Prophylactic effects of nutrition, dietary strategies, exercise, lifestyle and environment on nonalcoholic fatty liver disease

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a chronic liver disease and its prevalence has risen sharply. However, whether nutrition, dietary strategies, exercise, lifestyle and environment have preventive value for NAFLD remains unclear.

METHODS

Through searching 4 databases (PubMed, Web of Science, Embase and the Cochrane Library) from inception to January 2025, we selected studies about nutrition, dietary strategies, exercise, lifestyle and environment in the prevention of NAFLD and conducted a narrative review on this topic.

RESULTS

Reasonable nutrient intake encompassing macronutrients and micronutrients have an independent protective relationship with NAFLD. Besides, proper dietary strategies including mediterranean diet, intermittent fasting diet, ketogenic diet, and dietary approaches to stop hypertension diet have their inhibitory effects on the developmental process of NAFLD. Moreover, right exercises including walking, jogging, bicycling, and swimming are recommended for the prevention of NAFLD because they could effectively reduce weight, which is an important risk factor for NAFLD, and improve liver function. In addition, embracing a healthy lifestyle including reducing sedentary behavior, not smoking, sleeping well and brushing teeth regularly is integral since it not only could reduce the risk of NAFLD but also significantly contribute to overall prevention and control. Finally, the environment, including the social and natural environments, plays a potential role in NAFLD prevention.

CONCLUSION

Nutrition, dietary strategies, exercise, lifestyle and environment play an important role in the prevention of NAFLD. Moreover, this review offers comprehensive prevention recommendations for people at high risk of NAFLD.

Distinct clusters of bacterial and fungal microbiota in end-stage liver cirrhosis correlate with antibiotic treatment, intestinal barrier impairment, and systemic inflammation

Decompensated liver cirrhosis (dLC) is associated with intestinal dysbiosis, however, underlying reasons and clinical consequences remain largely unexplored. We investigated bacterial and fungal microbiota, their relation with gut barrier integrity, inflammation, and cirrhosis-specific complications in dLC-patients. Competing-risk analyses were performed to investigate clinical outcomes within 90 days. Samples were prospectively collected from 95 dLC-patients between 2017 and 2022. Quantitative metagenomic analyses clustered patients into three groups (G1-G3) showing distinct microbial patterns. G1 (n = 39) displayed lowest diversity and highest Enterococcus abundance, G2 (n = 24) was dominated by Bifidobacteria, G3 (n = 29) was most diverse and clustered most closely with healthy controls (HC). Of note, bacterial concentrations were significantly lower in cirrhosis compared with HC, especially for G1 that also showed the lowest capacity to produce short chain fatty acids and secondary bile acids. Consequently, fungal overgrowth, dominated by Candida spp. (51.63%), was observed in G1. Moreover, G1-patients most frequently received antibiotics (n = 33; 86.8%), had highest plasma-levels of Zonulin (p = 0.044) and a proinflammatory cytokine profile along with numerically higher incidences of subsequent infections (p = 0.09). In conclusion, distinct bacterial clusters were observed at qualitative and quantitative levels and correlated with fungal abundances. Antibiotic treatment significantly contributed to dysbiosis, which translated into intestinal barrier impairment and systemic inflammation.

Development and validation of a score model for predicting the risk of first esophagogastric variceal hemorrhage and mortality in patients with hepatocellular carcinoma

AIMS

Esophagogastric variceal bleeding, especially first variceal hemorrhage, represents a challenging complication in the management of patients with hepatocellular carcinoma (HCC), and its presence significantly herald poor patient prognosis. The stratification system for the risk of first variceal hemorrhage and mortality has not been validated in patients with HCC. We aimed to develop and validate a simple score for the prediction of initial variceal bleeding and mortality in patients with HCC.

METHODS

This multicenter retrospective-prospective study included HCC patients at three tertiary hospitals in China from January 2016 to December 2023. The bleeding following endoscopy for hepatocellular carcinoma (BFE-HCC) score was constructed by the least absolute contraction and selection operator (LASSO) regression combined with multivariate logistic regression analysis. The performance of the score model was evaluated using the receiver operating characteristic (ROC) curve, the calibration curve, and the decision curve analysis (DCA). Finally, the of the results was further verified in an independent external cohort.

