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Oliveira ICCS, Marinsek GP, Correia LVB, da Silva RCB, Castro IB, Mari RB. Tributyltin (TBT) toxicity: Effects on enteric neuronal plasticity and intestinal barrier of rats' duodenum. Auton Neurosci 2024; 253:103176. [PMID: 38669866 DOI: 10.1016/j.autneu.2024.103176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 03/20/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024]
Abstract
Tributyltin (TBT) is a biocide used in the formulation of antifouling paints and it is highly harmful. Despite the ban, the compound persists in the environment, contaminating marine foodstuffs and household products. Therefore, considering the route of exposure to the contaminant, the gastrointestinal tract (GIT) acts as an important barrier against harmful substances and is a potential biomarker for understanding the consequences of these agents. This work aimed to evaluate histological and neuronal alterations in the duodenum of male Wistar rats that received 20 ng/g TBT and 600 ng/g via gavage for 30 consecutive days. After the experimental period, the animals were euthanized, and the duodenum was intended for neuronal histochemistry (total and metabolically active populations) and histological routine (morphometry and histopathology). The results showed more severe changes in neuronal density and intestinal morphometry in rats exposed to 20 ng/g, such as total neuronal density decrease and reduction of intestinal layers. In rats exposed to 600 ng/g of TBT, it was possible to observe only an increase in intraepithelial lymphocytes. We conclude that TBT can be more harmful to intestinal homeostasis when consumed in lower concentrations.
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Affiliation(s)
- I C C S Oliveira
- UNESP- São Paulo State University, Institute of Biosciences, Paulista Coast Campus (CLP), São Vicente, SP, Brazil.
| | - G P Marinsek
- UNESP- São Paulo State University, Institute of Biosciences, Paulista Coast Campus (CLP), São Vicente, SP, Brazil.
| | - L V B Correia
- UNIFESP- Federal University of São Paulo, Institute of Health and Society, Baixada Santista Campus, Santos, SP, Brazil
| | - R C B da Silva
- UNIFESP- Federal University of São Paulo, Institute of Health and Society, Baixada Santista Campus, Santos, SP, Brazil
| | - I B Castro
- UNIFESP- Federal University of São Paulo, Institute of Marine Science, Baixada Santista Campus, Santos, SP, Brazil.
| | - R B Mari
- UNESP- São Paulo State University, Institute of Biosciences, Paulista Coast Campus (CLP), São Vicente, SP, Brazil.
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2
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Sun L, Li T, Tang H, Yu K, Ma Y, Yu M, Qiu Y, Xu P, Xiao W, Yang H. Intestinal Epithelial Cells-Derived Hypoxia-Inducible Factor-1α Is Essential for the Homeostasis of Intestinal Intraepithelial Lymphocytes. Front Immunol 2019; 10:806. [PMID: 31040849 PMCID: PMC6476974 DOI: 10.3389/fimmu.2019.00806] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 03/26/2019] [Indexed: 12/18/2022] Open
Abstract
Hif-1α is a master regulator which involved in the transcriptional regulation of anti-inflammatory or cellular responding to hypoxia. Previous work shows that the absence of Hif-1α results in the destruction of intestinal epithelial cell (IEC) and abnormalities of intestinal barrier function. However, we know very little about other functions of Hif-1α on intestinal intraepithelial lymphocyte (IEL). Therefore, we generated a transgenic mouse (Hif1-αΔIEC mice), which was knocked out Hif1-α specifically in IECs, to study the effect of Hif1-α on IEL. IELs were isolated from the small intestine and colon of mice, respectively, and examined by flow cytometry and quantitative real-time PCR. All the cytokines expression was detected by quantitative real-time PCR. The NSAID enteropathy was induced by gavaged with 5 mg/kg indomethacin and the experimental colitis was induced by administration of 2.5% DSS. We found that the number of IELs is increased in Hif1-α ΔIEC mice. It is showed that knockout of Hif1-α in IECs led to significant changes in IEL phenotype, including a marked decline in the CD8αα+ and TCRγδ+ population. The reduction of CD8αα+ IELs is accompanied by increased apoptosis, decreased proliferation and weakened migration in Hif1-αΔIEC mice. Moreover, absence of intestinal epithelial Hif1-α markedly changed the population of IELs in NSAID-induced small intestinal injury and increased susceptibility to dextran sulfate sodium-induced colitis. In summary, our results first time demonstrate that IEC-derived Hif1-α is essential for maintaining IELs homeostasis and intestinal microbiota.
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Affiliation(s)
- Lihua Sun
- Department of General Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Teming Li
- Department of General Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Hanlin Tang
- Department of General Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Kun Yu
- Department of General Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Yuanhang Ma
- Department of General Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Min Yu
- Department of General Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Yuan Qiu
- Department of General Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Pengyuan Xu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Weidong Xiao
- Department of General Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Hua Yang
- Department of General Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, China
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Zhou C, Qiu Y, Yang H, Xiao WD. Mechanism of differentiation and regulation of CD4 + intraepithelial lymphocytes: Relationship with inflammatory bowel disease. Shijie Huaren Xiaohua Zazhi 2018; 26:1598-1604. [DOI: 10.11569/wcjd.v26.i27.1598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
CD4+ intraepithelial lymphocytes are a special type of lymphocytes located in the lower layer of the intestinal epithelium. According to the difference of cell phenotypes and functions, CD4+ intraepithelial lymphocytes can be divided into multiple subgroups, including Th1 cells, Th2 cells, and Th17 cells. The proliferation, differentiation, and apoptosis of CD4+ intraepithelial lymphocytes can be regulated by a variety of transcription factors, intestinal microbes, and nutrients. CD4+ intraepithelial lymphocytes play an important role in the pathogenesis of inflammatory bowel disease. In this article, we will review the mechanism of differentiation and regulation of CD4+ intraepithelial lymphocytes and their relationship with inflammatory bowel disease, with an aim to provide some new clues to the pathogenesis of inflammatory bowel disease.
