Potential conflict of interest: Nothing to report.
Macrophage migration inhibitory factor (MIF), a multipotent protein that exhibits both cytokine and chemotactic properties, is expressed by many cell types, including hepatocytes and nonparenchymal cells. We hypothesized that MIF is a key contributor to liver injury after ethanol exposure. Female C57BL/6 or MIF−/− mice were fed an ethanol-containing liquid diet or pair-fed control diet for 4 (11% total kcal;early response) or 25 (32% kcal; chronic response) days. Expression of MIF messenger RNA (mRNA) was induced at both 4 days and 25 days of ethanol feeding. After chronic ethanol, hepatic triglycerides and plasma alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were increased in wildtype, but not MIF−/−, mice. In order to understand the role of MIF in chronic ethanol-induced liver injury, we investigated the early response of wildtype and MIF−/− to ethanol. Ethanol feeding for 4 days increased apoptosis of hepatic macrophages and activated complement in both wildtype and MIF−/− mice. However, tumor necrosis factor alpha (TNF-α) expression was increased only in wildtype mice. This attenuation of TNF-α expression was associated with fewer F4/80+ macrophages in liver of MIF−/− mice. After 25 days of ethanol feeding, chemokine expression was increased in wildtype mice, but not MIF−/− mice. Again, this protection was associated with decreased F4/80+ cells in MIF−/− mice after ethanol feeding. Chronic ethanol feeding also sensitized wildtype, but not MIF−/−, mice to lipopolysaccharide, increasing chemokine expression and monocyte recruitment into the liver. Conclusion: Taken together, these data indicate that MIF is an important mediator in the regulation of chemokine production and immune cell infiltration in the liver during ethanol feeding and promotes ethanol-induced steatosis and hepatocyte damage. (HEPATOLOGY 2013)
Long-term excessive alcohol consumption can lead to alcoholic liver disease (ALD).1 ALD is one of the leading causes of preventable death and accounts for ∼4% of global mortality. In the United States, ALD is responsible for more liver-related mortalities than hepatitis C viral (HCV) infection.2 The clinical presentation of ALD is variable. Most chronic alcohol abusers accumulate fat in their liver, which can lead to further progression to varying degrees of hepatic inflammation, cell death, and fibrosis in some individuals.
The liver is an important innate and adaptive immune organ with a broad range of actions involving both cellular and soluble factors. This complex, dynamic organ houses a large population of natural killer, natural killer T cells, and Kupffer cells and is the principal site of production of complement proteins, as well as other molecules important for orchestrating an immune response.3 The essential role of Kupffer cell activation and sensitization in ALD has been well characterized.4
In addition to the contribution of cellular components of the innate immune system to ALD, soluble innate immune factors were first identified as key factors in the progression of ALD when Yin et al.5 found that tumor necrosis factor receptor-1 −/− mice are protected from injury associated with long-term ethanol feeding. Chronic excessive alcohol consumption also leads to increased endotoxin load in the liver, which induces TLR4-TRIF-dependent responses in Kupffer cells.6 The role of the complement system in the progression of ethanol-induced liver injury has also been investigated. Ethanol exposure increases activation of complement, indicated by increased C3a in the serum and C3b/iC3b/C3c deposition in liver.7 Mice deficient in C3 or C5 are protected from ethanol-induced liver injury.7, 8
While these insights into the role of innate immune mediators are critical for understanding the progression of ALD, emerging evidence indicates chemokines also play a critical role in disease pathogenesis. Mandrekar et al.9 reported that monocyte chemotactic protein-1 (MCP-1) is essential for macrophage activation, production of inflammatory mediators, and hepatic steatosis after ethanol feeding in mice. In addition to the strong correlation between ALD and increases in proinflammatory mediators, these data bring forth the possibility that additional chemokines may play a major role in disease progression.
