Originally published online as doi:10.1189/jlb.0107062 on April 30, 2007
Published online before print April 30, 2007
(Journal of Leukocyte Biology. 2007;82:457-464.)
© 2007
by Society for Leukocyte Biology
Lymphocyte function during hepatic ischemia/reperfusion injury
Charles C. Caldwell,
Johannes Tschoep and
Alex B. Lentsch1
The Laboratory of Trauma, Sepsis and Inflammation Research, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
1 Correspondence: University of Cincinnati College of Medicine, Department of Surgery, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA. E-mail: alex.lentsch{at}uc.edu

ABSTRACT
The liver is the primary organ affected by ischemia/reperfusion
(I/R) injury after shock, surgical resection, or transplantation.
The actions of myeloid leukocytes have been well studied and
are thought to be the primary cells responsible for propagating
the injury response. However, there is an emerging view that
T lymphocytes can also regulate liver I/R-induced inflammation.
Resident lymphocytes found within the liver include conventional

ß TCR cells as well as unconventional NK and


T cells.
These lymphocytes can alter inflammation through the secretion
of soluble mediators such as cytokines and chemokines or through
cognate interactions in an antigen-dependent manner. Expression
of these mediators will then result in the recruitment of more
lymphocytes and neutrophils. There is evidence to suggest that
T cell activation in the liver during I/R can be driven by antigenic
or nonantigenic mechanisms. Finally, immune cells are exposed
to different oxygen tensions, including hypoxia, as they migrate
and function within tissues. The hypoxic environment during
liver ischemia likely modulates T cell function, at least in
part through the actions of hypoxia-inducible factor-1

. Further,
this hypoxic environment leads to the increased concentration
of extracellular adenosine, which is generally known to suppress
T cell proinflammatory function. Altogether, the elucidation
of T lymphocyte actions during liver I/R will likely allow for
novel targets for therapeutic intervention.
Key Words: liver inflammation T cells

INTRODUCTION
Ischemia/reperfusion (I/R) injury is a component of a number
of clinical situations including stroke, shock, transplantation,
and myocardial infarction. Despite important increases in medical
care, prevention of I/R-related injuries continues to be problematic.
I/R injury of the liver results most commonly from resection
surgery, transplantation, and trauma. Following reperfusion,
initiation of an acute inflammatory response is a key contributing
factor, resulting in tissue injury. A significant portion of
the injury is a result of leukocyte-dependent damage. The actions
of Kupffer cells and neutrophils have been well studied and
reviewed and are thought to be the cells responsible for initiating
and propagating the injury response. However, there is an emerging
view that T lymphocytes also regulate liver I/R-induced inflammation.

ORIGIN OF HEPATIC T LYMPHOCYTES
During development, the fetal liver acts as the primary site
of erythropoiesis from mid-gestation. Just prior to birth, the
bone marrow becomes active in the generation of hemopoietic
cells. In the adult liver,

30% of the livers cells are
nonhepatocytes [
1
]. These cells include stellate cells, endothelial
cells, macrophages, dendritic cells (DC), and lymphocytes and
give the liver the ability to generate a variety of acute-phase
proteins, chemokines, and cytokines [
2
].
Blood supply to the liver originates from the gut and contains endotoxins and foreign antigens from the gastrointestinal tract. Kupffer cells are derived from blood monocytes, which have become differentiated and localized to the liver. These cells represent a first line of defense to these antigens in that they have the ability to phagocytose normal amounts of antigens and endotoxins. If the amount of antigen exceeds the phagocytic capacity of the Kupffer cells, then DC located in the central veins and portal tract [3
] will bind the antigen and migrate to extrahepatic lymph nodes. Here, the DC will present portions of the antigen within the context of the MHC to T cells, which are specific toward the antigen. These antigen-specific T cells will expand in numbers and subsequently migrate to the liver. Here, they will interact with antigen-presenting Kupffer and endothelial cells to clear the foreign antigen. Once the challenge is cleared, more than 90% of the T cells will undergo apoptosis [4
], and some T cells will remain in the liver as memory T cells. As the liver ages, more T cells will accumulate such that in the average adult liver, there are
1010 resident lymphocytes [5
, 6
]. Other resident lymphocytes include NK T (NKT) cells and 
TCR-bearing cells. NKT cells are a subset of T cells, which coexpress an
ß TCR but also express a variety of molecular markers, typically associated with NK cells, such as NK1.1 [7
]. They differ from conventional
ß T cells in that their TCRs are far more limited in diversity and in that they recognize lipids and glycolipids presented by CD1d molecules, a member of the CD1 family of antigen-presenting molecules, rather than peptide-MHC complexes. 
TCR-bearing cells or 
T cells are preferentially localized in nonlymphoid tissues [8
]. Antigen recognition by 
T cells is limited as compared with conventional T cells, and the repertoire of natural ligands is not well developed [9
, 10
].