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Affiliation(s)
- Chao Zhou
- Department of General Surgery, Xinqiao Hospital Affiliated to the Army Medical University, Chongqing 400037, China
| | - Yuan Qiu
- Department of General Surgery, Xinqiao Hospital Affiliated to the Army Medical University, Chongqing 400037, China
| | - Hua Yang
- Department of General Surgery, Xinqiao Hospital Affiliated to the Army Medical University, Chongqing 400037, China
| | - Wei-Dong Xiao
- Department of General Surgery, Xinqiao Hospital Affiliated to the Army Medical University, Chongqing 400037, China
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Luo B, Chen K, Feng Q, Xiao W, Ma D, Yang H, Zhang C. The interplay of BMP4 and IL‑7 regulates the apoptosis of intestinal intraepithelial lymphocytes under conditions of ischemia̸reperfusion. Int J Mol Med 2018; 41:2640-2650. [PMID: 29436597 PMCID: PMC5846653 DOI: 10.3892/ijmm.2018.3480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 01/11/2018] [Indexed: 12/22/2022] Open
Abstract
The number and function of intestinal intraepithelial lymphocytes (IELs) have been found to be significantly reduced following induction of acute intestinal mucosal damage via intestinal ischemia̸reperfusion (I̸R). However, the mechanism underlying this reduction remains unclear. Therefore, it was hypothesized that the interplay of bone morphogenetic protein (BMP)4 and interleukin (IL)‑7 regulates IEL function and number. Recent studies have demonstrated that the different components of the BMP2̸4 signaling pathway are expressed in intestinal epithelial cells (IECs) via the activation of nuclear factor (NF)‑κB. In the present study, reverse transcription‑polymerase chain reaction analysis and flow cytometry demonstrated that IELs express BMP receptors (BMPRIA, BMPRIB, ActRIA and BMPRII) and non‑canonical signal transduction molecules (NF‑κB). an in vivo mouse intestinal I̸R model was used, and I̸R was shown to increase the expression of BMP4 in IECs and upregulate the expression levels of BMPRIA, BMPRIB and phosphorylated NF‑κB in IELs. Following isolation and culture of IELs, it was observed that exogenous BMP4 also upregulated the expression of BMPRIA and BMPRIB and activated NF‑κB signaling in IELs, inducing IEL apoptosis. In addition, the rate of apoptosis of IELs decreased following treatment with the BMP‑specific antagonist Noggin or with the NF‑κB inhibitor pyrrolidine dithiocarbamate. Furthermore, it was observed that exogenous IL‑7 can decrease BMP4 protein expression in IECs and the expression of phosphorylated NF‑κB protein in IELs. The findings of the present study suggest that, under conditions of I̸R, IEC‑derived BMP4 activates NF‑κB signaling in IELs, inducing IEL apoptosis, further aggravating the dysfunction of the intestinal mucosal barrier. However, these effects may be alleviated by IL‑7 treatment. Therefore, BMP4 and IL‑7 appear to be involved in the interaction between IECs and IELs and in the mechanism underlying intestinal mucosal barrier dysfunction.
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Affiliation(s)
- Binyu Luo
- Department of General Surgery Two, Nanchong Central Hospital, The Second Clinical College of North Sichuan Medical University, Nanchong, Sichuan 637000, P.R. China
| | - Kang Chen
- Department of General Surgery, Xinqiao Hospital, The Third Military Medical University, Chongqing 400037, P.R. China
| | - Qi Feng
- Department of General Surgery, Xinqiao Hospital, The Third Military Medical University, Chongqing 400037, P.R. China
| | - Weidong Xiao
- Department of General Surgery, Xinqiao Hospital, The Third Military Medical University, Chongqing 400037, P.R. China
| | - Dan Ma
- Department of General Surgery, Xinqiao Hospital, The Third Military Medical University, Chongqing 400037, P.R. China
| | - Hua Yang
- Department of General Surgery, Xinqiao Hospital, The Third Military Medical University, Chongqing 400037, P.R. China
| | - Chaojun Zhang
- Department of General Surgery, Xinqiao Hospital, The Third Military Medical University, Chongqing 400037, P.R. China
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Diet-dependent, microbiota-independent regulation of IL-10-producing lamina propria macrophages in the small intestine. Sci Rep 2016; 6:27634. [PMID: 27302484 PMCID: PMC4908404 DOI: 10.1038/srep27634] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 05/23/2016] [Indexed: 02/07/2023] Open
Abstract
Intestinal resident macrophages (Mϕs) regulate gastrointestinal homeostasis via production of an anti-inflammatory cytokine interleukin (IL)-10. Although a constant replenishment by circulating monocytes is required to maintain the pool of resident Mϕs in the colonic mucosa, the homeostatic regulation of Mϕ in the small intestine (SI) remains unclear. Here, we demonstrate that direct stimulation by dietary amino acids regulates the homeostasis of intestinal Mϕs in the SI. Mice that received total parenteral nutrition (TPN), which deprives the animals of enteral nutrients, displayed a significant decrease of IL-10-producing Mϕs in the SI, whereas the IL-10-producing CD4+ T cells remained intact. Likewise, enteral nutrient deprivation selectively affected the monocyte-derived F4/80+ Mϕ population, but not non-monocytic precursor-derived CD103+ dendritic cells. Notably, in contrast to colonic Mϕs, the replenishment of SI Mϕs and their IL-10 production were not regulated by the gut microbiota. Rather, SI Mϕs were directly regulated by dietary amino acids. Collectively, our study highlights the diet-dependent, microbiota-independent regulation of IL-10-producing resident Mϕs in the SI.
