Cholangiocyte Epithelial to Mesenchymal Transition (EMT) is a potential molecular mechanism driving ischemic cholangiopathy in liver transplantation

Donation after circulatory death (DCD) has expanded the donor pool for liver transplantation. However, ischemic cholangiopathy (IC) after DCD liver transplantation causes inferior outcomes. The molecular mechanisms of IC are currently unknown but may depend on ischemia-induced genetic reprograming of the biliary epithelium to mesenchymal-like cells. The main objective of this study was to determine if cholangiocytes undergo epithelial to mesenchymal transition (EMT) after exposure to DCD conditions and if this causally contributes to the phenotype of IC. Human cholangiocyte cultures were exposed to periods of warm and cold ischemia to mimic DCD liver donation. EMT was tested by assays of cell migration, cell morphology, and differential gene expression. Transplantation of syngeneic rat livers recovered under DCD conditions were evaluated for EMT changes by immunohistochemistry. Human cholangiocytes exposed to DCD conditions displayed migratory behavior and gene expression patterns consistent with EMT. E-cadherin and CK-7 expressions fell while N-cadherin, vimentin, TGFβ, and SNAIL rose, starting 24 hours and peaking 1–3 weeks after exposure. Cholangiocyte morphology changed from cuboidal (epithelial) before to spindle shaped (mesenchymal) a week after ischemia. These changes were blocked by pretreating cells with the Transforming Growth Factor beta (TGFβ) receptor antagonist Galunisertib (1 μM). Finally, rats with liver isografts cold stored for 20 hours in UW solution and exposed to warm ischemia (30 minutes) at recovery had elevated plasma bilirubin 1 week after transplantation and the liver tissue showed immunohistochemical evidence of early cholangiocyte EMT. Our findings show EMT occurs after exposure of human cholangiocytes to DCD conditions, which may be initiated by upstream signaling from autocrine derived TGFβ to cause mesenchymal specific morphological and migratory changes.

Introduction interstitial fibrosis and tubular atrophy after kidney transplant, which is one of the major causes of graft loss and is, in part, due to long ischemic times [22][23][24].
Given that EMT is associated with a loss of epithelial cells in response to IRI as well as a pro-fibrotic phenotype, it is reasonable to conclude that EMT may be involved in the development of IC. However, data regarding hypoxia-induced EMT in biliary epithelial cells is lacking. Thus, the goal of this study was to demonstrate the presence of an IRI-induced EMT in an in vitro model of preservation injury using primary human cholangiocytes. We hypothesize that cells exposed to ischemia and reperfusion will undergo an epithelial-to-mesenchymal transition, and that this effect will be more pronounced in cholangiocytes that are subjected to warm ischemia compared to cold storage alone. The long-term goal is to understand mechanisms of ischemic cholangiopathy after DCD liver transplantation to later serve as potential therapeutic targets to expand the liver donation pool and improve transplantation success. The data presented in this study were successful in demonstrating strong associations of EMT attributes (gene expression, morphology, cytokinesis) with known initiators of IC in DCD liver transplantation (prolonged preservation ischemia). We also demonstrate a causal link between TGF β receptor activation and ischemia-induced cholangiocyte morphological changes characteristic of EMT. This holds promise for the goal of therapeutically targeting EMT circuits to prevent or reverse ischemic cholangiopathy in patients receiving an expanded criteria liver allograft.

Cell model
Human primary biliary epithelial cells (cholangiocytes, Celprogen; Torrance, CA; catalog # 36755-12) were cultured on collagen plates using Human Cholangiocyte growth media (Celprogen). Cells at 80% confluency were used for studies. To simulate DCD recovery and preservation conditions, cell cultures were subjected to both periods of warm and cold ischemia. Cell culture plates were placed in a plastic airtight box (Tupperware) purged with 95% nitrogen and 5% CO 2 for 5 minutes followed by placing the box first in a 37 degree water bath for 60 minutes and then in a cold room on melting ice for cold storage at 2-4 C for 20 hours. After storage, the cells were returned to the 37 C incubator, exposed to atmospheric oxygen, and cultured as usual. Cells were removed from culture at 1, 5, and 7 days after storage ischemia and reoxygenation for study and analysis. Some cells were pretreated with the selective TGFβ receptor antagonist Galunisertib in DMSO (1μM) or DMSO (0.03%) for an hour prior to exposure to ischemia.