HEPATIC LYMPHOCYTE FUNCTION
Liver-resident T lymphocytes can alter inflammation through
the secretion of soluble mediators such as cytokines and chemokines
or through cognate interactions in an antigen-dependent manner.
Table 1
lists the liver-resident lymphocytes as well as other
resident leukocytes and the primary cytokines produced by each
cell type. In general, lymphocytes can have a pro- or anti-inflammatory
phenotype determined by the production of IFN-

or IL-4. Hepatic
T lymphocytes respond similarly, as ex vivo stimulation of liver
resident mononuclear cells with a T cell-specific mitogen results
in the production of IFN-

and IL-4 (C. C. Caldwell, unpublished
data). This indicates the presence of Th1 (or Tc1) and Th2 (or
Tc2) cells in the liver and contrasts sharply with T cells taken
from lung, peritoneum, or secondary lymphoid tissue, where T
cell stimulation results predominantly in IFN-

production (C.
C. Caldwell, unpublished data). The manner in which T cell-derived
IFN-

affects the inflammatory response to liver I/R is not understood
completely. However, IFN-

stimulates Kupffer cells to produce
TNF-

, IL-1, and prostanoids [
37
] and results in hepatocyte
production of CC chemokines [
38
]. Thus, it is likely that T
cell release of IFN-

contributes to the early induction of hepatic
inflammation after I/R.
In contrast to IFN-

, IL-4 is an important anti-inflammatory
cytokine, which functions to terminate leukocyte proinflammatory
actions [
39
,
40
]. In the liver, IL-4 appears to suppress inflammation.
For example, IL-4 counteracts the effect of IL-1 and IL-6 on
the production of acute-phase proteins by hepatocytes [
41
,
42
]. Therefore, IL-4 production may regulate the inflammatory
actions of leukocytes and hepatocytes. Finally, other liver-resident
leukocytes produce a variety of inflammatory mediators, which
can contribute to or suppress hepatic inflammatory reactions
through direct and indirect actions on lymphocyte function.
The cytokines TNF-
and IL-6 are produced by T cells. IL-6 is a candidate downstream mediator of the protective and proproliferative effects of ischemic preconditioning against hepatic I/R [43
]. TNF-
appears to be a critical but bifunctional mediator during hepatic I/R in that in its absence, liver I/R-mediated injury as well as priming for liver regeneration are blunted [44
]. During kidney I/R, increased intracellular cytokine production of TNF-
by CD3+ T cells was found [45
]. Further, it was found that TCR-deficient mice had a significant, functional and structural protection, which in turn was associated with a decreased level of TNF-
and IL-6 proteins in postischemic kidney tissue compared with wild-type mice [46
]. Although this remains to be shown during liver I/R, it is possible that modulation of TNF-
and IL-6 expression by T cells could be used to mediate tissue damage, as well as subsequent regeneration.