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Qiu Y, Peng K, Liu M, Xiao W, Yang H. CD8αα TCRαβ Intraepithelial Lymphocytes in the Mouse Gut. Dig Dis Sci 2016; 61:1451-60. [PMID: 26769056 DOI: 10.1007/s10620-015-4016-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 12/16/2015] [Indexed: 12/12/2022]
Abstract
The epithelium of the mouse small intestine harbors an abundant CD8αα(+)TCRαβ(+) intraepithelial lymphocyte (IEL) population. This unique IEL subset is a self-reactive population that requires exposure to self-agonists for selection in the thymus, similarly to other regulatory T cell populations. After leaving the thymus, these cells directly seed the intestinal epithelium, which provides a unique combination of cellular interactions together with cytokines, nutrients, and antigens that guide the lineage-specific differentiation and function of these IELs. For instance, epithelial cells and nearby immune cells secrete a number of cytokines, including interleukin-15 (IL-15), IL-7, and transforming growth factor-β, resulting in an assortment of cellular responses, including activation of master transcription factors, cell proliferation, and cytokine secretion. Recent advances have also highlighted the importance of diet-derived substances and commensal metabolites, such as the aryl hydrocarbon receptor ligands and vitamin D, in controlling the survival and gene expression of CD8αα(+)TCRαβ(+) IELs. Furthermore, these cells function in the epithelium and require constant communication between cells in the form of cell-to-cell contacts. These interactions tune the antigen sensitivity of the TCR and maintain the quiescence of the CD8αα(+)TCRαβ(+) IELs. Finally, we discuss how these cells might contribute to tolerance and immunopathological responses in the gut. Therefore, an increased understanding of CD8αα(+)TCRαβ(+) IELs in the gut will help us understand how these cells participate in immune regulation and protection.
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Affiliation(s)
- Yuan Qiu
- Department of General Surgery, Xinqiao Hospital, The Third Military Medical University, Shapingba, Chongqing, 400037, China
| | - Ke Peng
- Department of General Surgery, Xinqiao Hospital, The Third Military Medical University, Shapingba, Chongqing, 400037, China
| | - Minqiang Liu
- Department of General Surgery, Xinqiao Hospital, The Third Military Medical University, Shapingba, Chongqing, 400037, China
| | - Weidong Xiao
- Department of General Surgery, Xinqiao Hospital, The Third Military Medical University, Shapingba, Chongqing, 400037, China.
| | - Hua Yang
- Department of General Surgery, Xinqiao Hospital, The Third Military Medical University, Shapingba, Chongqing, 400037, China.
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Feng Y, Barrett M, Hou Y, Yoon HK, Ochi T, Teitelbaum DH. Homeostasis alteration within small intestinal mucosa after acute enteral refeeding in total parenteral nutrition mouse model. Am J Physiol Gastrointest Liver Physiol 2016; 310:G273-84. [PMID: 26635320 PMCID: PMC4754738 DOI: 10.1152/ajpgi.00335.2015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 11/24/2015] [Indexed: 01/31/2023]
Abstract
Feeding strategies to care for patients who transition from enteral nutrient deprivation while on total parenteral nutrition (TPN) to enteral feedings generally proceed to full enteral nutrition once the gastrointestinal tract recovers; however, an increasing body of literature suggests that a subgroup of patients may actually develop an increased incidence of adverse events, including death. To examine this further, we studied the effects of acute refeeding in a mouse model of TPN. Interestingly, refeeding led to some beneficial effects, including prevention in the decline in intestinal epithelial cell (IEC) proliferation. However, refeeding led to a significant increase in mucosal expression of proinflammatory cytokines, including tumor necrosis factor-α (TNF-α), as well as an upregulation in Toll-like receptor 4 (TLR-4). Refeeding also failed to prevent TPN-associated increases in IEC apoptosis, loss of epithelial barrier function, and failure of the leucine-rich repeat-containing G protein-coupled receptor 5-positive stem cell expression. Transitioning from TPN to enteral feedings led to a partial restoration of the small bowel microbial population. In conclusion, while acute refeeding led to some restoration of normal gastrointestinal physiology, enteral refeeding led to a significant increase in mucosal inflammatory markers and may suggest alternative strategies to enteral refeeding should be considered.
