BASIC AND EXPERIMENTAL RESEARCH
Erythropoietin Increases Survival and Attenuates
Fulminant Hepatic Failure Injury Induced by
D-Galactosamine/Lipopolysaccharide in Mice
Ziv Ben-Ari,
1,2,3,8
Veacheslav Zilbermints,
4,3
Orit Pappo,
5
Orna Avlas,
2
Eran Sharon,
5,3
Franklin Greif,
5,3
Yelena Cheporko,
2
Amiram Ravid,
3,6
Rivka Shapiro,
3,7
and Edith Hochhauser
2,3
Background. Liver transplantation is the only therapy of proven benefit in fulminant hepatic failure (FHF). Lipopoly-
saccharide (LPS), D-galactosamine (GalN)-induced FHF is a well-established model of liver injury in mice. Erythro-
poietin has a powerful tissue-protective effect in animal models. The aim of this study was to investigate the effect and
mechanism of recombinant human erythropoietin (rhEPO) administration in FHF mice.
Methods. C57BL/6 (n42) mice were studied in vivo in a fulminant model induced by GalN/LPS. rhEPO was admin-
istered 30 min after the induction of FHF. Serum liver enzymes and hepatic tumor necrosis factor (TNF)- and
interleukin (IL)-1 levels were determined. Histologic analysis was performed, and apoptotic cells were identified by
immunohistochemistry for caspase-3. Nuclear factor (NF)-B and c-Jun-N-terminal kinase (JNK) activation were
studied using Western blot analysis.
Results. After the induction of FHF, all control mice died within 12 hr of GalN/LPS administration. However, 83% of
mice that were administered rhEPO were alive 2 weeks later, and overall survival improved (Kaplan-Meier, P0.001).
The serum liver enzymes, hepatic TNF- and IL-1 levels, liver histologic injury, and apoptotic hepatocytes were
significantly reduced in FHF mice that were administered rhEPO compared with untreated mice. A significant decrease
in hepatic NF-B and JNK activation was noted in FHF rhEPO-treated mice compared with FHF untreated mice.
Conclusions. The administration of rhEPO brought about increased survival and attenuation of the hepatic injury.
This was associated with decreased hepatic NF-B and JNK activation and thus TNF- and IL-1 levels. These findings
have important implications for the potential use of rhEPO in FHF.
Keywords: Erythropoietin, Fulminant hepatic failure, TNF-, NF-B, JNK.
(Transplantation 2011;92: 18–24)
F
ulminant hepatic failure (FHF) is a rare clinical syndrome
with multiple causes. The course of FHF is variable, and
the mortality rate is high (1). Liver transplantation is the only
therapy that has been proven beneficial, but the rapidity of
progression and the variable course of FHF limit its applica-
tion. Moreover, effective use of this limited resource requires
accurate prognostication and subsequent lifelong immuno-
suppression (1). In the United States, spontaneous survival of
FHF occurs in approximately 45%, in 25% of liver transplan-
tations and in 30% mortality without transplantation, of
adults with FHF (1).
Sepsis and endotoxemia are frequent complications
that occur in up to 80% of patients with FHF (2). Endotoxin
is a Gram-negative bacterial lipopolysaccharide (LPS) that
releases a wide variety of inflammatory mediators, which are
considered to be related to the development of FHF and to
multiple organ failure (3, 4). D-Galactosamine (GalN) to-
gether with LPS injection has often been used as an animal
model of FHF (3, 4). Mice treated with a combination of
LPSGalN selectively develop hepatic failure, which is much
1
Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah Tikva,
Israel.
2
Cardiac and Liver Research Laboratory, Felsenstein Medical Research
Center, Petah Tikva, Israel.
3
Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
4
Department of Surgery A, Rabin Medical Center, Beilinson Hospital, Petah
Tikva, Israel.
5
Department of Histopathology, Rabin Medical Center, Beilinson Hospital,
Petah Tikva, Israel.
6
Laboratory for Endocrine Immunology, Felsenstein Medical Research
Center, Petah Tikva, Israel.
7
Institute of Gastroenterology, Nutrition and Liver diseases, Schneider
Children’s Medical Center of Israel.
8
Address correspondence to: Ziv Ben-Ari, M.D., Liver Institute, Rabin Med-
ical Center, Beilinson Hospital, Petah Tikva 49100, Israel.
E-mail: gbenari@bezeqint.net
Z.B.-A. participated in research design, writing of the manuscript, perfor-
mance of the research, and data analysis; V.Z., O.P., E.S., Y.C., and A.R.
participated in the performance of the research and data analysis; O.A.
participated in the performance of the research and in data analysis; F.G.
contributed new reagents and analytic tools; R.S. participated in research
design and data analysis; and E.H. participated in research design,
writing of the manuscript, performance of the research, and data analysis
and contributed new reagents and analytic tools.
Received 28 December 2010. Revision requested 17 January 2011.
Accepted 27 March 2011.
Copyright © 2011 by Lippincott Williams & Wilkins
ISSN 0041-1337/11/9201-18
DOI: 10.1097/TP.0b013e31821cdea5
18 | www.transplantjournal.com Transplantation • Volume 92, Number 1, July 15, 2011