Here we investigated the role of one such chemokine, macrophage migration inhibitory factor (MIF), in the development of ethanol-induced liver injury. MIF is a multipotent protein that exhibits cytokine, chemokine, and hormonal characteristics. It is constitutively expressed and stored in preformed intracellular pools that are rapidly released upon stimulation. MIF binds to CD74, which forms heterodimeric complexes with CD44 and CXCR2/CXCR4.10 MIF released from liver stimulates peritoneal macrophages to release TNF-α and interleukin (IL)1β.11 MIF also stimulates release of MCP-1 from endothelial cells and recruits monocytes by way of CCR2 signaling.12 MIF is an important contributor to many diseases including various cancers, sepsis, and a number of liver pathologies.13 Patients with liver cirrhosis and hepatocellular carcinoma have increased serum levels of MIF. Additionally, there is a positive correlation between MIF expression and necro-inflammation in liver of patients with hepatitis B viral infection.14 Akyildiz et al.15 provided evidence that increased MIF expression in the liver is due to infiltrating monocytes in patients with nonalcoholic steatohepatitis (NASH). Importantly, the serum concentration of MIF is increased in ALD patients and positively correlates with concentration of serum transaminases.16, 17
Since MIF is a multipotent regulator of innate immune responses, we hypothesized that MIF is a critical mediator of ALD pathogenesis. If MIF functions as a chemoattractant during ethanol exposure, recruiting monocytes to the liver and regulating proinflammatory responses, then MIF−/− mice should be protected from chronic ethanol-induced liver injury. Indeed, ethanol feeding to wildtype mice increased MIF expression in liver and concentration in the plasma, as well as enhanced the recruitment of peripheral monocytes to the liver. In contrast, ethanol feeding to MIF−/− mice decreased F4/80+ cells and did not elicit recruitment of peripheral monocytes. This change in monocyte population in the liver was associated with protection of MIF−/− mice from chronic ethanol-induced hepatic steatosis, proinflammatory cytokine production, and sensitization to lipopolysaccharide (LPS).
Eight to 10-week-old female mice were used to perform the following studies. C57BL/6 or 129/Sv-C57BL/6 mice were purchased from the Jackson Laboratory (Bar Harbor, ME). MIF−/− mice on a C57BL/6 background were obtained from Dr. R. Bucala (Yale University, New Haven, CT)18 and a breeding colony was established at the Cleveland Clinic Foundation (CCF). CYP2E1−/− mice on a 129/Sv-C57BL/6N mixed background were obtained from Dr. A. Cederbaum (Mount Sinai School of Medicine, New York, NY) and used to establish a breeding colony at CCF.
All procedures involving animals were approved by the Cleveland Clinic Institutional Animal Care and Use Committee. Mice were housed in plastic cages with microisolator lids. Animals were fed 5.5% (total kcal) ethanol for 2 days, 11% for 2 days (4 days), 22% for 1 week (11 days), 27% for 1 week (18 days), and finally 32% for 1 week (25 days). Control mice were pair-fed an identical liquid diet except the diet is isocalorically substituted with maltose dextrans in place of ethanol.8, 19 See Supporting Materials for additional details.
Blood was drawn from mice by way of the vena cava and placed on ice. Plasma was collected by centrifugation for 2.5 minutes at 10,000g. Samples were denatured in Laemmli buffer for western blot analysis and then stored at −20°C. Plasma (2 μL) samples were loaded onto 4%-12% reducing sodium dodecyl sulfate (SDS)-polyacrylamide gradient gels. MIF antibody (Torrey Pines Biolabs, Secaucus, NJ) was used at 1:500 in 1% bovine serum albumin to detect immunoreactive protein using enhanced chemiluminescence, images were collected, and signal intensities were quantified using Eastman Kodak Image Station 4000R.
RNA Isolation and Quantitative Real-Time Polymerase Chain Reaction (qRT-PCR).
RNA was isolated from liver, reverse transcribed, and analyzed by way of qRT-PCR. Data were collected using a Stratagene Mx3000P thermal cycler (Agilent Technologies, Santa Clara, CA). Relative messenger RNA (mRNA) expression was determined by comparing expression levels of target mRNA to 18S rRNA. Statistical analyses were performed on the ΔCt values (mean Ct from gene of interest − mean Ct from 18S).20
Immunohistochemical analysis of F4/80, C3b/iC3b/C3c, and Ly6c was performed using optimal cutting temperature (OCT) frozen liver sections. Staining for immunoreactive MIF and 4-hydroxynonenol adducts was performed in paraffin-embedded liver sections. Terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) positive staining in liver was analyzed using the ApopTag plus In Situ Apoptosis Detection Kit (S7111, Millipore, Billerica, MA).
Hematoxylin and eosin-stained liver sections were examined and assigned an inflammatory score by a liver pathologist (Xiuli Liu, M.D., Anatomic Pathology, Cleveland Clinic, Cleveland, OH). Total inflammatory scoring included both the degree of lobular inflammation in clusters and mononuclear cell infiltration with a diffuse distribution.