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Affiliation(s)
- Yongjia Feng
- 1Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan;
| | - Meredith Barrett
- 1Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan; ,2General Surgery, Department of Surgery, the University of Michigan Medical School, Ann Arbor, Michigan;
| | - Yue Hou
- 1Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan; ,3University of Michigan, Ann Arbor, Michigan; and
| | - Hong Keun Yoon
- 1Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan; ,3University of Michigan, Ann Arbor, Michigan; and
| | - Takanori Ochi
- 1Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan; ,4Department of Pediatric Surgery, Juntendo Hospital, Juntendo University, Tokyo, Japan
| | - Daniel H. Teitelbaum
- 1Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan;
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Aryl Hydrocarbon Receptor Activation Down-Regulates IL-7 and Reduces Inflammation in a Mouse Model of DSS-Induced Colitis. Dig Dis Sci 2015; 60:1958-66. [PMID: 25799939 DOI: 10.1007/s10620-015-3632-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 03/11/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS The pathogenesis of inflammatory bowel disease (IBD) is associated with dysregulation of intestinal immune system. Aryl hydrocarbon receptor (AHR) is believed to control the chronic inflammation in the gut. Besides, interleukin-7 (IL-7) is proved to be an important cytokine that activates mucosal inflammation in IBD. Moreover, intraepithelial lymphocytes (IELs) are one of the key immunological compartments involved in regulating intestinal inflammation. In this study, we investigated the function of 6-formylindolo (3,2-b) carbazole (Ficz), a ligand of AHR, on IL-7, colitis, and IEL phenotypes. METHODS Colitis was induced by administration of dextran sulfate sodium (DSS) to wild-type C57BL/6J mice for 7 days. Mice were weighted, colon tissues were collected and measured, and histology analyses were performed. IELs were isolated from colon, and the phenotype and activation of IELs were examined using flow cytometry detection. The expression of AHR and IL-7 was measured by immunofluorescence, Western blot, and RT-PCR. RESULTS Ficz down-regulated epithelial-derived IL-7 expression in mice with DSS-induced colitis and ameliorated DSS-induced colitis. Ficz also decreased CD8αβ(+) and CD8(+) IEL subpopulations, enhanced TCRγδ(+) IEL subpopulation, and reduced the percentage of activated CD4(+) and CD8(+) subpopulations. CONCLUSIONS Ficz could down-regulate epithelial-derived IL-7 expression in mice with DSS-induced colitis and inhibit inflammation in the gastrointestinal tract of mice. AHR-related compounds might be the new and promising therapeutic medicaments for the treatment of patients with IBD.
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Freeman JJ, Feng Y, Demehri FR, Dempsey PJ, Teitelbaum DH. TPN-associated intestinal epithelial cell atrophy is modulated by TLR4/EGF signaling pathways. FASEB J 2015; 29:2943-58. [PMID: 25782989 DOI: 10.1096/fj.14-269480] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 03/02/2015] [Indexed: 12/12/2022]
Abstract
Recent studies suggest a close interaction between epidermal growth factor (EGF) and TLR signaling in the modulation of intestinal epithelial cell (IEC) proliferation; however, how these signaling pathways adjust IEC proliferation is poorly understood. We utilized a model of total parenteral nutrition (TPN), or enteral nutrient deprivation, to study this interaction as TPN results in mucosal atrophy due to decreased IEC proliferation and increased apoptosis. We identified the novel finding of decreased mucosal atrophy in TLR4 knockout (TLR4KO) mice receiving TPN. We hypothesized that EGF signaling is preserved in TLR4KO-TPN mice and prevents mucosal atrophy. C57Bl/6 and strain-matched TLR4KO mice were provided either enteral feeding or TPN. IEC proliferation and apoptosis were measured. Cytokine and growth factor abundances were detected in both groups. To examine interdependence of these pathways, ErbB1 pharmacologic blockade was used. The marked decline in IEC proliferation with TPN was nearly prevented in TLR4KO mice, and intestinal length was partially preserved. EGF was significantly increased, and TNF-α decreased in TLR4KO-TPN versus wild-type (WT)-TPN mice. Apoptotic positive crypt cells were 15-fold higher in WT-TPN versus TLR4KO-TPN mice. Bcl-2 was significantly increased in TLR4KO-TPN mice, while Bax decreased 10-fold. ErbB1 blockade prevented this otherwise protective effect in TLR4KO-sTPN mice. TLR4 blockade significantly prevented TPN-associated atrophy by preserving proliferation and preventing apoptosis. This is driven by a reduction in TNF-α abundance and increased EGF. Potential manipulation of this regulatory pathway may have significant clinical potential to prevent TPN-associated atrophy.
