aims & Methods

By integrating multidimensional omics analysis and a myeloid-specific Klf4 knockout mouse model, we dynamically dissected microenvironmental remodeling during AILI progression. Liver samples were collected for RNA sequencing, combined with single-cell transcriptomics, flow cytometry, and molecular interaction validation to clarify the KLF4-dependent cellular subpopulation interaction network. In vivo liver imaging, histology, biochemical assays, and molecular experiments were performed to validate KLF4-dependent intercellular interactions. Primary hepatocytes and hepatocyte cell lines were used for in vitro verification.

Results

Myeloid-specific KLF4 deletion led to an increase in CXCL2⁺CXCL3⁺CD24⁺ monocytes, which activated the NF-κB signaling pathway to secrete CXCL2/CXCL3 chemokines. These chemokines bound to the CXCR2 receptor on neutrophils, driving neutrophil infiltration and neutrophil extracellular traps (NETs) formation, while amplifying the TNF-α signaling pathway. Concurrently, myeloid KLF4 knockout induced enrichment of CXCL1⁺IL17RA⁺ endothelial cells. Neutrophil-derived NETs promoted endothelial phenotypic switching toward pro-inflammatory polarization, while endothelial-derived CXCL1 further recruited neutrophils, establishing a "monocyte-neutrophil-endothelial" cellular subpopulation interaction that perpetuated microenvironmental inflammation.

Conclusion

This study reveals the molecular mechanism by which KLF4 drives inflammatory cascades in the AILI microenvironment through regulation of the myeloid-endothelial interaction network. We propose therapeutic strategies targeting NETs formation or the CXCL2/CXCL3-CXCR2 axis, providing novel targets for precise intervention in AILI.