RESULTS

We recruited 351 patients from three centers (median age 56 years, 85.5% male and 83.5% with cirrhosis), 56.6% patients presented high-risk (HR) varices, and 35% patients experienced variceal bleeding. Multivariate logistic analysis revealed that the presence of cirrhosis, a history of acute variceal bleeding (AVB), Child-Pugh score, ALBI score, tumor size and portal vein tumor thrombosis (PVTT) Vp4 were independent predictors of HR varices. The BFE-HCC is composed of six variables: white blood cell count, HR varices, Child-Pugh score, HCC therapy modality, Vp4, and tumor stage. The area under the curve (AUC) of BFE-HCC was 0.82, and the calibration plots and decision curve analysis exhibited outstanding performance compared with the MELD, ALBI, and Child-Pugh scores. In addition, Patients with BFE-HCC ≥ 4 were at increased risk of mortality (P<0.01).

CONCLUSIONS

The BFE-HCC score is hopeful to predict initial variceal bleeding and mortality in patients with HCC, offering a promising tool for prognostic assessment and treatment decisions.

Copper homeostasis and neurodegenerative diseases

Copper, one of the most prolific transition metals in the body, is required for normal brain physiological activity and allows various functions to work normally through its range of concentrations. Copper homeostasis is meticulously maintained through a complex network of copper-dependent proteins, including copper transporters (CTR1 and CTR2), the two copper ion transporters the Cu -transporting ATPase 1 (ATP7A) and Cu-transporting beta (ATP7B), and the three copper chaperones ATOX1, CCS, and COX17. Disruptions in copper homeostasis can lead to either the deficiency or accumulation of copper in brain tissue. Emerging evidence suggests that abnormal copper metabolism or copper binding to various proteins, including ceruloplasmin and metallothionein, is involved in the pathogenesis of neurodegenerative disorders. However, the exact mechanisms underlying these processes are not known. Copper is a potent oxidant that increases reactive oxygen species production and promotes oxidative stress. Elevated reactive oxygen species levels may further compromise mitochondrial integrity and cause mitochondrial dysfunction. Reactive oxygen species serve as key signaling molecules in copper-induced neuroinflammation, with elevated levels activating several critical inflammatory pathways. Additionally, copper can bind aberrantly to several neuronal proteins, including alpha-synuclein, tau, superoxide dismutase 1, and huntingtin, thereby inducing neurotoxicity and ultimately cell death. This study focuses on the latest literature evaluating the role of copper in neurodegenerative diseases, with a particular focus on copper-containing metalloenzymes and copper-binding proteins in the regulation of copper homeostasis and their involvement in neurodegenerative disease pathogenesis. By synthesizing the current findings on the functions of copper in oxidative stress, neuroinflammation, mitochondrial dysfunction, and protein misfolding, we aim to elucidate the mechanisms by which copper contributes to a wide range of hereditary and neuronal disorders, such as Wilson's disease, Menkes' disease, Alzheimer's disease, Parkinson's disease, amyotrophic lateral sclerosis, Huntington's disease, and multiple sclerosis. Potential clinically significant therapeutic targets, including superoxide dismutase 1, D-penicillamine, and 5,7-dichloro-2-[(dimethylamino)methyl]-8-hydroxyquinoline, along with their associated therapeutic agents, are further discussed. Ultimately, we collate evidence that copper homeostasis may function in the underlying etiology of several neurodegenerative diseases and offer novel insights into the potential prevention and treatment of these diseases based on copper homeostasis.

Living Donor Liver Transplantation for Pediatric Wilson's Disease-related Acute Liver Failure-Hard Work With High Rewards

Background

Liver transplantation (LT) is indicated for children with Wilson's disease (WD) presenting with acute liver failure (ALF) or with chronic liver disease (CLD) that has progressed to decompensation. We present our experience of living donor liver transplantation (LDLT) for pediatric WD, discuss the challenges of managing WD-ALF and compare outcomes of children presenting with WD-ALF with WD-CLD.

Methods

We compared presentation and outcomes of the WD-ALF and WD-CLD cohorts. Fifty-three children (WD-ALF: 28 (53%), WD-CLD: 25 (47%)) underwent LDLT for WD.

Results

WD-ALF group had higher Kings New Wilson Index (KNWI) (15 vs 9, P = 0.001), higher pediatric end-stage liver disease/model for end-stage liver disease score (35 vs 20, P = 0.001), were more frequently encephalopathic (64% vs 4%, P = 0.001), and had ongoing hemolysis (86% vs 28%, <0.001). Preoperative mechanical ventilation, operative continuous renal replacement therapy (CRRT), therapeutic plasma exchange (TPE) was needed in 32%, 46.5%, and 89% of WD-ALF children, respectively. WD-ALF patients had longer postoperative ICU stay (4.5 days vs 3 days, P = 0.001), longer hospital stay (20.5 days vs 14 days, P = 0.001), more major complications (57% vs 20%, P = 0.006). WD-ALF cohort also had more postoperative neurological complications (42.9% vs 8%, P = 0.004) and invasive fungal infections (21.4% vs none, P = 0.024). There were two perioperative (90 day) mortalities in WD-ALF group and none in WD-CLD group. Patient survival of the entire cohort at median follow-up of 26 months was 94.3% and all survivors had good allograft function neurological sequelae. Patient survival was inferior for WD-ALF cohort though the difference was not statistically significant (88.5% vs 100%, log rank test, P = 0.089).