Liver nonparenchymal cells (NPCs) were isolated from wildtype and MIF−/− mice, stained with fluorochrome-conjugated CD45, CD11c, and Ly6C. See Supporting Information for additional details.
Values are reported as means ± standard error of the mean (SEM). Multiple feeding trials were performed and combined for final data analysis. Data were analyzed by analysis of variance (ANOVA) using general linear models procedure (SAS, Cary, NC). If data were not normally distributed, data were log transformed. Multiple comparisons were analyzed using least square means.
Chronic Ethanol Feeding Induces Expression of MIF in the Liver and Causes Liver Steatosis and Liver Injury in Mice.
MIF is produced in the liver and multiple cell types in the liver can respond to MIF by way of interaction with its receptor CD74. Ethanol feeding to wildtype mice increased the expression of MIF mRNA in liver at 4 days, 11% (kcal) ethanol compared to pair-fed mice; this increase was maintained over 25 days, 32% (kcal) ethanol (Fig. 1A,B). In contrast, ethanol feeding had no effect on hepatic expression of CD74 mRNA. The content of MIF in the plasma was also increased after 25 days, 32% ethanol feeding in wildtype mice (Fig. 1C), consistent with previous reports that ethanol feeding to rats increases circulating MIF.21 MIF was localized to both parenchymal and nonparenchymal cells in the liver indicated by diffuse immunohistochemical staining in both control and ethanol-fed mice (Fig. 1D). MIF and CD74 were detected by western blot in both parenchymal and nonparenchymal cell populations isolated from liver of control and ethanol-fed mice (Fig. 1E).
If MIF contributes to the pathophysiological effects of ethanol, then mice deficient in MIF should be protected from ethanol-induced liver injury. Wildtype and MIF−/− mice were allowed free access to the Lieber-DeCarli ethanol diet for 25 days, 32% or pair-fed control diets. Ethanol increased hepatic triglycerides, as well as activity of plasma ALT and AST, in wildtype mice compared to pair-fed controls; this response was reduced in MIF−/− mice (Fig. 2A). Chronic ethanol feeding also increased the number of TUNEL-positive hepatocyte nuclei in liver of wildtype mice, but not MIF−/− mice (Fig. 2B), indicating that MIF was required for chronic ethanol-induced apoptosis of hepatocytes.
Protection from Chronic Ethanol-Induced Liver Injury in MIF−/− Mice Is Independent of Ethanol Intake or Metabolism.
Protection from chronic ethanol-induced liver injury in MIF−/− mice was not due to differences in ethanol intake or metabolism. Wildtype and MIF−/− mice had similar intakes of ethanol-containing diet (data not shown). Plasma ethanol concentrations were similar between wildtype and MIF−/− mice when measured 90 minutes after an oral gavage of ethanol to mice never before exposed to ethanol, as well as 2 hours into the dark cycle on 23-day, 32% ethanol feeding (Supporting Fig. 1). Induction of CYP2E1 in the liver was similar after chronic ethanol feeding in both wildtype and MIF−/− mice (Fig. 2C). Consistent with the equivalent increase in CYP2E1 expression between genotypes, accumulation of 4-hydroxynonenol (4HNE) adducts in the liver, an indicator of oxidant stress, during ethanol feeding was independent of genotype (Fig. 2D).
Maintenance of Kupffer Cells and TNF-α Production Are MIF-Dependent During Early Ethanol Feeding.
To understand the mechanisms by which MIF contributes to chronic ethanol-induced liver injury, early inflammatory responses were evaluated in wildtype and MIF−/− mice after 4 days, 11% ethanol feeding. Ethanol feeding increased TUNEL-positive nuclei in the liver of both wildtype and MIF−/− mice at 4 days, 11% ethanol feeding (Fig. 3A). In contrast to apoptosis of hepatocytes at 25 days, 32% ethanol feeding, the distribution of TUNEL-positive cells to the hepatic sinusoid indicated the apoptotic death of Kupffer cells at this early timepoint. This was confirmed by colocalization of TUNEL+ nuclei with F4/80+ cells (Supporting Fig. 3E). These data are similar to previous reports of Kupffer cell apoptosis, rather than hepatocytes, early in the response to ethanol. Complement activation, assessed by the accumulation of immunoreactive C3b/iC3b/C3c in the liver, was also detected after 4 days, 11% ethanol in both wildtype and MIF−/− mice (Fig. 3B). However, while 4 days, 11% ethanol feeding increased TNF-α production in wildtype mice, MIF−/− mice were protected (Fig. 3C). These results suggest that while apoptosis of Kupffer cells and the activation of complement induced by early ethanol feeding is independent of MIF, increased expression of TNF-α by early ethanol feeding resulted from an MIF-dependent mechanism.19
MIF Mediates Early and Chronic Ethanol-Induced Macrophage/Monocyte Replenishment and Recruitment.