RECRUITMENT OF LYMPHOCYTES TO THE LIVER
Chemokines play a key role in the trafficking and homing of
leukocytes [
47
]. During development and effector function,
T lymphocytes have a differential expression of chemokine receptors.
First, pre-thymocytes are induced by stromal cell-derived factor
1 via the thymocyte-expressing CXCR4 to migrate to the thymus
for differentiation to thymocytes [
48
,
49
]. The progression
of the early thymocytes to naïve thymocytes includes the
transcription of TCR-

, rearrangement of TCR-ß, and
expression of TCR on the surface. After this differentiation,
the naïve T cells enter the circulation expressing CCR7,
until they come into contact with their specific antigen, presented
by an APC in secondary lymphoid tissues [
50
]. Upon progression
into effector cells, T cells no longer express CCR7 and depending
on the antigenic stimulation, express a new repertoire of chemokine
receptors. In general, a proinflammatory T cell will express
CXCR3 and CCR5, and anti-inflammatory T cells will express CCR4,
CCR8, and CCR3 [
51
]. However, although the cytokine production
of differentiated Th1 or Th2 cells depends mainly on the tissue
of origin and the infection, chemokine receptor surface expression
is an insufficient indicator of T cell trafficking [
52
].
Significant involvement of T lymphocytes in hepatic I/R was first demonstrated in 1997 in a report, which found that T lymphocytes accumulated rapidly in the liver after reperfusion [53
]. This study showed that CD4, but not CD8, T lymphocytes were recruited into the postischemic liver within 1 h of reperfusion. The briskness of this response is surprising, as it preceded the influx of innate immune cells to the injured tissue. Later, studies by our group confirmed this rapid recruitment of CD4 T cells [54
]. The mechanisms by which T cells are recruited so rapidly to the postischemic liver remain undefined. However, other studies have shown that hepatic expression of MCP-1, MIP-1
, MIP-1ß, MIP-2, RANTES, and IFN-inducible protein 10 (IP-10) is up-regulated 24 h after liver I/R [55
]. A summary of potential chemokines produced specifically during liver I/R and their receptors is listed in Table 2
. Most of the up-regulated chemokines are chemotactic to neutrophils and monocytes, except for RANTES, which is specific for T cells and has been implicated in lymphocyte recruitment to the liver [65
]. RANTES has been proposed as a major mediator of antigen-independent T lymphocyte activation [66
]. RANTES can initiate T lymphocyte signaling directly, initially, via a G protein-coupled pathway and later, via activation of a tyrosine kinase pathway [67
]. Other chemokine transcripts found to be elevated after liver I/R injury are CXCL9, -10, and -11, which are induced by IFN-
and attract activated T lymphocytes and NK cells by binding to CXCR3 receptors [68
].

REGULATION OF NEUTROPHIL RECRUITMENT BY CD4 T CELLS
As mentioned above, CD4 lymphocytes are recruited into the postischemic
liver long before any appreciable neutrophil accumulation. Antibody
depletion of CD4 T cells and CD4 knockout mice showed reduced
liver recruitment of neutrophils after I/R [
53
,
54
]. The mechanism
by which CD4 T cells regulate subsequent neutrophil accumulation
appears to be related to their release of IL-17 (
Fig. 1
), which
is preferentially expressed and secreted by activated CD4 lymphocytes
[
69
]. Furthermore, in a model of peritoneal inflammation, IL-17
was found to mediate neutrophil recruitment by increasing the
production of the chemokines MIP-2 and KC by the peritoneal
mesothelium [
70
]. IL-17 has also been shown to induce CXC chemokine
production by other cell types, including epithelial cells,
fibroblasts, osteoblasts, and endothelial cells [
71
72
73
].
Our studies found that production of the CXC chemokine MIP-2
was decreased in CD4 knockout mice and that in wild-type mice
treated with anti-IL-17 antibodies, MIP-2 production was also
reduced [
54
]. In both of these experiments, liver neutrophil
accumulation was also reduced. Moreover, adoptive transfer of
CD4 lymphocytes into CD4 knockout mice resulted in dramatic
increases in the expression of MIP-2 and the degree of liver
neutrophil recruitment [
54
]. Thus, it would appear that CD4
lymphocytes are an important regulator of hepatic neutrophil
recruitment during liver I/R and that this occurs via their
release of IL-17
(Fig. 1)
.