Conclusion

LDLT is a curative treatment for children with WD with excellent short-term and long-term outcomes. WD-ALF patients can have a complicated postoperative course but have good long-term survival.

Challenges and Recent Advances in Diagnosing Wilson Disease

Wilson disease (WD) is a rare autosomal recessive disorder caused by ATP7B gene mutations, leading to pathological copper accumulation that primarily affects the liver, brain, and eyes. Diagnosing WD remains a significant challenge due to its highly variable clinical presentation, which ranges from asymptomatic biochemical abnormalities to acute liver failure and severe neuropsychiatric manifestations. Traditional diagnostic markers, such as serum ceruloplasmin, urinary copper excretion, and liver biopsy, lack sufficient specificity and sensitivity, often leading to delays in diagnosis and misclassification. Additionally, the absence of a single gold-standard test and the overlap with other hepatic and neurological disorders further complicate early detection. Recent advances in diagnostic techniques offer promising solutions to overcome these limitations. Novel biomarkers, including relative exchangeable copper (REC) and ATP7B protein quantification in dried blood spots have demonstrated improved accuracy in distinguishing WD from other conditions. Advanced imaging modalities, such as anterior segment optical coherence tomography (AS-OCT), quantitative susceptibility mapping (QSM), and copper-64 positron emission tomography imaging provide noninvasive tools for detecting early disease-related changes. Furthermore, next-generation sequencing (NGS) enhances genetic screening, facilitating earlier diagnosis, and family screening. A comprehensive approach integrating conventional and emerging diagnostic methodologies is essential for improving early detection and patient outcomes. Greater awareness of the limitations of traditional tests and the incorporation of novel biomarkers and imaging techniques into clinical practice can help refine diagnostic accuracy, reduce delays, and optimize treatment strategies for WD.

Sex differences in the mediating role of brain-derived neurotrophic factor between inflammation and memory in cirrhotic patients with minimal hepatic encephalopathy

Minimal hepatic encephalopathy (MHE) affects attention, visuo-motor coordination, and visual perception, with mixed evidence on its impact on memory. Brain-derived neurotrophic factor (BDNF) is associated with memory dysfunction, and plays a crucial role in modulating neuroplasticity. This study investigates the mediating role of BDNF in the relationship between pro-inflammatory cytokines (IL-6, IL-15, IL-18), and declarative memory performance, and the moderating effects of sex. Sixty-eight cirrhotic patients and 22 healthy volunteers performed the Psychometric Hepatic Encephalopathy Score for MHE diagnosis and logical memory subtest (Wechsler Memory Scale-III). Moderated mediation analysis using bias-corrected bootstrapping and multiple regression was performed. Results showed that increased levels of IL-18 and IL-15 were significantly associated with lower BDNF levels (p = 0.03 and p = 0.02 respectively). However, no direct effect was observed between IL-18 and IL-15 and memory. The conditional effects of BDNF on memory were significant only for women with and without MHE, and lower BDNF levels were associated with lower memory performance (without MHE: p = 0.002; MHE: p = 0.001). Moreover, BDNF mediated indirectly the relationship between pro-inflammatory cytokines and memory. IL-18 and IL-15 impacted memory through reduced BDNF levels only in women with and without MHE, whereas IL-6 showed no significant effect on BDNF or memory across groups. These findings underscore the important role of BDNF in memory in cirrhotic patients, especially women with MHE, by mediating the IL-18 and IL-15 effects. The study highlights the role of IL-18 and IL-15 cytokines in neuroplasticity-related memory decline, positioning BDNF as a key biomarker for inflammation-associated cognitive impairment in this population.