Because of MIF's potent chemokine activity, we hypothesized that decreased TNF-α expression in the MIF−/− mice after 4 days, 11% ethanol feeding could be due to a failure to repopulate the liver with macrophages after the ethanol-induced apoptosis of resident Kupffer cells. To test this hypothesis, expression of F4/80, a macrophage marker, was measured in wildtype and MIF−/− mice. The quantity of F4/80 mRNA and protein expression was not affected by genotype in pair-fed controls (Fig. 3D,E). However, the response to ethanol feeding differed by genotype. In wildtype mice, ethanol feeding for 4 days, 11% had no affect on F4/80 mRNA; however, F4/80 mRNA was reduced after ethanol feeding in MIF−/− mice (Fig. 3D). Similarly, the number of F4/80+ cells in the liver was not affected by ethanol feeding in wildtype mice, but was reduced in MIF−/− mice (Fig. 3E). These data suggest that MIF was required to maintain macrophage populations in the liver during the early response to ethanol.
If MIF is required to replenish Kupffer cells after ethanol feeding, MIF−/− mice should exhibit sustained depletion of macrophages during chronic ethanol feeding. Similar to 4 days, 11% ethanol feeding, both expression of F4/80 mRNA and the number of F4/80+ cells was sustained in wildtype mice after 25 days, 32% ethanol feeding. However, MIF−/− mice expressed less F4/80 mRNA and had fewer F4/80+ cells after 25 days, 32% ethanol feeding (Fig. 4A,B).
In order to better characterize the effect of chronic ethanol feeding on monocyte populations in the liver, nonparenchymal cells were analyzed by way of flow cytometry. The number of CD45+ cells (total leukocytes) was increased in wildtype mice after chronic ethanol feeding, but no increase was seen in MIF−/− mice (Fig. 4C). This CD45+ population included large proportions of CD11c+ and Ly6C+ cells after 25 days, 32% ethanol feeding in wildtype mice; however, the number of CD11c+ and Ly6C+ cells in MIF−/− mice was not affected by ethanol feeding (Fig. 4C/D). To determine the cellular origin of the Ly6C+ cells, NIMP14, a marker of neutrophils, was examined to distinguish infiltrating mononuclear and polymorphonuclear cells. The number of NIMP14+ cells was not influenced by diet or genotype either after 25 days, 32% ethanol feeding (Supporting Fig. 4A) or in response to 4-hour LPS challenge (Supporting Fig. 4B). These data therefore suggest that infiltrating Ly6C+ cells are likely of mononuclear cell origin.
Production of Proinflammatory Mediators and Chemokines Is Increased in Liver After Ethanol Feeding in an MIF-Dependent Manner.
Increased monocyte infiltration was associated with increased expression of proinflammatory mediators and chemokines after ethanol feeding. Toll-like receptor 4 (TLR4) and TNF-α gene expression was elevated in wildtype mice, but not in MIF−/− mice (Fig. 5A). MCP-1, a potent chemoattractant of macrophages and dendritic cells, CXCL10, which attracts monocytes, T cells and NK cells, and MIP-2, a chemoattractant produced by monocytes were investigated as potential contributors to monocyte infiltration. MCP-1, CXCL10, and MIP2 mRNA expression was increased in wildtype mice after chronic ethanol feeding (Fig. 5B). MIF−/− mice were protected from ethanol-induced expression of these chemokines.
MIF Mediates Sensitization to LPS Challenge in Mice After Chronic Ethanol Feeding.
To determine if MIF contributes to more severe, acute inflammation, similar to that observed in alcoholic steatohepatitis (ASH), wildtype and MIF−/− mice were challenged with LPS 4 hours prior to euthanasia after chronic ethanol feeding. After LPS challenge, pair-fed wildtype mice exhibited some total liver inflammation, as measured by mononuclear cell infiltration and lobular inflammation (Fig. 6B); chronic ethanol-feeding exacerbated this response (Fig. 6A, black arrows). In contrast, MIF−/− mice were less prone to liver inflammation both in pair- and ethanol-fed mice (Fig. 6B). Increased liver inflammation in wildtype mice was coupled with enhanced chemotactic activity in LPS-challenged mice. MCP-1, intercellular adhesion molecule 1 and E-selectin (CD62E) mRNA expression was exacerbated after chronic ethanol and LPS; however, MIF−/− mice were not sensitized to challenge with LPS after chronic ethanol feeding (Fig. 6C).
