An Unexpected Role of Neutrophils in Clearing Apoptotic Hepatocytes In Vivo

Reviewer #1 (Public Review):

This study by Cao et al. demonstrates role of Neutrophil in clearing apoptotic hepatocytes by directly burrowing into the apoptotic hepatocytes and ingesting the effete cells from inside without causing inflammation. The authors applied intravital microscopy, Immunostaining and electron microscopy to visualize perforocytosis of neutrophil in hepatocytes. They also found that neutrophil depletion impairs the clearance of apoptotic hepatocytes causing impaired liver function and generation of autoantibodies, implying a role of defective neutrophil- mediated clearance of apoptotic cells in Autoimmune Liver disease. The experiments were well designed and conducted, the results were reasonably interpreted, and the manuscript was clearly written with logical inputs.

One weak point is that the signals/mechanisms that determine why neutrophil specifically target apoptotic hepatocytes in liver and no other organs or cells is not clearly understood.

Reviewer #2 (Public Review):

Neutrophils are the most abundant circulating leukocytes in human. They play important roles in innate immune responses to infections and tissue injuries. Although they are dept in phagocytosis of microbes, neutrophils are not known to normally conduct efferocytosis or phagocytose host cells including apoptotic cells and play a significant role in apoptotic cell removal. In this report the authors provide evidence to suggest that neutrophils are involved in removal of apoptotic hepatocytes with certain specificity (i.e., they do not remove HEK293 or HUVEC endothelial cells). Moreover, the authors also show that neutrophils can burrow into the target cells and possibly ingest the target cells from the inside. The authors thus term this neutrophil-mediated efferocytosis process as "perforocytosis". Furthermore, evidence is provided to suggest that this neutrophil-mediated efferocytosis process keeps the number of apoptotic cells low in the livers and that defects in the processes may associate with autoimmune liver (AIL) disease phenotypes. Therefore, many of these findings are novel and the study is of important implications in our understanding of the role of neutrophils in autoimmune disease.

By examination of HE-stained, noncancerous liver tissue sections from patients with hepatocellular carcinoma and hepatic hemangioma, the authors observed that cells with neutrophil nuclear morphology were inside apoptotic hepatocytes. The authors also further characterized this observation by staining the sections with neutrophil and apoptosis markers. In addition, the authors observed the same phenomena in mouse livers using intravital microscopy, which also recorded the time course of the disappearance of a neutrophil-associated apoptotic cell. The author went on further characterization of neutrophil-mediated efferocytosis of cultured hepatic cells in vitro and demonstrated the process was specific for apoptotic hepatic cells, but not HEK293 or endothelial cells. The in vitro system was then used to characterize the molecular bases for neutrophil-mediated efferocytosis of apoptotic hepatic cells. The evidence was provided to suggest that IL1b and IL-8 released from and selectins upregulated in apoptotic hepatic cells were important. Importantly, the authors used two methods to deplete the neutrophils and showed that the neutrophil depletion increased apoptotic cells in livers. Finally, the authors showed that neutrophil depletion caused defects in liver function parameters. At the end, the authors presented evidence to suggest that AIL disease may be due to defective neutrophils that fail to perform "perforocytosis."

Although the evidence in its totality indicates that neutrophils burrow into apoptotic hepatocytes, the significance of this "perforocytosis" phenomenon and the circumstances under which it may occur remain to be better defined. In both neutrophil depletion models, the TNUEL-positive cells were not definitively identified rather than assuming they were hepatocytes. In addition, there are discrepancies in the number of neutrophils and apoptotic cells in mouse liver studies; Figure 2a WT (many neutrophils; locations unclear) vs Figure 5A Ctr (a few neutrophils that appear in or near a vessel), and Figure 2a DTR (a few apoptotic cells) vs Figure 5A Depletion (many apoptotic cells). Importantly, Figure 5a Ctrl, which is presumably a section from a mouse without any surgical treatment or without inflammation, the sole TUNNEL signal does not appear to be associated with neutrophils. Does this mean that "perforocytosis" primarily occurs in inflamed livers (Of note, human liver samples in Figure 1 are from patient with tumors. There should be inflammation in the livers of these patients). The data on human AIL patient neutrophils raises more questions: how many AIL patients have been examined? Do these AIL neutrophils lack IL1, IL8 receptors, and/or selectin ligands? Are there increases in apoptotic hepatocytes in AIL patients? Additionally, the overall numbers of apoptotic cells even in the absence of neutrophils are rare; thus, it is questionable that such rarity of apoptotic cells can cause significant AIL phenotypes.