CD24+LCN2+ liver progenitor cells in ductular reaction contributed to macrophage inflammatory responses in chronic liver injury.

BACKGROUND: CD24+CK19+/CD24+SOX9+ resident liver cells are activated and expanded after chronic liver injury in a ductular reaction. However, the sources and functions of these cells in liver damage remain disputed. RESULTS: The current study combined genetic lineage tracing with in vitro small-molecule-based reprogramming to define liver progenitor cells (LPCs) derived from hepatic parenchymal and non-parenchymal tissues. tdTom+ hepatocytes were isolated from ROSA26tdTomato mice following AAV8-Tbg-Cre-mediated recombination, EpCAM+ biliary epithelial cells (BECs) from wild-type intrahepatic bile ducts and ALB/GFP-EpCAM- cells were isolated from AlbCreERT/R26GFP mice. A cocktail of small molecules was used to convert the isolated cells into LPCs. These in vitro cultured LPCs with CD24 and SOX9 expression regained the ability to proliferate. Transcriptional profiling showed that the in-vitro cultured LPCs derived from the resident LPCs in non-parenchymal tissues expressed Lipocalin-2 (Lcn2) at high levels. Accordingly, endogenous Cd24a+Lcn2+ LPCs were identified by integration of sc-RNA-sequencing and pathological datasets of liver dysfunction which indicates that LPCs produced by ductular reactions might also originate from the resident LPCs. Transplantation of in-vitro cultured Cd24a+Lcn2+ LPCs into CCl4-induced fibrotic livers exacerbated liver damage and dysfunction, possibly due to LCN2-dependent macrophage inflammatory response. CONCLUSIONS: CD24+LCN2+ LPCs constituted the expanding ductular reaction and contributed to macrophage-mediated inflammation in chronic liver damage. The current findings highlight the roles of LPCs from distinct origins and expose the possibility of targeting LPCs in the treatment of chronic hepatic diseases.

SARS-CoV-2 BA.2 (Omicron) variant infection in pediatric liver transplanted recipients and cohabitants during 2022 Shanghai outbreak: a prospective cohort.

BACKGROUND: The Omicron variant BA.2 was the dominant variant in the COVID-19 outbreak in Shanghai since March 2022. We aim to investigate the characteristics of SARS-CoV-2 Omicron variant infection in pediatric liver-transplanted recipients. METHODS: We conducted a single-center, prospective, observational, single-arm study. We enrolled pediatric liver-transplanted patients infected with the Omicron variant BA.2 from March 19th to October 1st, 2022 and analyzed their demographic, clinical, laboratory, and outcome data. The management of COVID-19 was conducted according to the 9th trial edition of the Chinese guideline. The immunosuppressive therapy was tailored considering the patients' infection developments and liver functions. RESULTS: Five children were included. The primary diseases included Niemann-Pick disease, propionic acidemia, decompensated cirrhosis, biliary atresia, and Crigler-Najjar syndrome type I. All of the patients were onset with fever before or when getting RNA-positive results at the age of 3 (Range: 1-13) years. The infection duration was 29 (Range: 18-40) days. Three and two children were diagnosed with mild and moderate COVID-19 respectively. Two patients were tested RNA-positive within 14 days after having been tested negative. The immunosuppressants were paused or extenuated in four patients. Eight of all nine cohabitants were injected with at least two doses of inactivated SARS-CoV-2 vaccine. The disease courses were significantly longer than the patients (P < 0.05). CONCLUSIONS: Post-transplant immunosuppression slows down the virus clearance and increases the risk of relapse but does not affect symptom duration or infection severity in pediatric patients. Patients can usually gain a favorable outcome and prognosis by extenuating immunosuppressants.

Single-cell transcriptomics uncovers cellular architecture and developmental trajectories in hepatoblastoma.