Cell migration assay
To both measure migratory and invasive behavior and to select out cells with such behavior, normal or preserved cholangiocytes were placed on 24-well cell invasion assay plates coated with collagen (CBA-110-Col, Cell Biolabs, San Diego, CA) and allowed to culture for 48 hours. After culture, cells that may have migrated through the collagen matrix and attached onto the fiber pad below were recovered, washed, and expanded in cell culture to select out specific migratory phenotypes for later analysis. Cells on the top that refuse to migrate were also collected and expanded in cell culture to serve as non-reactive controls. Finally, Naïve colangiocytes were also used as non-stimulated controls since they never experienced DCD conditions nor did they migrate through the collagen migration chambers.

Cell morphology
Morphology of cultured cholangiocytes was assessed using light microscope at 400x magnification in normal (Naive) cells before and after exposure to 24 hours of cold storage (CS) with or without 1 hour of warm ischemia prior to the CS. Cell morphology is graded on a scale of 1-4 in a blinded manner. A score of (1) refers to normal cuboidal appearing epithelial cells, (2) are mostly cuboidal appearing cells, (3) refers to most cells having a spindle appearing mesenchymal cell morphology, and (4) refers to all cells having a spindle mesenchymal appearance.

Immunocytochemistry
Cells were grown on cover slips, fixed in 10% formalin, permeabilized with citrate buffer microwaving, and stained with specific primary antibodies to one of the following targets: cytokeratin-7 (CK-7), E-Cadherin, SNAIL, N-Cadherin, and Vimentin. After incubating for 2 hours at 37 C, the primary antibodies were washed away and the cells were probed with a secondary antibody directed at the primary and labeled with Alexa Fluor-488 or -647. Imaging was performed using a fluorescent microscope and images processed using ImageJ (NIH, Bethesda, MD, USA). These analyses were performed and compared between 3 groups of cholangiocytes: normal control cholangiocytes, (Fresh), cells exposed to 24 hours of cold ischemia storage (CS) and cells exposed to 60 minutes of warm ischemia conditions followed by 24 hours of cold ischemia storage (WI+CS). Analyses were repeated for cells cultured for 24 hours, and 1, 2 and 3 weeks after the corresponding storage conditions.

Reverse transcription polymerase chain reaction
For the initial RNA isolation procedures, the RNeasy Mini Kit (Qiagen, Germantown, MD) was utilized according to manufacturer's instructions. Briefly, 1 x 107 cells were pelleted and lysed with RLT buffer from the kit. 70% ethanol was added, the sample was transferred to the RNeasy Mini spin column, and the column centrifuged for 15 seconds at > 10,000 rpm. After several column wash steps, the RNA was eluted from the column membrane with 30 μl RNasefree water. Residual DNA contamination was removed by a DNase treatment protocol (Qiagen RNase-free DNase Set). Purified RNA was analyzed on the NanoDrop ONE for purity and concentration.
Purified, quantitated RNA samples were converted into complementary DNA (cDNA) for compatibility with subsequent qRT-PCR. A commercially available reverse transcriptase (RT) cDNA synthesis kit (iScript cDNA Synthesis Kit, Bio-Rad) was used on RNA samples, producing a presumed 1:1 cDNA product.
A CFX Connect Real-Time PCR Detection System (Bio-Rad) was used for real-Time PCR. cDNA samples were transferred to a 96-well PCR plate and iTaq Universal SYBR Green Supermix (Bio-Rad), and forward / reverse primer pairs for human TGF β were added to each well. The plate was sealed, centrifuged for 5 minutes on a plate-spinner, and then analyzed in the CFX Connect according to manufacturer's instructions. CFX Maestro software collects, compiles, and analyzes the resulting data, including amplification cycle and melting curves. Data were expressed relative to the GAPDH reference product.