Silymarin exerts antioxidant and antiviral effects on Zika virus infection

The Zika virus (ZIKV) - Orthoflavivirus zikaense - epidemic and its association with severe neurological disorders have created an urgent need to understand the disease pathogenesis and identify potential therapeutic targets. In previous investigations, we have shown that oxidative stress is associated with the pathogenesis of ZIKV infection in vitro and in vivo, and that silymarin has anti-ZIKV action in vitro. Here, we characterised the antioxidant and antiviral effects of silymarin against ZIKV infection in an animal model. We observed an increase in the levels of biomarkers of oxidative damage and in antioxidant enzyme activities in the livers of ZIKV-infected C57BL/6 mice. However, these effects were reversed in ZIKV-infected animals that were treated with silymarin. Furthermore, silymarin reduced the viral load in the livers of animals. Next, by in vitro studies, we confirmed that the anti-ZIKV action of silymarin is independent of its antioxidant activity. This work reinforces the potential use of silymarin against Zika fever.

The Elements of Life, Photosynthesis and Genomics

I am a Professor of Biochemistry, Biophysics and Structural Biology and Plant and Microbial Biology at the University of California in Berkeley. I was born and raised in India, emigrated to the United States to attend university, earning a B.S. in Molecular Biology and a Ph.D. in Biochemistry at the University of Wisconsin in Madison. Following post-doctoral studies with Lawrence Bogorad at Harvard University where I became interested in genetic control of trace element quotas, I joined the department of Chemistry and Biochemistry at UCLA. One of the first to appreciate essential trace metals as potential regulators of gene expression, I articulated the details of the nutritional Cu regulon in Chlamydomonas. In parallel, I used genetic approaches to discover the genes governing missing steps in tetrapyrrole metabolism, including the attachment of heme to apocytochromes in the thylakoid lumen and the factors catalyzing the formation of ring V in chlorophyll. After biochemistry and classical genetics, I embraced genomics, taking a leadership role on the Joint Genome Institute's efforts on the Chlamydomonas genome and more recently, contributing to high quality assemblies of several genomes in the green algal radiation, and large transcriptomic and proteomic datasets - focusing on the diel metabolic cycle in synchronized cultures and acclimation to key environmental and nutritional stressors - that are well-used and appreciated by the community. A new venture in Berkeley is the promotion of Auxenochlorella protothecoides as the true "green yeast" and as a platform for engineering algae to produce useful bioproducts.

An 11-year retrospective study on hepatitis C in Saudi Arabia: Seroconversion, recovery rates, and viral genotype distribution

Hepatitis C virus (HCV) infection remains a global health concern. This study analyzed 95,864 plasma samples from Saudi patients between 2011 and 2022 to examine HCV seroconversion, viral load, and genotype distribution. Serological screening was performed using the ARCHITECT anti-HCV assay, and HCV RNA levels were quantified with real-time RT-PCR. Of the 970 HCV-positive cases, 47.9 % experienced spontaneous recovery, while 52.1 % had persistent infection. The annual seropositivity rate declined significantly from 2.05 % in 2011 to 0.34 % in 2022. Genotyping of 107 persistently infected samples showed genotypes 4 (49.5 %) and 1a (17.8 %) as the most common, with other genotypes appearing less frequently. Additionally, 13 (12.1 %) samples had untypable genotypes. This study highlights the decrease in HCV infection rates, the high rate of spontaneous recovery, and the predominance of genotypes 4 and 1a. Ongoing surveillance and genotyping, including untypable cases, are essential for effective HCV management in Saudi Arabia.

Farnesoid X receptor activation alleviates hepatic encephalopathy by improving hepatic ammonia metabolism in murine models

BACKGROUND

Hepatic encephalopathy (HE) is a mental and neurological complication induced by acute or chronic hepatic failure. Emerging evidence indicates that the farnesoid X receptor (FXR), a multifunctional nuclear receptor and transcription factor, plays a pivotal role in regulating the expression of key genes associated with ammonia metabolism. However, the effect of FXR activation on HE has remained largely uncharted.

METHODS

We established mouse models of HE by intraperitoneal injection of thioacetamide (TAA) and partial hepatectomy (PHx). Subsequently, we administered obeticholic acid (OCA) to activate FXR and investigated its effects on HE through comprehensive biochemical, biological, histological and behavioral analysis. Additionally, in vitro experiments were conducted to examine the impact of FXR activation on ammonia stress.

FINDINGS

In the animal model of HE, activation of FXR upregulated the expression of key enzymes involved in ammonia metabolism pathway within the liver, thereby enhancing urea cycle functionality, reducing plasma ammonia levels, and mitigating liver injury. Furthermore, FXR activation significantly improved behavioral activities in mice and mitigated inflammation in the brain. Finally, our findings demonstrated that activating FXR could enhance ammonia metabolism and ammonia tolerance of C3A cells.

INTERPRETATION

Our data provide novel evidence demonstrating that the activation of FXR by OCA exerts regulatory control over the expression of enzymes involved in ammonia metabolism, thereby effectively alleviating HE. Consequently, FXR could emerge as a promising novel target for HE treatment.