BACKGROUND AND AIMS: Hepatoblastoma (HB) is the predominant type of childhood liver cancer. Treatment options for the clinically advanced HB remain limited. We aimed to dissect the cellular and molecular basis underlying HB oncogenesis and heterogeneity at the single-cell level, which could facilitate a better understanding of HB at both the biological and clinical levels. APPROACH AND RESULTS: Single-cell transcriptome profiling of tumor and paired distal liver tissue samples from five patients with HB was performed. Deconvolution analysis was used for integrating the single-cell transcriptomic profiles with the bulk transcriptomes of our HB cohort of post-neoadjuvant chemotherapy tumor samples. A single-cell transcriptomic landscape of early human liver parenchymal development was established for exploring the cellular root and hierarchy of HB oncogenesis. As a result, seven distinct tumor cell subpopulations were annotated, and an effective HB subtyping method was established based on their compositions. A HB tumor cell hierarchy was further revealed to not only fit with the classical cancer stem cell (CSC) model but also mirror the early human liver parenchymal development. Moreover, FACT inhibition, which could disrupt the oncogenic positive feedback loop between MYC and SSRP1 in HB, was identified as a promising epigenetic-targeted therapeutic strategy against the CSC-like HB1-Pro-like1 subpopulation and its related high-risk "Pro-like1" subtype of HB. CONCLUSIONS: Our findings illustrate the cellular architecture and developmental trajectories of HB via integrative bulk and single-cell transcriptome analyses, thus establishing a resourceful framework for the development of targeted diagnostics and therapeutics in the future.

GRWR Correlates with the Metabolism of Tacrolimus after Pediatric Living Donor Liver Transplantation According to Donor CYP3A5 Polymorphism.

Objectives: Tacrolimus is characterized by high pharmacokinetic variability in combination with a narrow therapeutic range. However, influence of donor CYP3A5 genotype and graft-to-recipient body weight ratio (GRWR) on tacrolimus' pharmacokinetics after pediatric living donor liver transplantation (LDLT) remains unclear. Methods: A total of 174 LDLT recipients (<6 y) were grouped according to donor CYP3A5 genotypes (nonexpressor (NEX) or expressor (EX)) and GRWR (<3.0% (SS, small-size) or ≥3.0% (LS, large-size)): SS/NEX (n = 40), SS/EX (n = 38), LS/NEX (n = 48), and LS/EX (n = 48). Pharmacokinetics of tacrolimus and clinical outcomes were analyzed. Results: The relationships between the concentration-dose ratio and donor CYP3A5 genotypes and graft size were examined 3, 7, 14, and 30 days after the transplantation. Tacrolimus C0 levels varied greatly among groups, although recipients started with the same initial dosage. LS/EX recipients had significantly lower C0 levels in comparison with those of other groups. The use of CYP3A5-EX-grafts and a greater GRWR both resulted in significantly higher TAC dose requirements and lower C/D ratios. However, the significance of GRWR no longer exists 3 months after transplantation. The multivariate generalized linear mixed model analysis showed that donor CYP3A5 genotypes (F = 11.876; P = 0.01) and GRWR (F = 4.631; P = 0.033) were independent impact factors for C/D ratios 3, 7, 14, and 30 days after transplantation. Donor CYP3A5-EX genotype was associated with significantly increasing risks of infectious complications and significantly lower Cylex ATP values. However, no significant difference was observed in acute rejections among 4 groups. Conclusions: Monitoring of C0 levels alone is not reliable to guide tacrolimus administration. Donor CYP3A5 and GRWR both significantly affect tacrolimus pharmacokinetics after pediatric LDLT. The use of Cylex ATP tests would be helpful to avoid overimmunosuppression.

Virulent Staphylococcus aureus colonizes pediatric nares by resisting killing of human antimicrobial peptides.