MIF was originally described as a T-cell-derived factor that inhibited macrophage movement.22 Since its original discovery, it has become clear that MIF is a multipotent cytokine/chemokine that contributes to many proinflammatory responses in various pathogenic states including sepsis, colitis, metabolic disorders, and multiple types of arthritis.23 Here we provide the first evidence that MIF plays a major role in the progression of ethanol-induced liver injury. Ethanol exposure increased the expression of MIF mRNA in the liver, as well as the concentration of MIF in the circulation. MIF was involved in both the early and chronic innate immune responses in the liver after ethanol feeding (summarized in Fig. 7).
The mechanisms for the progression of ethanol-induced liver injury are complex and dynamically regulated over time and hepatocellular location. Very early in the innate immune response to ethanol, there is an increase in apoptosis of Kupffer cells in the liver.19 This increase in Kupffer cell apoptosis elicits activation of the classical complement pathway and an increase in inflammatory cytokine production.8 One important activity of MIF is to decrease activation-induced apoptosis of Kupffer cells by way of p53 inhibition.18 However, since TUNEL+ nuclei were equivalent between wildtype and MIF−/− mice, it is unlikely that MIF plays a role in this early ethanol-induced apoptosis of Kupffer cells.
During chronic ethanol feeding, MIF was required to elicit the infiltration of non-Kupffer cell monocyte populations and to maintain Kupffer cell numbers in the liver. MIF was critical for infiltration of CD11c+ and Ly6C+ monocytes in wildtype mice after chronic ethanol feeding. Ethanol feeding decreases splenic dendritic cells, without decreasing numbers of dendritic cell precursors, differentiation, or turnover in mice,24 suggesting that dendritic cells migrate from the spleen, a major reserve of monocytes,25 to the liver during ethanol feeding. In mouse models of NASH, increased MCP-1 production leads to recruitment of bone marrow-derived Ly6C+ monocytes to the liver.26 In ethanol-induced liver injury, expression of MCP-1 mRNA was increased in wildtype mice; this response was lost in MIF−/− mice. These data indicate MIF directly, and/or indirectly by way of MCP-1, recruits monocytes from peripheral immune reservoirs. While we cannot rule out the possibility of Kupffer cell proliferation, it is unlikely the maintenance of the Kupffer cell population was due to proliferation, as the data available suggest that proliferation occurs primarily in T-helper (Th)2 responses.27
MIF is produced by many cell types and may act in an endocrine and/or paracrine fashion. Ethanol feeding in mice increased expression of MIF mRNA in liver and protein content in plasma. MIF is expressed in both hepatocytes and infiltrating leukocytes in liver of patients with alcoholic hepatitis.16 In the present study, MIF and CD74 protein was detected in both hepatocytes and nonparenchymal cells; however, the precise cellular origin of MIF protein in the plasma cannot be determined. Neither MIF nor CD74 protein was increased by ethanol in isolated hepatocytes or nonparenchymal cells after 25 days, 32% ethanol feeding, despite the increased mRNA expression of MIF in the liver. Because MIF is stored in preformed pools and rapidly released, it is likely that during chronic inflammation MIF is expressed and then released into the circulation.
The mechanisms by which ethanol increases the expression and release of MIF are likely complex. While regulation of MIF expression and secretion is not well understood, recent studies have provided insights into possible mechanisms of control. For example, microRNA-451 directly interacts with the 3′ untranslated region (UTR) of MIF and regulates MIF expression.28 Further, Golgi-Associated Protein p115 is essential for releasing MIF from cytoplasmic pools. When p115 was depleted in human monocytes, MIF release into the extracellular environment also decreased.28 Additionally, cells stimulated with LPS in vitro secreted both MIF and p115 into their supernatant.29 CYP2E1−/− mice did not induce the expression of MIF mRNA after chronic ethanol feeding compared to wildtype mice (Supporting Fig. 2), suggesting that MIF induction is due, at least in part, to the metabolism of ethanol by way of CYP2E1. Another contributor to induction of MIF during ethanol exposure may be related to localized hypoxia in the liver during ethanol metabolism.30, 31 Ischemia-reperfusion, which results in hypoxia, is associated with increased serum MIF, as well as increased expression of MIF mRNA and protein.11 Further, MIF enhances its own expression under hypoxic conditions.30 Taken together, it is likely that ethanol metabolism by way of CYP2E1, in conjunction with localized ethanol-induced hypoxia in the liver, contribute to increased MIF expression during chronic ethanol feeding.