ANTIGENIC AND NONANTIGENIC STIMULATION OF T CELLS DURING LIVER I/R
The question of whether T cell involvement in liver I/R is driven
by antigenic or nonantigenic mechanisms has not been elucidated.
Some studies show that use of MHC II-blocking antibodies has
no effect on serum alanine transaminase following hepatic I/R
[
74
]. This study suggested that T cells play a beneficial role
not involving the

ß TCR and that lymphocyte actions
occur through a nonantigenic mechanism. It is well established
that during hepatic I/R, inflammatory cytokines such as IL-12
and IL-18 are expressed rapidly [
75
,
76
]. Furthermore, non-naive
as well as unconventional T cells can be functionally activated
by these cytokines in a manner independent of TCR engagement
[
77
78
79
]. Taken collectively, these studies suggest the possibility
of nonantigenic activation of T cells during the initial stages
of I/R in the liver. Alternatively, recent studies in other
models of I/R have discovered the presence of an IgM, which
reacts with self-antigens generated by damaged tissues [
80
,
81
]. These self-reactive IgMs activate the classical pathway
of complement and contribute substantially to the initiation
of the injury response. A similar mechanism may be applicable
to liver I/R but to date, has not been examined.
To successfully mount an immune response to an antigen, T lymphocytes need to receive two different signals. The first signal is delivered by the antigen upon its binding to the TCR. This antigen-specific event is usually termed signal one. The second signal, signal two, is costimulation delivered by APC and is a nonantigen-specific event. There are a large number of different costimulatory molecules, and they vary greatly in their expression patterns and function [82
]. One of the most widely studied, costimulatory pathways is the CD40-CD154 pathway. CD40 is a member of the TNF receptor superfamily and is expressed on APC such as DC, macrophages, and B cells. Ligation of CD40 by its cognate ligand CD154 (which is transiently expressed on activated Th cells) leads to costimulation of the target cell. Specifically, during liver I/R, it has been shown that gene therapy-mediated CD154 blockade (Ad-CD40 Ig), antibody-induced systemic CD154 blockade (MR1 mAb), and genetically targeted CD154 absence (CD154 KO mice) ameliorated otherwise fulminant injury in a warm liver I/R model [83
]. These beneficial effects resulting from the disruption of CD154-CD40 signaling were accompanied by diminished liver T cell sequestration, decrease of vascular endothelial growth factor (VEGF) expression, inhibition of TNF-
and Th type 1 cytokine production, and induction of antiapoptotic (Bcl-2/Bcl-xl) and depression of proapoptotic (caspase-3) proteins.
Another costimulatory pathway studied widely is the CD28/CD80/86 pathway. CD28 is constitutively expressed on T cells. The ligands for CD28 are CD80 and CD86 (B7-1, B7-2), members of the Ig superfamily, which are transiently expressed on activated APC. CD80 and CD86 are increased in the liver after I/R [84
, 85
]. Ligation of CD28 by these molecules in conjunction with antigen recognition via the TCR complex leads to activation of the T cell. An additional feature of this pathway is the existence of an alternative receptor for CD80/86—CD152 (CTLA-4)—which unlike CD28, is up-regulated after T cell activation and results in suppressive T cell function. Indirect evidence for a critical role for T cells in kidney I/R came from blocking one of the costimulatory pathways necessary for T cell activation. Blocking the B7-CD28 costimulation pathway by CTLA-4 Ig, a recombinant fusion protein, containing the extracellular domain of human CTLA-4 (a homologue of CD28), resulting in T cell anergy, ameliorated renal dysfunction and decreased mononuclear cell infiltration in a model of renal cold ischemia [86
]. It has yet to be elucidated whether such treatment during liver I/R would yield similar results.
The liver sinusoidal endothelial cell (LSEC) has been described as a new type of APC, which resides in the liver [87
, 88
]. LSEC are also believed to express the costimulatory moieties CD40, CD80, and CD86 and stimulate T cells through peptide presentation in the context of MHC Classes I and II molecules [80
, 89
]. This would allow endothelial activation by T cells and vice versa, as a result of TCR-MHC and CD40-CD154- or CD28-B7-dependent pathways. However, in a contrary report, which compared LSEC and DC directly, it was found that LSEC expressed surface markers only reflective of an endothelial phenotype. Further, highly purified LSEC had undetectable levels of the costimulatory receptors CD40, CD80, and CD86 and only minimal MHC Class II. This report concluded that LSEC are poor stimulators of T cells, but other properties, such as their high capacity for antigen uptake and direct access to circulating lymphocytes, may enable them to contribute to the unique, immunologic function of the liver [90
].

