Activation of necroptosis in human and experimental cholestasis

Cholestasis encompasses liver injury and inflammation. Necroptosis, a necrotic cell death pathway regulated by receptor-interacting protein (RIP) 3, may mediate cell death and inflammation in the liver. We aimed to investigate the role of necroptosis in mediating deleterious processes associated with cholestatic liver disease. Hallmarks of necroptosis were evaluated in liver biopsies of primary biliary cholangitis (PBC) patients and in wild-type and RIP3-deficient (RIP3^−/−) mice subjected to common bile duct ligation (BDL). The functional link between RIP3, heme oxygenase-1 (HO-1) and antioxidant response was investigated in vivo after BDL and in vitro. We demonstrate increased RIP3 expression and mixed lineage kinase domain-like protein (MLKL) phosphorylation in liver samples of human PBC patients, coincident with thioflavin T labeling, suggesting activation of necroptosis. BDL resulted in evident hallmarks of necroptosis, concomitant with progressive bile duct hyperplasia, multifocal necrosis, fibrosis and inflammation. MLKL phosphorylation was increased and insoluble aggregates of RIP3, MLKL and RIP1 formed in BLD liver tissue samples. Furthermore, RIP3 deficiency blocked BDL-induced necroinflammation at 3 and 14 days post-BDL. Serum hepatic enzymes, fibrogenic liver gene expression and oxidative stress decreased in RIP3^−/− mice at 3 days after BDL. However, at 14 days, cholestasis aggravated and fibrosis was not halted. RIP3 deficiency further associated with increased hepatic expression of HO-1 and accumulation of iron in BDL mice. The functional link between HO-1 activity and bile acid toxicity was established in RIP3-deficient primary hepatocytes. Necroptosis is triggered in PBC patients and mediates hepatic necroinflammation in BDL-induced acute cholestasis. Targeting necroptosis may represent a therapeutic strategy for acute cholestasis, although complementary approaches may be required to control progression of chronic cholestatic liver disease.Cholestasis is a pathological condition characterized by disruption of bile flow, resulting in intrahepatic and systemic retention of bile acids, with a concomitant toxic response in liver parenchymal cells, inflammation, progression to fibrosis and, ultimately, cirrhosis and premature death. Cholestatic liver injury may arise from a large number of inflicting insults, including genetic disorders, drug toxicity, hepatobiliary malignancies or obstruction of the biliary tract.¹ Liver transplantation remains one of the few available options for these patients.² This calls for novel therapeutic approaches, based in a better understanding of molecular, cellular and biochemical mechanisms underlying pathogenesis of cholestasis.Inappropriate activation of cell death is intimately associated with the pathogenesis of cholestatic liver diseases.³ In addition to apoptosis, different regulated necrotic cell death routines are emerging, defined as genetically controlled cell death processes with morphological hallmarks of oncotic necrosis.⁴ Necroptosis, the most well-studied pathway of regulated necrosis, depends on receptor-interacting protein (RIP) 3 kinase activity. In particular conditions, RIP1 and RIP3 engage in physical interactions upon activation of death receptors,⁵ creating a filamentous amyloid protein complex called necrosome.⁶ Upon phosphorylation by active RIP3, mixed lineage kinase domain (MLKL) oligomerizes and translocates to cellular membranes, hence compromising their ability to preserve ionic homeostasis.^{7, 8}Activation of necroptosis appears to constitute a pathophysiological event in chronic inflammatory liver diseases, namely alcoholic and non-alcoholic steatohepatitis (NASH).^{9, 10, 11} Although controversial,¹² necroptosis has also been suggested to mediate experimental acetaminophen-induced hepatotoxicity in early phases,^{13, 14} and phosphorylated MLKL (p-MLKL) is detected in liver biopsies of patients with drug-induced liver injury (DILI),⁷ frequently associated with cholestasis.¹⁵ In agreement with a role of necroptosis in cholestatic liver injury, combined ablation of hepatocyte-specific caspase-8 and nuclear factor-κB essential modulator results in spontaneous massive liver necrosis and cholestasis in mice, with a concomitant formation of necrosome complexes in the foci of necrotic areas.¹⁶ Further, in an animal model of chronic hepatitis and severe cholestasis, absence of RIP3 attenuates cholestasis and jaundice, suggesting the involvement of RIP3 signaling in cholestasis.¹⁷In this study, we provide evidence of hallmarks of necroptosis activation in human primary biliary cholangitis (PBC) liver tissue. Further, we show that, in mice subjected to common bile duct ligation (BDL), genetic ablation of RIP3 protects hepatocytes from oxidative stress, inflammation and necrosis, but fails to prevent BDL-induced secondary fibrosis.