BACKGROUND: The nasal carriage of Staphylococcus aureus introduces risks for subsequent infections, the rate of which is particularly high in children. The colonization mechanisms of S. aureus are not fully understood. METHODS: The epidemiological characteristics of nasal colonizing strains from pediatric patients undergoing liver transplantation and healthy pre-school children were analyzed first. Phenotypes, including biofilm formation and hemolytic activity, were tested for all the isolates. Bacterial pathogenicity indicated by a mouse skin abscess model and resistance to antimicrobial peptides (AMPs) was compared between the predominant genotypes from each group. RESULTS: The ST188 clone dominated in healthy children, whereas ST59 was prevalent for the pediatric patients. Although ST22 was the second most abundant genotype in the patient group, it was rarely found in healthy children. Interestingly, the colonizing ST59 and ST22 genotypes were more virulent, as indicated by the increased ability for hemolysis in vitro and severe subcutaneous abscesses in the mouse model, compared with ST188. We observed that the virulent ST59 and ST22 displayed higher resistance to antibiotics compared with ST188. Most of the ST59 and ST22 were methicillin-resistant S. aureus (MRSA), and all of the ST188 strains were methicillin-susceptible (MSSA). Moreover, we observed that the virulent ST59 and ST22 can resist killing by human antimicrobial peptides (AMPs). Mechanically, upon stimulation by AMPs, the virulent S. aureus can induce high expression of a phenol-soluble modulin transporter (Pmt) system. CONCLUSION: Pediatric patients can be colonized by virulent S. aureus clones, which are able to resist AMPs' killing through the Pmt system. The residence of virulent strains necessitates the continuous monitoring of potential infections, as well as annealing, to take protective decolonization measures.

Pure Laparoscopic Living Donor Hepatectomy With/Without Fluorescence-Assisted Technology and Conventional Open Procedure: A Retrospective Study in Mainland China.

Background: The application of laparoscopy in donor liver acquisition for living donor liver transplantation (LDLT) has become increasingly popular in the past decade. Indole cyanide green (ICG) fluorescence technique is a new adjuvant method in surgery. The purpose was to compare the safety and efficacy of laparoscopic and open surgery in living donor left lateral hepatectomy, and to evaluate the application of ICG in laparoscopy. Methods: Donors received LDLT for left lateral lobe resection from November 2016 to November 2020 were selected and divided into pure laparoscopy donor hepatectomy (PLDH) group, fluorescence-assisted pure laparoscopy donor hepatectomy (FAPLDH) group and open donor hepatectomy (ODH) group. We compared perioperative data and prognosis of donors and recipients. Quality of life were evaluated by SF-36 questionnaires. Results: The operation time of PLDH group (169.29 ± 26.68 min) was longer than FAPLDH group (154.34 ± 18.40 min) and ODH group (146.08 ± 25.39 min, p = 0.001). The blood loss was minimum in FAPLDH group (39.48 ± 10.46 mL), compared with PLDH group (52.44 ± 18.44 mL) and ODH group (108.80 ± 36.82 mL, p=0.001). The post-operative hospital stay was longer in PLDH group (5.30 ± 0.98 days) than FAPLDH group (4.81 ± 1.03 days) and ODH group (4.64 ± 1.20 days; p = 0.001). Quality of life of donors undergoing laparoscopic surgery was better. Conclusion: Laparoscopic approaches for LDLT contribute to less blood loss, better cosmetic satisfaction. The fluorescence technique can further reduce bleeding and shorten operation time. In terms of quality of life, laparoscopic surgery is better than open surgery. Laparoscopy procedure for living-donor procurement with/without fluorescence-assist can be performed as safely as open surgery.

Modified Dual Hepatic Vein Anastomosis in Pediatric Living-Donor Liver Transplantation Using Left Lateral Segment Grafts With Two Wide Orifices.

Background: The anatomic variation of hepatic vein in the left lateral segment (LLS) increases the risk of outflow complication in pediatric living liver transplantation (LDLT). Here, we share a modified method for dual hepatic vein reconstruction in pediatric LDLT using LLS with two wide orifices. Methods: From Sep 2018 to Dec 2019, 434 pediatric LDLTs using LLS were performed in our center. Hepatic veins of grafts were classified into three types with emphasis on the number, size, and location of orifices at the cut surface: a single opening (type I, n = 341, 78.57%); two adjacent orifices (type II, n = 66, 15.21%); two wide orifices with orifices distances <20 mm (type IIIa, n = 15, 3.46%); and two wide orifices with orifices distances >20 mm (type IIIb, n = 12, 2.76%). Rv was defined as the ratio of diameter of V2 and V3 (refer to hepatic vein drained segments II and III). We developed a modified dual hepatic vein anastomosis to reconstruct outflow for type IIIb grafts with Rv ≤1. Briefly, the hepatic vein of segment II was anastomosed to the common stump of middle hepatic vein (MHV) and left hepatic vein (LHV), followed by unification of V3 and the longitudinal incision orifice in inferior venous cave (IVC). Results: During median follow-up of 15.6 months (7.5-22.9 months), no hepatic vein complications occurred. Conclusion: This novel modified dual hepatic vein anastomosis could serve as a feasible surgical option for type IIIb LLS grafts with Rv ≤1 in pediatric LDLT.