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Affiliation(s)
- Jennifer J Freeman
- *Department of Surgery, Section of Pediatric Surgery, and Center for Organogenesis, University of Michigan, Ann Arbor, Michigan, USA; and School of Medicine, Department of Pediatrics, University of Colorado, Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Yongjia Feng
- *Department of Surgery, Section of Pediatric Surgery, and Center for Organogenesis, University of Michigan, Ann Arbor, Michigan, USA; and School of Medicine, Department of Pediatrics, University of Colorado, Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Farokh R Demehri
- *Department of Surgery, Section of Pediatric Surgery, and Center for Organogenesis, University of Michigan, Ann Arbor, Michigan, USA; and School of Medicine, Department of Pediatrics, University of Colorado, Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Peter J Dempsey
- *Department of Surgery, Section of Pediatric Surgery, and Center for Organogenesis, University of Michigan, Ann Arbor, Michigan, USA; and School of Medicine, Department of Pediatrics, University of Colorado, Denver, Anschutz Medical Campus, Denver, Colorado, USA
| | - Daniel H Teitelbaum
- *Department of Surgery, Section of Pediatric Surgery, and Center for Organogenesis, University of Michigan, Ann Arbor, Michigan, USA; and School of Medicine, Department of Pediatrics, University of Colorado, Denver, Anschutz Medical Campus, Denver, Colorado, USA
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Qiu Y, Wang W, Xiao W, Yang H. Role of the intestinal cytokine microenvironment in shaping the intraepithelial lymphocyte repertoire. J Leukoc Biol 2015; 97:849-857. [PMID: 25765675 DOI: 10.1189/jlb.3ru1014-465r] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 01/17/2015] [Accepted: 02/16/2015] [Indexed: 12/11/2022] Open
Abstract
Local resident IELs are composed of distinct subsets of T cells with potent cytolytic and immunoregulatory capacities. As IELs are located within this unique interface between the core of the body and the outside environment, the specific development and function of intestinal IELs must be tightly regulated. To accomplish this, the cytokine microenvironment of the intestine has evolved sophisticated mechanisms that modulate the phenotype, ontogeny, and function of these cells. In this review, we summarize the evidence demonstrating the origin of certain intestinal cytokines, including IL-7, IL-15, IL-2, TGF-β, and SCF and discuss what influence such cytokines may have on IELs. Moreover, we review data suggesting that the abnormal expression of cytokines that leads to the heightened activation of IELs may also contribute to immunopathological responses or exacerbate inflammatory diseases, such as IBD and celiac disease, or promote cancer development and progression.
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Affiliation(s)
- Yuan Qiu
- Department of General Surgery, Xinqiao Hospital, The Third Military Medical University, Chongqing, China
| | - Wensheng Wang
- Department of General Surgery, Xinqiao Hospital, The Third Military Medical University, Chongqing, China
| | - Weidong Xiao
- Department of General Surgery, Xinqiao Hospital, The Third Military Medical University, Chongqing, China
| | - Hua Yang
- Department of General Surgery, Xinqiao Hospital, The Third Military Medical University, Chongqing, China
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11
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Ralls MW, Demehri FR, Feng Y, Woods Ignatoski KM, Teitelbaum DH. Enteral nutrient deprivation in patients leads to a loss of intestinal epithelial barrier function. Surgery 2015; 157:732-42. [PMID: 25704423 DOI: 10.1016/j.surg.2014.12.004] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 11/17/2014] [Accepted: 12/03/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To investigate the effect of nutrient withdrawal on human intestinal epithelial barrier function (EBF). We hypothesized that unfed mucosa results in decreased EBF. This was tested in a series of surgical small intestinal resection specimens. DESIGN Small bowel specifically excluding inflamed tissue, was obtained from pediatric patients (aged 2 days to 19 years) undergoing intestinal resection. EBF was assessed in Ussing chambers for transepithelial resistance (TER) and passage of fluorescein isothiocyanate (FITC)-dextran (4 kD). Tight junction and adherence junction proteins were imaged with immunofluorescence staining. Expression of Toll-like receptors (TLR) and inflammatory cytokines were measured in loop ileostomy takedowns in a second group of patients. RESULTS Because TER increased with patient age (P < .01), results were stratified into infant versus teenage groups. Fed bowel had significantly greater TER versus unfed bowel (P < .05) in both age populations. Loss of EBF was also observed by an increase in FITC-dextran permeation in enteral nutrient-deprived segments (P < .05). Immunofluorescence staining showed marked declines in intensity of ZO-1, occludin, E-cadherin, and claudin-4 in unfed intestinal segments, as well as a loss of structural formation of tight junctions. Analysis of cytokine and TLR expression showed significant increases in tumor necrosis factor (TNF)-α and TLR4 in unfed segments of bowel compared with fed segments from the same individual. CONCLUSION EBF declined in unfed segments of human small bowel. This work represents the first direct examination of EBF from small bowel derived from nutrient-deprived humans and may explain the increased incidence of infectious complications seen in patients not receiving enteral feeds.
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Affiliation(s)
- Matthew W Ralls
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Farokh R Demehri
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Yongjia Feng
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Daniel H Teitelbaum
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI.
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12
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Xiao W, Feng Y, Holst JJ, Hartmann B, Yang H, Teitelbaum DH. Glutamate prevents intestinal atrophy via luminal nutrient sensing in a mouse model of total parenteral nutrition. FASEB J 2014; 28:2073-87. [PMID: 24497581 DOI: 10.1096/fj.13-238311] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Small intestine luminal nutrient sensing may be crucial for modulating physiological functions. However, its mechanism of action is incompletely understood. We used a model of enteral nutrient deprivation, or total parenteral nutrition (TPN), resulting in intestinal mucosal atrophy and decreased epithelial barrier function (EBF). We examined how a single amino acid, glutamate (GLM), modulates intestinal epithelial cell (IEC) growth and EBF. Controls were chow-fed mice, T1 receptor-3 (T1R3)-knockout (KO) mice, and treatment with the metabotropic glutamate receptor (mGluR)-5 antagonist MTEP. TPN significantly changed the amount of T1Rs, GLM receptors, and transporters, and GLM prevented these changes. GLM significantly prevented TPN-associated intestinal atrophy (2.5-fold increase in IEC proliferation) and was dependent on up-regulation of the protein kinase pAkt, but independent of T1R3 and mGluR5 signaling. GLM led to a loss of EBF with TPN (60% increase in FITC-dextran permeability, 40% decline in transepithelial resistance); via T1R3, it protected EBF, whereas mGluR5 was associated with EBF loss. GLM led to a decline in circulating glucagon-like peptide 2 (GLP-2) during TPN. The decline was regulated by T1R3 and mGluR5, suggesting a novel negative regulator pathway for IEC proliferation not previously described. Loss of luminal nutrients with TPN administration may widely affect intestinal taste sensing. GLM has previously unrecognized actions on IEC growth and EBF. Restoring luminal sensing via GLM could be a strategy for patients on TPN.