Rat liver transplant model
With the approval of the VCU Institutional Animal Care and Use Committee (IACUC), syngeneic liver transplants between adult male Brown Norway rats (Envigo, North America, n = 24) were performed as previously described by our group [25,26]. All rats were housed in single cages in the VCU Vivarium and were allowed food and water ad libitum before surgery and after. After surgery, the rats were cared for in the lab for 24 hours to ensure wound closure, infection control, and hemostasis. Then they were returned to the vivarium for another 6 days with daily monitoring by lab personnel and staff veterinarians. All rats were anesthetized and maintained in a surgical plane of anesthesia with inhalation isoflurane (1-2%) during the surgery with 100% oxygen as the carrier gas. Some donor livers were subjected to a 30-minute warm ischemia period prior to recovery by clamping the hepatic pedicle (DCD conditions) and all were flushed with cold UW solution and stored for 20 hours at 2-4 C before transplantation. Donors died of exsanguination under anesthesia during the liver recovery. Recipient livers were removed through a midline incision. The inferior vena cava, portal vein, and bile duct were cuffed with PE tubing sections and tied into the respective recipient vessels with 7-0 proline. The superior vena cava was anastomosed with 8-0 proline and the livers were revascularized within 18 minutes from the start. After surgery, rats were allowed to awaken after receiving buprenorphine SR Lab for post-operative pain control for 72 hours. Recipient rats were monitored for vital signs every 15 minutes until upright and then every hour for the next 4 hours. Animal well-being was assessed by the presence of normal physiological variables and the absence of pathological indicators such as infection, refractory pain, or porphyrin staining. Two-ml of warm lactated Ringers solution was administered subcutaneous for volume replacement. Serial measurements of alanine aminotransferase (ALT) and total bilirubin were obtained 1, 3 and 7 days after surgery by penile vein blood draw (0.2 ml). One week following transplantation and at the onset of hyperbilirubinemia in the DCD liver recipients, the rats were re-anesthetized with isoflurane and the liver grafts removed for immunohistochemical (IHC) evaluation of SNAIL and CK-7 using HRP-labelled primary antibodies against rat SNAIL and CK-7 followed by staining with DAB. Recipient rats were euthanized by exsanguination under anesthesia during the recovery of the livers grafts.

Statistical analyses
All data were tested for distribution normality. Some data were analyzed by parametric Oneway ANOVA with Bonferroni multiple comparison correction. Cell counts, histological scores, and relative intensity staining or expression ratios were analyzed by the non-parametric Kruskal-Wallis one-way ANOVA followed by the Mann-Whitney test for stochastic dominance. Most data are expressed as mean plus or minus the standard deviation. IHC and other cell results were derived from 4 independent experiments usually run in triplicate. Liver transplants were repeated 6 times per group. Statistical analysis were performed using GraphPad InState and Prism software. A P value less than 0.05 was considered statistically significant.

Human cholangiocytes cell model
Cholangiocytes exposed to DCD conditions (DCD Cells) had a significantly increased migratory behavior on the cell invasion assay as shown in Fig 1. This was demonstrated by significantly higher cell staining of cells being measured on the fiber pads under the collagen matrix, indicating cells from above physically moved from top to bottom through the matrix. Fresh control cholangiocytes without exposure to DCD conditions (Normal Cells) did not migrate to reach the lower fiber pad.
Cells that were exposed to prolonged cold storage for 24 hours with or without prior warm ischemia for one hour displayed a mesenchymal morphology compared to their baseline cuboidal epithelial cell appearance. These morphological changes are clearly seen in Fig 2 with DCD cells exposed to both WI and CS expressing morphology similar to mesenchymal cells.
Changes in protein expression profiles in cholangiocytes exposed to DCD ischemia conditions compared to fresh non-ischemic control cells are shown in  (Fig 4 panel B). Similarly, the loss of the epithelial specific marker E-cadherin increases as the time from the ischemic exposure increases (Fig 4 panel C) while the opposite happens for the expression of the mesenchymal specific marker vimentin (Fig 4 panel D). Values are mean ± SD from 4 independent experiments. These same trends can be visualized in the fluorescence intensity of the raw data images in Fig 3. A western blot analysis of changes in mesenchymal specific cell markers (i.e. vimentin, SNAIL, and N-cadherin) over time in cholangiocytes isolated after exposure to DCD ischemic conditions is shown in Fig 5 (panel D). The relative expression of these markers significantly increased in a time-dependent manner over the baseline values prior to ischemic exposure (panels A-C). Specifically, as the time from DCD exposure progresses from 24 hours to 3 Cholangiocytes migrated through the matrix at increased rates depending on how long they were allowed to recover after exposure to DCD conditions. Specifically, a progressively larger percentage of cells reached the bottom of the chamber after 48 hours as the recovery time increased from 1-7 days (panel B). Results are expressed as mean +/-SD, n = 5.
https://doi.org/10.1371/journal.pone.0246978.g001  Human cholangiocyte-specific protein staining (upper panels) includes both CK7 and E-cadherin from groups of cells that include Naïve cells without DCD ischemia, from cells with 24 hour exposure to cold storage (CS), and from cells exposed to both cold storage and 60 minutes of warm ischemia (WI). Each antibody (Ab) specific stain is paired with the same cells stained with the nuclear stain DAPI (blue images). For the epithelial markers, the magnitude of the specific staining DECREASES as the degree of DCD ischemia increases (Naïve to CS to CS+WI). The bottom groups of cells are similar to the top except these cells were stained for the mesenchymal specific markers SNAIL, N-cadherin, and Vimentin. Opposite to the pattern seen with epithelial markers, the mesenchymal specific markers are shown to INCREASE in staining intensity as the level of DCD ischemic stress increases (Naïve to CS to CS+WI). These protein expression patterns are consistent with cells undergoing an epithelial-to-mesenchymal transition (EMT). Magnification is 200x.
https://doi.org/10.1371/journal.pone.0246978.g003 weeks, the expression of these markers increased. Furthermore, there was a clearly higher expression response of these markers in the warm ischemic group, relative to cold ischemia alone (panels A-D).
The differential expression of cholangiocyte TGF β from cells exposed to DCD conditions that remained on the top of the migration chamber after 24 hours compared to cells that migrated through the chamber to the bottom are shown in Fig 6. Gene expression was