Pediatric living-donor liver transplantation using right posterior segment grafts.

BACKGROUND: The right posterior segment (RPS) graft was introduced to overcome graft size discrepancy in living donor liver transplantation (LDLT). However, it was very rarely used in pediatric patients. Here we presented 4 pediatric LDLT cases receiving RPS graft between January 2015 and April 2020 in our center. A total of 1868 LDLT procedures were performed in this period. METHODS: Recipients included 1 boy and 3 girls with a median age of 45 months (range from 40 to 93 months). They were diagnosed with progressive familial intrahepatic cholestasis, propionic academia, ornithine transcarbamylase and biliary atresia, respectively. Four donors were all mothers with a median age of 32.5 years (31-38 years). Computer tomography angiography indicated posterior right branches branched off separately from main portal veins (type III variation). Three of these donor livers had 1 orifice of right hepatic veins (RHV). In the remaining 1 donor liver, the RHV showed 3 orifices and an outflow patch plastic was performed. Inferior right hepatic veins weren't found in four donor grafts. The median graft weight was 397.5 g (352-461 g) and the median graft-to-recipient weight ratio was 2.38% (1.44-2.80%). RESULTS: Postoperative complications occurred in neither donors nor recipients. Within the median follow-up duration of 29 months (14-64 months), four children are all alive with normal liver function. CONCLUSION: In summary, for older children weighed more than 15 kg with donors' variation of type III portal veins, the use of RPS grafts could be a feasible and favorable option.

Bile Acids Impair Vaccine Response in Children With Biliary Atresia.

Background: Vaccination is the best way to protect children under 5 years from death or disability. Children with biliary atresia (BA), which is the most common pediatric cholestatic end-stage liver disease (PELD), are more vulnerable to infectious diseases. However, the vaccination coverage and factors modulating vaccine responses in children with BA are largely unknown. Methods: In this study, 288 children (median age: 7 months) diagnosed with BA before liver transplantation were enrolled for the evaluation of vaccination status and the factors affecting the immune response to the hepatitis B (HBV) vaccine. Moreover, 49 BA children (median age: 4 months) were enrolled for flow cytometric analysis of CD4+ T cells and CD19+ B cell subsets and correlations with serum bile acid levels. Results: Generally, these children had very low routine vaccination rates for the meningococcal serogroup AC (Men AC) (41.2%), measles-mumps-rubella (MMR) (31.3%), poliomyelitis (Polio) (25.3%), hepatitis A (HAV) (25.0%), Japanese encephalitis (JE) (15.0%), diphtheria-tetanus-pertussis (DTP) (14.2%), meningococcal serogroup A (Men A) (13.5%) and varicella (VAR) (10.8%) vaccines, but not for the HBV (96.2%) and bacillus Calmette-Guérin (BCG) (84.7%) vaccines. Remarkably, 19.8% (57/288) of the patients had HBV infection. Out of 220 patients vaccinated for HBV, 113 (51.4%), 85 (38.6%) and 22 (10%) had one, two or three doses of the HBV vaccine, respectively. Furthermore, logistic regression analysis revealed that the bile acid level was an independent factor associated with poor HBV vaccine response (p = 0.03; OR = 0.394; 95% CI = 0.170-0.969). Immunophenotyping showed that bile acids were only negatively correlated with the CD19+CD27+IgG+ post-class-switched memory B cell ratio (p = 0.01). Conclusion: This study reveals the overall vaccination rates of routine vaccines in Chinese BA children are very low and the poor HBV vaccine responses are associated with bile acids, possibly via the inhibition of CD19+CD27+IgG+ post-class-switched memory B cell response. Clinical Trial Registration: http://www.chictr.org.cn, identifier ChiCTR1800019165.