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Affiliation(s)
- Weidong Xiao
- 1Section of Pediatric Surgery, University of Michigan, Mott Children's Hospital F3970, Ann Arbor, MI 48109-5245, USA.
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Qiu Y, Yu M, Yang Y, Sheng H, Wang W, Sun L, Chen G, Liu Y, Xiao W, Yang H. Disturbance of intraepithelial lymphocytes in a murine model of acute intestinal ischemia/reperfusion. J Mol Histol 2013; 45:217-27. [PMID: 24122227 DOI: 10.1007/s10735-013-9544-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 10/03/2013] [Indexed: 12/27/2022]
Abstract
Strategically located at the epithelial basolateral surface, intraepithelial lymphocytes (IELs) are intimately associated with epithelial cells and maintain the epithelial barrier integrity. Intestinal ischemia-reperfusion (I/R)-induced acute injury not only damages the epithelium but also affects the mucosal barrier function. Therefore, we hypothesized that I/R-induced mucosal damage would affect IEL phenotype and function. Adult C57BL/6J mice were treated with intestinal I/R or sham. Mice were euthanized at 6 h after I/R, and the small bowel was harvested for histological examination and to calculate the transmembrane resistance. Occludin expression and IEL location were detected through immunohistochemistry. The IEL phenotype, activation, and apoptosis were examined using flow cytometry. Cytokine and anti-apoptosis-associated gene expressions were measured through RT-PCR. Intestinal I/R induced the destruction of epithelial cells and intercellular molecules (occludin), resulting in IEL detachment from the epithelium. I/R also significantly increased the CD8αβ, CD4, and TCRαβ IEL subpopulations and significantly changed IEL-derived cytokine expression. Furthermore, I/R enhanced activation and promoted apoptosis in IELs. I/R-induced acute intestinal mucosal damage significantly affected IEL phenotype and function. These findings provide profound insight into potential IEL-mediated epithelial barrier dysfunction after intestinal I/R.
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Affiliation(s)
- Yuan Qiu
- Department of General Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
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Miyasaka EA, Feng Y, Poroyko V, Falkowski NR, Erb-Downward J, Gillilland MG, Mason KL, Huffnagle GB, Teitelbaum DH. Total parenteral nutrition-associated lamina propria inflammation in mice is mediated by a MyD88-dependent mechanism. THE JOURNAL OF IMMUNOLOGY 2013; 190:6607-15. [PMID: 23667106 DOI: 10.4049/jimmunol.1201746] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Enteral nutrient deprivation via total parenteral nutrition (TPN) administration leads to local mucosal inflammatory responses, but the underlying mechanisms are unknown. Wild-type (WT) and MyD88(-/-) mice underwent jugular vein cannulation. One group received TPN without chow, and controls received standard chow. After 7 d, we harvested intestinal mucosally associated bacteria and isolated small-bowel lamina propria (LP) cells. Bacterial populations were analyzed using 454 pyrosequencing. LP cells were analyzed using quantitative PCR and multicolor flow cytometry. WT, control mucosally associated microbiota were Firmicutes-dominant, whereas WT TPN mice were Proteobacteria-domiant. Similar changes were observed in MyD88(-/-) mice with TPN administration. UniFrac analysis showed divergent small bowel and colonic bacterial communities in controls, merging toward similar microbiota (but distinct from controls) with TPN. The percentage of LP T regulatory cells significantly decreased with TPN in WT mice. F4/80(+)CD11b(+)CD11c(dull/-) macrophage-derived proinflammatory cytokines significantly increased with TPN. These proinflammatory immunologic changes were significantly abrogated in MyD88(-/-) TPN mice. Thus, TPN administration is associated with significant expansion of Proteobacteria within the intestinal microbiota and increased proinflammatory LP cytokines. Additionally, MyD88 signaling blockade abrogated decline in epithelial cell proliferation and epithelial barrier function loss.
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Affiliation(s)
- Eiichi A Miyasaka
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
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Kovalenko PL, Basson MD. Changes in morphology and function in small intestinal mucosa after Roux-en-Y surgery in a rat model. J Surg Res 2012; 177:63-69. [PMID: 22487386 PMCID: PMC3837583 DOI: 10.1016/j.jss.2012.03.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 02/29/2012] [Accepted: 03/08/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Currently there is no an appropriate model to study intestinal mucosal atrophy in vivo that preserves the nutritional status of the organism. MATERIALS AND METHODS We created a defunctionalized segment of jejunum via a dead-end Roux-en-Y anastomosis in rats. We compared tissue morphometric parameters in the intestinal mucosa of the defunctionalized bowel with that of the mucosa proximal and distal to the anastomosis. We further measured extracellular signal-regulated kinase (ERK) activation within the mucosa as well as sucrase-isomaltase and dipeptidyl peptidase-4 levels as markers of intestinal mucosal differentiation by Western blotting of mucosal scrapings. RESULTS Three days after anastomosis, the defunctionalized bowel exhibited decreased diameter and thickness of both the mucosa and the fibromuscular layer compared with adjacent bowel in continuity for luminal nutrient flow or with bowel from control animals. Sucrase-isomaltase and dipeptidyl peptidase-4 levels also were decreased. Furthermore, mucosal ERK activation, assessed as the ratio of phosphorylated to total ERK, also was reduced. Animal weights did not differ between bypassed and control animals. CONCLUSIONS Deprivation of nutrient flow in a segment of bowel by defunctionalizing Roux-en-anastomosis produces mucosal atrophy as indicated by altered histology, differentiation marker expression, and ERK signaling, in animals that are otherwise able to maintain enteral nutrition.