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Mechanism of bile duct disease in extended criteria donor liver grafts measured by RT-PCR and shown as the relative expression from the GAPDH control gene (Δ Ct). DCD conditioned cells migrating to the bottom express multiple fold more TGF β compared to DCD conditioned cells that don't migrate (Top).
Human cholangiocyte morphology grades are shown in Fig 7. Most cholangiocyte cultures were exposed to DCD ischemic conditions and either pretreated with 0.01% DMSO in the culture media (Vehicle) or the selective TGF β receptor-1 antagonist (RA) Galunisertib (Rx, 1 μM in DMSO) one hour prior to exposure to DCD conditions (Panel A). Then cells were immediately counted and scored for the degree of morphometric change at time 0 or placed into the tissue culture incubator and scored at days-1, -5, and -7 after exposure to DCD conditions. As a control, naïve cells (not exposed to DCD conditions) were plated and cultured for 7 days and their cell morphology was determined as before on days 1, 5, and 7 (Fig 7 panel B). These cells controlled for morphological changes that may be due to time dependent cell culture over 7 There are three main groups, the fresh Naive cholangiocytes (Naive), vehicle DMSO control cholangiocytes, and cholangiocytes pretreated with the selective TGF β receptor-1 antagonist Galunisertib (1 μM, 1 hour before DCD ischemia). Cells were examined for morphometric changes immediately after induction of DCD ischemia (D0), 1 day after (D1), 5 days after (D5), or 7 days after (D7). The bar indicates the groups exposed to DCD ischemic conditions of 1 hour of warm ischemia and 24 hours of cold storage followed by the indicated time in days of return to normoxia and 37C temperatures. G1 refers to normal cuboidal appearance, GII to mostly cuboidal appearance, GIII refers to mostly spindle appearance, and GIV refers to spindle appearance. All images were graded in a blinded manner. � P <0.05 relative to the corresponding bar in the control or treated (Rx) groups at D0. N = 4.
https://doi.org/10.1371/journal.pone.0246978.g007 days and independent on DCD conditions. The morphological scores were based on the degree of change from purely cuboidal appearance characteristic of epithelium (Grade 1) to complete spindle shape characteristic of mesenchymal cells (Grade 4). Grade 2 cells were mostly cuboidal with some spindle shape while grade 3 were mostly spindle shape with some cuboidal appearance remaining. Naïve cells are cholangiocytes with no prior exposure to DCD conditions.