Immune cell function assays in the diagnosis of infection in pediatric liver transplantation: an open-labeled, two center prospective cohort study.

BACKGROUND: Limited studies have been performed in assessment of immune status of pediatric liver transplants (PLTs). We conducted this study to evaluate Cylex immune cell function assay in diagnosis of infection and its potential clinical application in Chinese infant PLTs. METHODS: In this prospective cohort study, 227 infant PLTs from two medical centers were enrolled, and 216 completed the study. Cylex ATP values were measured before and after liver transplantation (LT) at week 1, 2, 3, 4, 8, 12 and 24 respectively. Accordingly, patients' clinical records, including demographic data, liver function results, tacrolimus dosages and concentrations were collected and analyzed. RESULTS: One hundred and sixty of 216 PLTs (74.1%) were diagnosed infection based on the parameters including abnormal vital signs, imaging changes, and pathogens detection, while 44 (20.4%) were clinically stable and 12 (5.6%) experienced acute rejection. The median Cylex ATP value in infant PLTs post-surgery reduced significantly in infection group compared to stable group (median, 137 vs. 269 ng/mL, P<0.001). Receiver operating characteristic (ROC) curve analysis determined that the cut-off value of Cylex ATP was 152 ng/mL in diagnosis of infection [area under the curve (AUC): 0.784, 95% CI: 0.720-0.848]. Meanwhile, Cylex ATP value showed no correlation to tacrolimus dosage, blood concentration, dose-normalized concentration/dose ratio or Kaup index. However, it tended to correlate weakly with the white blood cell (WBC) number (R =0.462, P<0.0001) and lymphocyte counts (R =0.363, P<0.0001). CONCLUSIONS: In this study, we demonstrated that low Cylex ATP represented partly over-immunosuppression and had diagnostic value in infant PLTs with infections, which might assist individualized immunosuppression in PLT patients.

Outcome of Liver Transplantation for Neonatal-onset Citrullinemia Type I.

BACKGROUND: We evaluated the outcome of liver transplantation (LT) in neonatal-onset citrullinemia type I patients, especially its impact on neurological deficits and developmental retardation. METHODS: From October 2006 to October 2019, 5 of the 2003 children who received LT at Ren Ji Hospital had been diagnosed with citrullinemia type I. The primary indication for transplantation was repeated metabolic compensation and developmental retardation in 4 patients and prophylactic transplantation in the other. Among them, 3 patients received living donor LT and 2 received orthotopic LT. RESULTS: All recipients had successfully recovered within the median follow-up period of 32 months (range, 6-54 mo). Transplantation restored citrulline metabolism and liver function. Plasma ammonia and citrulline concentration decreased to normal levels with no further hyperammonemic episodes being reported, even after normal diet intake began. Meanwhile, uracil-2 and orotic acid were not detected in urinary excretion. Strikingly, patients suffered developmental retardation before LT showed improved psychomotor ability and significant catch-up growth during the follow-up period. Cognitive ability, including language skills and academic performance, also greatly improved. Three patients had sustained brain injuries and exhibited severe neurological deficits before transplantation, especially repeated generalized tonic-clonic seizures. LT halted neurological deterioration and controlled seizure episodes, which further facilitated the intellectual development and improvement of life quality. CONCLUSIONS: LT is an effective treatment for neonatal-onset citrullinemia type I patients, which reverses metabolism decompensation and improves quality of life. For patients who have suffered severe hyperammonemic insults, LT should be conducted at an early age to avoid further neurological or developmental deficits.

Hepatic artery reconstruction in pediatric liver transplantation: Experience from a single group.