MIF contributes to the progression of ethanol-induced liver injury in mice at multiple stages of injury. MIF−/− mice were protected from steatosis and inflammation, as well as hepatocyte injury and hepatocyte apoptosis after chronic ethanol feeding. Interestingly, MIF is the second protein, along with MCP-1,9 with chemotactic activity to be associated with regulation of hepatic triglyceride accumulation after ethanol feeding. Here, the effect of MIF in decreasing ethanol-induced triglyceride accumulation may be a direct effect of MIF and/or indirect effect by way of regulation of the expression of MCP-1. These data are consistent with the growing body of evidence indicating a clear and critical link between innate immune function and the regulation of metabolic activity.32, 33
Here we used multiple models of ethanol exposure to investigate specific aspects of the pathophysiology of ALD. The mouse model of chronic ethanol feeding (25 days, 32% kcal) results in hepatic steatosis and modest inflammation, but does not model more severe ethanol-induced liver injury. One important clinical presentation of ALD is acute severe alcoholic hepatitis, which is presented clinically as steatosis, hepatocyte ballooning/injury, and acute, severe infiltration of mono/polymorphonuclear cells.34 Thus, in order to interrogate the role of MIF in more severe inflammation, a model of LPS challenge after chronic ethanol feeding was used to better model severe ASH. Ethanol feeding exacerbated chemokine expression, as well as expression of molecules regulating leukocyte trafficking, in response to challenge with LPS in wildtype mice. However, these responses were attenuated in MIF−/− mice, suggesting that MIF is required to recruit leukocytes to the liver in response to a stimulus with LPS. Enhanced expression of chemokines and cell adhesion molecules after chronic ethanol feeding and LPS challenge was associated with increased mononuclear cell infiltration in a diffuse distribution and lobular inflammation in clusters in wildtype mice. These responses were decreased, but not completely ameliorated, in MIF−/− mice. These data parallel a previous report that demonstrated leukocyte rolling and adhesion to TNF-α-stimulated endothelial cells is decreased in the absence of MIF.35
Here we provide evidence that MIF is essential for ethanol-induced liver injury progression; MIF contributes to hepatic injury in response to ethanol consumption at multiple stages in the pathophysiology of ALD and ASH. The primary role of MIF is associated with maintenance of resident hepatic macrophages, regulation of expression of proinflammatory and chemotactic mediators and recruitment of peripheral monocytes. In summary, these results indicate that MIF contributes to the pathophysiology of ethanol-induced liver injury in mice and suggest that inhibition of MIF activity with small molecule inhibitors of MIF, such as ISO-1,36 may be an important therapeutic approach to the treatment of ALD. Importantly, polymorphisms in the promoter of the MIF gene, notably −173 G/C and the numbers of CAAT repeats, are associated with increased expression of MIF and are associated with increased risk for numerous inflammatory conditions, including arthritis and ulcerative colitis.37 MIF is known to be induced by glucocorticoids, as well as act as a negative regulator to glucocorticoid mediated responses, working to maintain normal immune function despite increases in antiinflammatory signals. Therefore, it will also be important to consider whether polymorphisms in the MIF promoter constitute a genetic susceptibility to the development of ALD and/or resistance to glucocorticoid therapies in severe, acute ASH.
We thank Richard Bucala, MD, PhD (Yale University, New Haven, CT) and Arthur Cederbaum (Mount Sinai School of Medicine, New York, NY) for providing the MIF−/− and CYP2E1−/− mice, respectively. We also thank Dave Schumick (Center for Medical Art and Photography, Cleveland Clinic, Cleveland, OH) for contributing original artwork (Fig. 7), Dr. Prakash Ramachandran (University of Edinburgh, Edinburgh, UK) for providing a protocol for isolating nonparenchymal cells, and Denise Hatala (Imaging Core, Lerner Research Institute, Cleveland Clinic, Cleveland, OH) for assisting with frozen liver (OCT) F4/80 staining.