Rat liver transplant model
Immunohistochemical detection of expression of the mesenchymal marker SNAIL and the epithelial marker CK-7 in fresh control liver tissue sections, sections from liver isografts with prior exposure to cold storage for 24 hours, and sections from liver isografts with prior exposure to warm ischemia for 30 minutes are shown in Fig 8 (panel A). All liver isografts were recovered from the recipients 7 days after transplantation. The appearance of SNAIL expression is clearly seen in the biliary epithelial cells with liver grafts that were exposed to cold storage ischemia and more so with exposure to warm ischemia (panel A upper row). Conversely, CK-7 expression weakened significantly in biliary epithelial cells in sections from livers with prior exposure to DCD conditions (warm and cold ischemia, panel A-lower row). The signal intensity for these stains are shown in Fig 8B for CK7 and SNAIL in livers without DCD or transplantation (Naïve) and transplanted livers with cold storage for 24 hours, and with cold storage for 24 hours and with 30 minutes of preceding warm ischemia.
Finally, plasma transaminase (ALT) and total bilirubin values from rats with isografts exposed to DCD conditions Vs. sham surgery controls are shown in Fig 8 (panel C). Transaminase levels rose dramatically on the first post-operative day in the DCD grafted recipients, compared to the controls but the levels normalized thereafter. Total bilirubin, however, stayed low in both groups until day 7 after transplantation, when it significantly spiked in the DCD group but not the control group, which were exposed only to cold storage for 24 hours.

Discussion
Ischemic cholangiopathy following DCD liver transplantation is characterized by loss of biliary epithelium, loss of intrahepatic microscopic bile ducts, biliary constriction, and fibrosis. Although the molecular mechanisms of these phenotypic changes are unknown, it is hypothesized that the biliary epithelia first undergo an Epithelial to Mesenchymal Transition (EMT) that establishes the genetic reprogramming of the cells to transform them into cells with a mesenchymal phenotype. This is supported by data showing the loss of epithelialization and the establishment of fibroblast like cells with both smooth muscle and migratory behaviors in our cholangiocyte cell model of IC. In this model, we demonstrate the migratory behavior in the invasion assays, the smooth muscle appearance from the morphological assessments, and the genotypic shift from epithelial-specific to mesenchymal-specific gene expression. These EMTspecific cellular changes are correlated to exposure of these cells to DCD preservation conditions and establish a strong correlation between these two events. We further hypothesize that these events are causative in that DCD conditions cause both EMT and IC because we can prevent or reverse morphological EMT changes in human cholangiocytes pretreated with a specific inhibitor of TGF β receptor-1, which is a canonical upstream activator of the EMT pathway in response to ischemic stress. What is lacking is evidence demonstrating detailed downstream signaling in cholangiocyte EMT, further causative evidence, and validation that EMT induced in human cholangiocyte cultures in response to DCD conditions can predict disease in human or animal models of ischemic cholangiopathy.
The hypothesis that EMT serves as a molecular mechanism of ischemic cholangiopathy is supported by data from this study and by similar events seen in kidney transplantation. Renal allografts can undergo chronic allograft nephropathy (CAN) or tubular atrophy with interstitial fibrosis (TA/IF) in some patients [22,23]. This causes the kidneys to slowly fail months after transplantation independent from episodes of acute rejection. GFR and renal function slowly falls as the nephropathy develops over time. Chronic multiple injuries induced by preservation injury, donor co-morbidities, acute cellular rejection episodes, immune-mediated reactions, and calcineurin cytotoxicity may all cause additive injury that drives CAN [27]. Histologically, this condition is characterized by a drop out and loss of either renal tubular epithelium or entire tubules with the appearance of interstitial fibrosis [28]. This drop out of renal