EFFECT OF ISCHEMIA ON T CELL FUNCTION DURING LIVER I/R
Immune cells are exposed to different oxygen tensions, including
hypoxia, as they develop, migrate, and function in primary,
secondary, and tertiary lymphoid organs with different infrastructure,
vasculature, and oxygen supply [
91
]. Hypoxic extracellular
environments occur in some normal tissues and during chronic
inflammation and ischemia. The mechanisms of lymphocyte adaptation
to hypoxia are likely to exist under such conditions. Cell adaptation
to hypoxia is accomplished partially by the transcriptional
activity of hypoxia-inducible factor-1 (HIF-1), which is a basic
helix–loop–helix/Per-aryl hydrocarbon receptor nuclear
translocator (ARNT)-Sim protein consisting of HIF-1

and HIF-1ß
subunits. HIF-1

activates the transcription of genes required
for glucose metabolism, erythropoiesis, vascularization, and
cell proliferation by binding to a
cis-acting hypoxia-response
element. The HIF-1

subunit may also affect cell metabolism and
signaling by its ability to interact directly with other proteins
such as p53, heat shock protein 90, and receptor for activated
C kinase 1. Multiple roles of HIF-1 as a transcriptional factor
and in protein–protein interactions complicate the understanding
of its role in vivo. The HIF-1ß subunit is also known
as ARNT and serves as a heterodimerization partner for other
transcription factors [
92
]. Oxygen-sensing mechanisms and the
subsequent regulation of HIF-1 expression are the subject of
intensive investigations. It has been shown that protein stability
plays the most important role in control of HIF-1

expression.
At high oxygen tensions, HIF-1

is targeted for destruction by
an E3 ubiquitin ligase containing the von Hippel-Lindau tumor-suppressor
protein (pVHL). In the currently accepted model, pVHL binds
to the oxygen-dependent degradation domain located in the central
region of HIF-1, which results in a subsequent degradation of
HIF-1

, mainly expressed under hypoxic conditions, but there
is also evidence for the accumulation of HIF-1

under some normoxic
conditions. These include the stabilization and transactivation
of HIF-1

by reactive nitrogen- or oxygen-derived species radicals
(RNS and ROS, respectively) [
93
], cytokines (TNF-

and IL-1ß)
[
94
], growth factors, such as the insulin growth factor [
95
],
and TCR activation [
92
] (
Fig. 2
). To study the effects of
HIF on T cell signaling, Turka and co-workers [
96
] examined
T cells lacking the gene encoding pVHL,
Vhlh. As germ-line deficiency
in
Vhlh results in embryonic lethality, mice were used containing
a conditional
Vhlh 2-
lox allele. Deletion of
Vhlh alone forces
oxygen-independent stabilization of HIF-1

at an early point
in T cell ontogeny and induces transcription of HIF-responsive
genes. The results suggest that hypoxic- and nonhypoxic-mediated
HIF stabilization may minimize the strength and duration of
Ca
2+ signaling by means of acceleration of cytoplasmic Ca
2+ clearance. In lymphocytes, changes in Ca
2+ signaling can mediate
lymphocyte homeostasis and function [
97
,
98
]. Thus, the hypoxic
environment during liver ischemia likely modulates T cells,
at least in part, through the actions of HIF-1

.