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Affiliation(s)
| | - Marc D. Basson
- Department of Surgery, Michigan State University, East Lansing, MI
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Cai YJ, Wang WS, Liang HY, Sun LH, Teitelbaum DH, Yang H. Keratinocyte growth factor up-regulates Interleukin-7 expression following intestinal ischemia/reperfusion in vitro and in vivo. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL PATHOLOGY 2012; 5:569-580. [PMID: 22949940 PMCID: PMC3430112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 07/02/2012] [Indexed: 06/01/2023]
Abstract
BACKGROUND Epithelial cell (EC)-derived Interleukin-7 (IL-7) plays a crucial role in control of neighboring intestinal intraepithelial lymphocytes (IEL) development and homeostasis, and IEL derived keratinocyte growth factor (KGF) promotes intestinal epithelial growth, which was regulated by EC-derived IL-7. On this basis, we hypothesize that there is a crosstalk between IELs and ECs, and KGF could regulate the EC-derived IL-7 expression, which should be associated with the protective effects by KGF on intestinal injury. METHODS Histological evaluation was performed in small intestine tissues of patients with intestinal obstruction and IL-7 expression was detected by immunofluorescence. Intestinal epithelial cells (LoVo) and adult C57BL/6J mice undergoing ischemia/reperfusion injury were treated with recombinant KGF. KGF, KGF receptor(KGFR) and IL-7 expressions were measured with western blot and immunofluorescence analysis. RESULTS IL-7 expression increased in the mild ischemia while decreased in severe ischemia small intestinal tissues of patients with intestinal obstruction. KGF expression significantly decreased while IL-7 expression increased early after acute intestinal I/R administration in a mouse model. KGF treatment significantly increased the IL-7 expression both in vitro and in vivo, while when the KGFR was blocked, the findings above were absent. In addition, our results showed changes of IL-7 expression at different stages after acute intestinal I/R administration, KGF treatment significantly attenuated the decreasing of IL-7 expression caused by acute intestinal I/R. CONCLUSION KGF could up-regulate the IL-7 expression both in vitro and in vivo through KGFR pathway, which should have associated with the protective effects of KGF in intestinal injury.
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Affiliation(s)
- Yu-Jiao Cai
- Department of General Surgery, Xinqiao Hospital, Third Military Medical UniversityChongqing, China
| | - Wen-Sheng Wang
- Department of General Surgery, Xinqiao Hospital, Third Military Medical UniversityChongqing, China
| | - Hong-Ying Liang
- Department of General Surgery, Xinqiao Hospital, Third Military Medical UniversityChongqing, China
| | - Li-Hua Sun
- Department of General Surgery, Xinqiao Hospital, Third Military Medical UniversityChongqing, China
| | - Daniel H Teitelbaum
- Department of Surgery, the University of Michigan Medical SchoolAnn Arbor, Michigan
| | - Hua Yang
- Department of General Surgery, Xinqiao Hospital, Third Military Medical UniversityChongqing, China
- Department of Surgery, the University of Michigan Medical SchoolAnn Arbor, Michigan
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Feng Y, Teitelbaum DH, Stenson WF. Epidermal growth factor/TNF-α transactivation modulates epithelial cell proliferation and apoptosis in a mouse model of parenteral nutrition. Am J Physiol Gastrointest Liver Physiol 2012; 302:G236-49. [PMID: 22075779 PMCID: PMC3341111 DOI: 10.1152/ajpgi.00142.2011] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Epidermal growth factor (EGF) and tumor necrosis factor-α (TNF-α) signaling are critical for effective proliferative and apoptotic actions; however, little is known about the codependency of these signaling pathways in the intestinal epithelium. Because total parenteral nutrition (TPN) is associated with loss of intestinal epithelial cell (IEC) proliferation and increased apoptosis, we utilized a mouse model to explore these transactivation pathways in small bowel epithelium. Mice underwent intravenous cannulation and were given enteral nutrition or TPN for 7 days. Outcomes included IEC proliferation, apoptosis, and survival. To address transactivation or dependence of EGF and TNF on IEC physiology, TNF-α receptor knockout (KO) mice, TNFR1-KO, R2-KO, or R1R2-double KO, were used. Exogenous EGF and pharmacological blockade of ErbB1 were performed in other groups to examine the relevance of the ErB1 pathway. TPN increased IEC TNFR1 and decreased EGF and ErbB1 abundance. Loss of IEC proliferation was prevented by exogenous EGF or blockade of TNFR1. However, EGF action was prevented without effective TNFR2 signaling. Also, blockade of TNFR1 could not prevent loss of IEC proliferation without effective ErbB1 signaling. TPN increased IEC apoptosis and was due to increased TNFR1 signaling. Exogenous EGF or blockade of TNFR1 could prevent increased apoptosis, and both pathways were dependent on effective ErbB1 signaling. Exogenous EGF prevented increased apoptosis in mice lacking TNFR2 signaling. TPN mice had significantly decreased survival vs. controls, and this was associated with the TNFR1 signaling pathway. We concluded that these findings identify critical mechanisms that contribute to TPN-associated mucosal atrophy via altered TNF-α/EGF signaling. It emphasizes the importance of both TNFR1 and TNFR2 pathways, as well as the strong interdependence on an intact EGF/ErbB1 pathway.