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tubules leads to the drop in renal function over time. One of the strongest single risk factor for later development of CAN may be DCD preservation injury in the donor. This is known to cause an EMT in tubular epithelial cells, which may causally contribute to CAN. A parallel epithelial transformation may be occurring in the microscopic intrahepatic bile ducts because they are exposed to the same stress during DCD recovery and because the underlying attributes of the disease in the renal allografts is similar to that seen in ischemic cholangiopathy. Namely, these livers show loss of tubular epithelia, loss of whole bile ducts, smooth muscle like behavior in larger bile ducts, and interstitial fibrosis leading to liver and biliary failure. This is consistent with an EMT occurring in these epithelia. Perhaps multiple stress factors and insults experienced by DCD livers also produce additive or potentiating stimuli that finally drive the EMT switch. This is supported in our own data in these models by the accumulating effects of both prolonged cold storage and prior exposure to warm ischemia because both cause greater EMT outcomes than just cold storage alone. This is verified clinically in the IC rates in DCD livers where livers with prolonged hypothermia experience lower rates of ischemic cholangiopathy compared to livers with both prolonged cold storage exposure and a period of prior warm ischemia (DCD conditions).
The initiators, modifiers, and downstream pathways of EMT in this model are not known, but we suspect activation of TGFβ synthesis and receptor signaling is involved. In canonical EMT signaling, early synthesis of TGFβ , followed by surface receptor ligation of the TGF β receptor, and downstream SMAD signaling often initiates the EMT cascade. Other non-Smad signaling may also be involved. These could include stress activation of MAP kinase pathways such as p38, either dependent on upstream TGFβ signaling or independently through other upstream signaling through TNF α or growth factors like Bone Morphogensis Proteins (BMP) and Hepatocyte Growth Factor (HGF) [29]. The p38 MAPK pathways may serve to modify the progression of a TGFβ-initiated EMT since p38 inhibitors can restrain the TGFβ response in epithelial cells [30]. Hepatocyte growth factor (HGF) may be another early initiator of EMT or serve to maintain the response initiated by TGFβ. HGF may be produced by existing mesenchymal cells already in the liver milieu, or from newly transformed cholangiocytes now assuming genetic and phenotypic mesenchymal properties. HGF binds to and activates c-MET, which are both expressed by human cholangiocytes [31].This signaling could serve to act as an early initiator of EMT by reducing the expression of e-cadherin, which is necessary for the cells to break apart to be able to later migrate. In fact, e-cadherin downregulation is observed in our transformed cholangiocytes after exposure to DCD conditions. While the data involving TGFβ and its associated signaling components or modulators are not yet understood in our models, we know they are causally operational since TGFβ mRNA expression dramatically increases in human cholangiocytes after DCD conditions. Furthermore, the molecule is only expressed in the cells exposed to DCD conditions that also assume a migratory behavior, suggesting that TGF β may have initiated the phenotypic shift in cytoskeletal protein reorganization towards an invasive phenotype. This is further supported by our ability to block these morphological changes in the exposed cholangiocyte by first pre-treating them with a selective TGFβ receptor-1 antagonist. These later data not only implicate autocrine TGFβ as an upstream initiator of EMT and IC-like behavior but supports the hypothesis that the descriptive changes in protein expression associated with EMT may be causatively involved in the IC phenotype. These data provide reassurance that if EMT in cholangiocytes exposed to DCD conditions significantly causes clinical IC in DCD liver allografts, then rational pharmacological manipulation of these initiator or downstream circuits could prevent or reverse clinical disease. The role of other early initiators in the EMT cascade in DCD exposed cholangiocytes such as BMP and HGF or modifiers like HDAC or HIF 1α also need to be explored. These pathways may represent attractive targets to either prevent or arrest an existing EMT and IC since small molecule biologically active and stable drug candidates already exist for these targets. That is the ultimate goal in studying these pathways.
The EMT changes observed in our primary human cholangiocyte model of DCD preservation injury support the hypothesis that EMT is a causal factor in the development of ischemic cholangiopathy in human liver allografts recovered from DCD donors. This is supported by preliminary data obtained from our early rat liver transplant model. In these studies, we observed that rat liver isografts exposed to 30 min of prior warm ischemia before cold storage began to show signs of biliary complications seven days after transplantation, compared to rat liver isografts without the prior exposure to warm ischemia. This is based on the rapid spike in total bilirubin values measured in the plasma of the recipient rats at day 7 after transplantation compared to the normal baseline values seen in the first 6 days after transplantation or in the rats with just exposure to cold storage. This suggests that something changed in the DCD livers that was causing complications in the normal handling of bile acids in the liver, which is an early clinical feature of IC in patients with DCD liver grafts. Furthermore, immunohistochemical analysis of these tissues in the two groups of rat liver isografts indicated an increased expression of SNAIL in the cholangiocytes in DCD livers, relative to livers with only cold storage. Conversely, we observed a decrease in the expression of the epithelial cell marker CK-7 in the DCD livers over time compared to livers with only cold storage. These early changes in gene expression in the DCD liver isografts at the time we observed biliary changes is consistent with the hypothesis that these livers were in the early stages of IC and that this may have been caused by the pre-existing exposure to warm ischemia at the time of liver recovery. To test this hypothesis directly, future studies will pharmacologically interfere with early EMT signaling after transplantation to see the effect this has on liver function and differential gene expression at longer reperfusion times.
In conclusion, primary human cholangiocytes exposed to warm ischemia and cold storage displayed morphologic, genetic, and phenotypic changes consistent with EMT. The expression of TGFβ is involved in morphological changes characteristic of IC. The EMT signaling pathway may be a targetable mechanism to treat post-transplant biliary complications in DCD liver allografts or to prevent IC from occurring by acting in the organ recovery or preservation period.