BACKGROUND: The reconstruction of hepatic artery is a challenging part of the pediatric liver transplantation procedure. Hepatic artery thrombosis (HAT) and stenosis are complications which may result in ischemic biliary injury, causing early graft lost and even death. METHODS: Two hundred and fifty-nine patients underwent liver transplantation in 2017 in a single liver transplantation group. Among them, 225 patients were living donor liver transplantation (LDLT) and 34 deceased donor liver transplantation (DDLT). RESULTS: In LDLT all reconstructions of hepatic artery were microsurgical, while in DDLT either microsurgical reconstruction or traditional continuous suture technique was done depending on different conditions. There were five (1.9%) HATs: four (4/34, 11.8%) in DDLT (all whole liver grafts) and one (1/225, 0.4%) in LDLT (P = 0.001). Four HATs were managed conservatively using anticoagulation, and 1 accepted salvage surgery with re-anastomosis. Until now, 3 HAT patients remain in good condition, whereas two developed biliary complications. One of them needed to be re-transplanted, and the other patient died due to biliary complications. CONCLUSIONS: Microsurgical technique significantly improves the reconstruction of hepatic artery in pediatric liver transplantation. The risk for arterial complications is higher in DDLT. Conservative therapy can achieve good outcome in selected HAT cases.

Pediatric living donor liver transplantation decade progress in Shanghai: Characteristics and risks factors of mortality.

BACKGROUND: Pediatric living donor liver transplantation (LDLT) has become the gold standard for patients with end-stage liver disease. With improvements in organ preservation, immunosuppression, surgical and anesthesia techniques, the survival rates and long-term outcomes of patients after LDLT have significantly improved worldwide. However, data on anesthetic management and postoperative survival rate of pediatric LDLT in China are rare. AIM: To review the status of pediatric LDLT in Shanghai and investigate the factors related to anesthetic management and survival rate in pediatric LDLT. METHODS: We conducted a retrospective observational study to investigate the status of pediatric LDLT in Shanghai by reviewing 544 records of patients who underwent pediatric LDLT since the first operation on October 21, 2006 until August 10, 2016 at Renji Hospital and Huashan Hospital. RESULTS: The 30-d, 90-d, 1-year, and 2-year survival rates were 95.22%, 93.38%, 91.36%, and 89.34%, respectively. The 2-year patient survival rate after January 1, 2011 significantly improved compared with the previous period (74.47% vs 90.74%; hazard ratio: 2.92; 95% confidence interval (CI): 2.16-14.14; P = 0.0004). Median duration of mechanical ventilation in the intensive care unit (ICU) was 18 h [interquartile range (IQR), 15.25-20.25], median ICU length of stay was 6 d (IQR: 4.80-9.00), and median postoperative length of stay was 24 d (IQR: 18.00-34.00). Forty-seven (8.60%) of 544 patients did not receive red blood cell transfusion during the operation. CONCLUSION: Pediatric end-stage liver disease (PELD) score, anesthesia duration, operation duration, intraoperative blood loss, and ICU length of stay were independent predictive factors of in-hospital patient survival. Pediatric end-stage liver disease score, operation duration, and ICU length of stay were independent predictive factors of 1-year and 3-year patient survival.

Postoperative Risk Factors and Outcome of Patients With Liver Transplantation Who Were Admitted to Pediatric Intensive Care Unit: A 10-Year Single-Center Review in China.