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Affiliation(s)
- Yongjia Feng
- Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Daniel H. Teitelbaum
- Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan
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Influence of alemtuzumab on the intestinal Paneth cells and microflora in macaques. Clin Immunol 2010; 136:375-86. [PMID: 20605528 DOI: 10.1016/j.clim.2010.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Revised: 05/10/2010] [Accepted: 05/10/2010] [Indexed: 01/09/2023]
Abstract
Alemtuzumab has been recently introduced for induction therapy in organ transplantation. However, the pathogenesis and molecular mechanism of the impact of such induction therapy on bacterial infections remain to be clarified. We found the alterations of Paneth cells including abnormal Paneth cell granules and expression of lysozyme and defensin 5 in response to lymphocyte depletion by alemtuzumab. Lymphocyte depletion resulted in decreased expression of TNF-alpha, IFN-gamma, IL-10 and TGF-beta in the intestine. The diversity of gut bacteria varied significantly between different times of alemtuzumab treatment. Abnormal expression of granule peptides might result in impairment of host gut microflora. The alterations in bacterial microflora had almost reversed 56days after alemtuzumab treatment, which was consistent with our results that Paneth cells were recovered to secrete antimicrobial peptides to govern gut microflora. These findings indicated the associations between changes of Paneth cell function and gut microflora and supported the important role of Paneth cells to barrier impairment with the use of alemtuzumab in organ transplantation.
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Nose K, Yang H, Sun X, Nose S, Koga H, Feng Y, Miyasaka E, Teitelbaum DH. Glutamine prevents total parenteral nutrition-associated changes to intraepithelial lymphocyte phenotype and function: a potential mechanism for the preservation of epithelial barrier function. J Interferon Cytokine Res 2010; 30:67-80. [PMID: 20028208 DOI: 10.1089/jir.2009.0046] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Total parenteral nutrition (TPN) results in a number of derangements to the intestinal epithelium, including a loss of epithelial barrier function (EBF). As TPN supplemented with glutamine has been thought to prevent this loss, this article further defined the impact of glutamine on EBF, and investigated potential mechanisms that contributed to the preservation of EBF. C57BL/6J male mice were randomized to enteral nutrition (control), TPN, or TPN supplemented with glutamine (TPN+GLN). Changes in intraepithelial lymphocyte (IEL)-derived cytokine expression were measured, and EBF was assessed with electrophysiologic methods and assessment of junctional protein expression. TPN resulted in a significant decline in EBF, and this loss of EBF was significantly prevented in the TPN+GLN group. Coincident with these changes was a loss of intraepithelial lymphocyte (IEL, mucosal lymphocyte)-derived IL-10 and increase in interferon-gamma (IFN-gamma) expression, and a decline in IEL numbers in the TPN group. A prevention in the increase in IFN-gamma and decline in IL-10 expression was seen in the TPN+GLN group. To determine the mechanism responsible for these glutamine-associated cytokine changes, we tested whether blockade of the IL-7 signaling pathway between epithelial cells (EC) and IEL would prevent these changes; however, blockade failed to influence IEL-derived cytokine changes. Glutamine-supplemented TPN leads to a specific IEL-derived cytokine profile, which may account for the preservation of EBF; and such action may be due to a direct action of glutamine on the IEL.
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Affiliation(s)
- Keisuke Nose
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Medical School and the C.S. Mott Children's Hospital, Ann Arbor, Michigan 48109-0245, USA
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Yang H, Feng Y, Sun X, Teitelbaum DH. Enteral versus parenteral nutrition: effect on intestinal barrier function. Ann N Y Acad Sci 2009; 1165:338-46. [PMID: 19538325 DOI: 10.1111/j.1749-6632.2009.04026.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Total parenteral nutrition (TPN), or the complete absence of enteral nutrients, is commonly used in a clinical setting. However, a major consequence of TPN administration is the development of mucosal atrophy and a loss of epithelial barrier function (EBF); and this loss may lead to an increase in clinical infections and septicemia. Our laboratory has investigated the mechanism of this TPN-associated loss of EBF using a mouse model. We have demonstrated that the mucosal lymphoid population significantly changes with TPN, and leads to a rise in interferon gamma (IFN-gamma) and decline in interleukin-10 (IL-10) expression-both of which contribute to the loss of EBF. Associated with these cytokine changes is a dramatic decline in the expression of tight junction and adherens junction proteins. This article discusses the potential mechanisms responsible for these changes, and potential strategies to alleviate this loss in EBF.
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Affiliation(s)
- Hua Yang
- Department of Surgery, the University of Michigan Medical School, Ann Arbor, Michigan, USA
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