HYPOXIA, ADENOSINE, AND T LYMPHOCYTE FUNCTION
Even short periods of hypoxia lead to the enhanced breakdown
of adenine nucleotides to adenosine because of the decreased
production of ATP and accumulation of AMP, which can be metabolized
further to adenosine through dephosphorylation by the cytosolic-5'-nucleotidase.
In addition to the substrate-dependent formation of adenosine
via cytosolic- and ecto-nucleotidases, the extracellular adenosine
concentrations may be potentiated further by preventing its
reuse through the inhibition of salvage pathways, i.e., hypoxia-dependent
inhibition of the enzyme, adenosine kinase, which rephosphorylates
the nucleoside to AMP [
99
]. This could be a significant source
of extracellular adenosine in conditions of deep hypoxia. In
the myocardium, for instance, adenosine formation is directly
proportional to the AMP concentration. Under normoxic conditions,
the adenosine formed is, in part, converted back into AMP by
phosphorylation via the enzyme adenosine kinase. As the metabolic
cycle between AMP and adenosine usually has a high turnover
rate, any decrease in the adenosine kinase activity will translate
automatically into enhanced adenosine formation, even when AMP
concentrations are increased only slightly, e.g., by hypoxia
[
99
].
Studies about the potential role of extracellular adenosine in inflammation were facilitated by identification of four types of adenosine receptors. The A1 and A3 receptors are Gi protein-coupled, and A2a and A2b are Gs protein-coupled receptors, which can activate adenylate cyclase and cause accumulation of intracellular cAMP [100
]. Accumulation of adenosine during ischemia and inflammation can protect normal tissues from injury as a result of suppressive signaling through adenosine receptors (Fig. 2)
. mRNA expression studies strongly suggest that the A2aR is the major functional adenosine receptor, which attenuates activation of immune cells [101
]. Further, A2aRs have been shown to play a nonredundant role in the down-regulation of acute inflammation [102
].
Abundant evidence strongly suggest that adenosine, through the A2aR, can inhibit peripheral T cell activation, proliferation, and production of inflammatory cytokines while enhancing the production of anti-inflammatory cytokines in these cells [92
, 103
]. During liver I/R, the use of an A2aR-selective agonist, ATL146e, as well as a selective A2aR antagonist, ZM241385, and deletion of the A2aR gene show convincingly that A2aR activation during reperfusion reduces murine liver I/R greatly [56
]. ATL146e attenuated liver damage and inflammation, as assessed by serum glutamic pyruvic transaminase, edema, myeloperoxidase, histology, immunohistochemistry, and the reduced induction of proinflammatory cytokine and chemokine transcripts [104
, 105
]. A2aR agonist treatment during reperfusion can be delayed for up to 1 h with little attenuation of protection. This suggests that A2aR agonist-mediated protection occurs downstream of oxygen radical production, which occurs early after reperfusion. It was shown further that activation of the A2aR on bone marrow-derived cells is primarily responsible for protecting the liver from reperfusion injury.

CONCLUSIONS
Only the spleen surpasses the liver in terms of the number and
variety of leukocytes. As such, the liver can be considered
a quasi-lymphoid organ. Of the leukocytes found within the liver,
lymphocytes have been shown recently to play a role in I/R,
although the mechanism by which this occurs remains to be elucidated
fully. Initially, during I/R, it appears that resident lymphocytes
modulate inflammation by the production of cytokines, such as
IFN-

, IL-4, and/or IL-17, as well as the production of chemokines
such as IP-10 and RANTES. Expression of these mediators will
then result in the recruitment of more lymphocytes and neutrophils.
As the phenotype of the recruited T cells has not been determined,
the role of these cells in liver I/R is unclear. Finally, the
most current evidence suggests that the actions of lymphocytes
are occurring through a mechanism, which does not involve the
ligation of a conventional

ß or unconventional


TCR.
However, published data do not rule out the involvement of NKT
cell interactions with the restricted CD1d MHC. Thus, it seems
likely that lymphocyte actions are triggered by paracrine signals
induced by the postischemic milieu.
Received January 24, 2007;
revised April 4, 2007;
accepted April 9, 2007.

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