INTRODUCTION: The aim of this study was to present our 10-year experience of pediatric intensive care unit (PICU) management with pediatric liver recipients and to understand the importance of close interdisciplinary cooperation in 2 hospitals. METHODS: A retrospective chart review study was performed according to our hospital's medical records and the pediatric liver transplant database of Renji hospital. RESULTS: A total of 767 patients received liver transplantation (LT) performed in Renji hospital between October 2006 and December 2016, of which 97 of them were admitted to PICU in our center for various complications developed after transplantation. 8.8% (16/208) and 14.4% (81/559) of patients were transferred to PICU in stages I and II, respectively, and was comparable in the 2 stages (P = .017). The majority of patients was late postoperative children (median 185 post-LT days) in stage I. More patients were transferred to PICU directly in stage II. PICU admitted more younger (median 8.2 months) and early postoperative patients in stage II. The median length of PICU stay was 11.0 (6.0-20.5) days. The median length of mechanical ventilation was 5.0 (0.0-12.0) days. The most frequent complications were pulmonary complications (52 [53.6%] patients), surgical complications (22 [22.7%] patients), sepsis (7 [7.2%]), and other miscellaneous complications (16 [16.5%] patients). The overall 28-day PICU mortality was 25.8% (n = 25) and 64.0% (n = 16) of the deaths happened in the early postoperative period. There was significant difference concerning mortality in children with surgical complications and medical problems (54.5% [12/22] vs 17.3% [13/75], P = .001). Multivariate analysis by regression showed that the pediatric risk of mortality III score was the only independent prognostic factor (P = .031). CONCLUSIONS: Multiple complications occur in children with LT. Although challenging, interdisciplinary cooperation between different hospitals is an effective mean to enable children to maximize the benefit gained from LT in China.

Expression of DEK in pancreatic cancer and its correlation with clinicopathological features and prognosis.

Background: The oncogene DEK, which was originally identified as part of the protein product of the DEK-CAN fusion oncogene, has been shown to promote tumorigenesis in a variety of cancer cell types. However, little is known about the expression and role of DEK in pancreatic ductal adenocarcinoma (PDAC), which is one of the most refractory malignant tumors worldwide and has poor prognosis. Our study aimed to understand the role of DEK in the development and progression of pancreatic adenocarcinoma. Materials and methods: We used western blotting and immunohistochemistry to examine the expression of DEK in pancreatic adenocarcinoma cells and tissues. We analyzed the correlation between DEK expression and clinicopathological characteristics and prognosis in 163 pancreatic adenocarcinoma patients. Results: Protein levels of DEK in pancreatic adenocarcinoma tissues (76/136, 55.9%) were significantly higher than those in adjacent non-tumor tissues (16.2%, 22/136). A high expression level of DEK was associated with poor prognosis (P<0.001).In addition, the combination of CA19-9 and DEK expression (P<0.001) was a better prognostic indicator than CA19-9 expression alone (P=0.012). Conclusions: DEK may play a significant role as a valuable biomarker in the development and progression of pancreatic adenocarcinoma. The combination of DEK and CA19-9 improves the prognostic prediction in patients with pancreatic adenocarcinoma.

The Effects of Liver Transplantation in Children With Niemann-Pick Disease Type B.

We evaluated the effects of liver transplantation (LT) in children with Niemann-Pick disease (NPD) type B. From October 2006 to October 2018, 7 of 1512 children who received LT at Ren Ji Hospital were diagnosed as NPD type B. The median age at diagnosis was 12 months (6-14 months) with initial presentations of hepatosplenomegaly, growth retardation, repeated pneumonia, and diarrhea. Even after comprehensive supporting treatments, all patients developed liver dysfunction, severe interstitial pulmonary disease, compromised lung function, and hypersplenism, with hypertriglyceridemia in 4 patients. They were transferred to our hospital for transplantation (median age, 6.5 years; range, 2.2-8.6 years). Among them, 4 patients received living donor LT, and 3 received whole-liver orthotopic LT. Splenectomy was conducted spontaneously. All patients are alive with a median follow-up of 10 months (range, 5-53 months). Liver function normalized within 3 weeks after transplantation and maintained stability. Thrombocytopenia and leukopenia were cured, as was hypertriglyceridemia. Strikingly, pulmonary disease was relieved after transplantation, as evidenced by resolution of interstitial lung disease and restored lung function. Bronchitis occurred only once among the 3 patients with a quick recovery during follow-up. Catch-up growth was observed in all patients, especially in 1 male patient, as his height z score increased from -3.9 to -1 at 4 years after transplantation. Patients with follow-up longer than 10 months indicated significant psychomotor ability improvement. Hypotonia was relieved in 4 patients after transplantation. However, intelligence developmental delay still existed in 4 patients during the follow-up. Three of them have been receiving intelligence recovery therapy, although the longterm effect needs more investigation. In conclusion, LT is a safe and effective treatment for patients with NPD type B with severe liver and pulmonary dysfunction.

ID3 Promotes Stem Cell Features and Predicts Chemotherapeutic Response of Intrahepatic Cholangiocarcinoma.

Cancer stem cells contribute to a high rate of recurrence and chemotherapeutic resistance in many types of cancer, including intrahepatic cholangiocarcinoma (ICC). Inhibitor of differentiation 3 (ID3) has been reported to promote cancer stem cells, but its role in ICC is obscure. In this study, we identified that ID3 is highly expressed in human ICC tissues compared with matched normal tissues and correlates with poor prognosis. Functional studies demonstrate that ID3 is required for stemness maintenance in cholangiocarcinoma both in vitro and in vivo. Consistent with the regulation of cancer stem cell features by ID3, transgenic expression of ID3 enhances chemoresistance of cholangiocarcinoma cells. Moreover, we found that ICC patients with low ID3 levels benefited from postoperative transarterial chemoembolization, whereas patients with high ID3 levels did not, indicating the significance of ID3 in individualized ICC therapy. Mechanistically, ID3 could interact with E47 and block E47 recruitment to the promoter of ß-catenin, which leads to activation of Wnt/ß-catenin signaling. Conclusion: Our results show that ID3 could promote the stemness of ICC by increasing the transcriptional activity of ß-catenin and could serve as a biomarker in predicting ICC patients' response to adjuvant chemotherapeutics.

EMT induced by loss of LKB1 promotes migration and invasion of liver cancer cells through ZEB1-induced YAP signaling.

Liver cancer cells often exhibit mesenchymal phenotypes, a critical phenotypic alteration of cancer cells termed the epithelial-mesenchymal transition (EMT). To examine whether liver kinase B1 (LKB1) serves a potential role in EMT in liver carcinogenesis, in the present study, it was determined that the expression of LKB1 decreased in the hepatocellular carcinoma (HCC) cell line, compared with a normal liver cell line. LKB1 overexpression decreased cell motility and invasiveness. Furthermore, the loss of LKB1 induced the expression of several EMT marker proteins, including that of Zinc Finger E-Box Binding Homeobox 1 (ZEB1). Notably, the expression of Yes-associated protein (YAP) was positively associated with that of ZEB1 in LKB1-knockdown cells with a mesenchymal phenotype. Here, we describe the direct regulation of the Hippo pathway effector YAP by ZEB1. The findings of the present study demonstrate that ZEB1 regulates the expression of YAP and regulates the expression of downstream target genes to promote malignant progression.

Isolation of cancer-associated fibroblasts and its promotion to the progression of intrahepatic cholangiocarcinoma.

Intrahepatic cholangiocarcinoma is a highly fatal tumor characterized by an abundant stromal environment. Cancer-associated fibroblasts play key roles in tumor growth and invasiveness and have been regarded as a potential therapeutic target. This study was designed to isolate human primary cancer-associated fibroblasts of intrahepatic cholangiocarcinoma to study tumor-stroma interactions and to analyze the clinical relevance of alpha-smooth muscle actin -positive cancer-associated fibroblasts in patients with intrahepatic cholangiocarcinoma. The isolated cancer-associated fibroblasts were positive for alpha-smooth actin, fibroblast-specific protein-1, fibroblast activation protein, and PDGFR-ß. In addition, cancer-associated fibroblasts were found to increase proliferation, migration, and invasion of cholangiocarcinoma cells in vitro and promote tumor growth of mice in vivo. Moreover, alpha-smooth muscle actin-positive expression of cancer-associated fibroblasts predicted unfavorable prognosis in patients with intrahepatic cholangiocarcinoma and showed correlation with presence of lymph node metastasis. This study may provide a useful tool to investigate further effect of cancer-associated fibroblasts on the molecular mechanism of cholangiocarcinoma cells as well as contribution of cancer-associated fibroblasts in lymphangiogenesis and lymph node metastasis.