FUNDING

This study was supported by the National Natural Science Foundation of China No: 81970726 (to W-D Chen), and Henan Provincial Key Project of Medical Science and Technology Research No: SBGJ202102215 (to WL Ye).

A functional seizure case in Wilson's disease

Wilson's disease (WD) is a rare disorder characterized by abnormal copper metabolism, leading to its accumulation in various tissues, particularly the brain and the liver. Psychiatric and neurological symptoms are common manifestations of WD. We present a case of a 22-year-old woman diagnosed with WD who exhibited neurological symptoms and experienced functional seizures (FS) that were misdiagnosed as epilepsy secondary to WD for almost two years. The patient's history of childhood trauma and interpersonal difficulties underscored the complex interplay between organic and psychogenic factors contributing to FS development. This case highlights the diagnostic challenges associated with the neuropsychiatric manifestations of Wilson's disease, as well as the complexities in differentiating functional seizures from epilepsy. It emphasizes the importance of comprehensive assessment and multidisciplinary care in optimizing patient outcomes.

Relevant clinical factors for early extubation in living-donor liver transplantation: A single-center retrospective cohort study

BACKGROUND

Clinical guidelines for early extubation after liver transplantation remain lacking, with significant variations in the rates of early extubation across transplantation centers.

AIM

To identify clinical factors, including the use of epidural analgesia, associated with early extubation in living-donor liver transplantation (LDLT).

METHODS

The medical records of LDLT recipients were analyzed in this study, categorizing them based on extubation timing as delayed (leaving the operating room without extubation) or early (tracheal tube removed immediately after surgery). A multivariate binary logistic regression analysis was performed. Subgroup analysis was conducted, excluding patients contraindicated for epidural analgesia owing to significant coagulopathy.

RESULTS

Total of 159 patients, 93 (58.5%) underwent early extubation. Relevant clinical factors of early extubation were shorter anhepatic time [adjusted odds ratio (OR) = 0.439, 95% confidence interval (CI): 0.232-0.831; P = 0.011], absence of high-dose vasoactive drug use at the end of surgery (OR = 0.235, 95%CI: 0.106-0.519; P < 0.001), and the use of epidural analgesia (OR = 15.730, 95%CI: 1.919-128.919; P = 0.010). In a subgroup analysis of 67 patients, epidural analgesia remained a relevant clinical factor for early extubation (adjusted OR = 19.381, 95%CI: 2.15-174.433; P = 0.008).

CONCLUSION

Shorter anhepatic time, absence of high-dose vasoactive drug use at the end of surgery, and the use of epidural analgesia are relevant clinical factors of early extubation following LDLT.

A novel fluorescent nanoprobe based on platinum nanoclusters with the characteristic of aggregation-induced emission for the detection of Cu2+ and D-penicillamine

In this work, platinum nanocluster (Pt NCs) with AIE property using L-glutathione (L-GSH) as the protecting ligand are reported. The solid-state photoluminescence quantum yields of obtained Pt NCs powder is as high as 8.0 %. The as-prepared Pt NCs exhibited solvent-induced emission. Specifically, they exhibited gradually enhanced red fluorescent emission as the volume ratio of ethanol to H2O increases. Additionally, the obtained Pt NCs presented excellent stability and resistance to photobleaching in the mixed solvent of ethanol and H2O. Based on the fluorescent quenching effect of Pt NCs induced by Cu2+ and the strong coordination interaction between Cu2+ and thiol group of D-penicillamine (D-Pen), a novel "off-on" fluorescent nanoprobe was proposed for quantifying the labelling amount percentage of commercially available D-penicillamine tablets. Experimental results demonstrated the fluorescent quenching from our proposed Pt NCs-based nanoprobe was linearly correlated with Cu2+ concentration within the range from 1 to 28 μM, with a limit of detect (LOD) of 0.13 μM. Besides, upon addition of D-Pen into a mixed system containing Pt NCs and Cu2+, fluorescent intensities of Pt NCs were recovered and exhibited concentration-dependent responses within a concentration of D-Pen from 1 to 120 μM, with an LOD of 0.058 μM. Spiked sample experiment validated that our proposed nanoprobe possessed an outstanding accuracy, which expands the potential application of metal nanoclusters exhibiting AIE effects in pharmaceutical analysis.

Risk factors and clinical outcomes in patients with HCV eradication by direct-acting antivirals: a systematic review and meta-analysis

BACKGROUND

In hepatitis C patients with sustained virologic response (SVR) achieved after direct-acting antivirals (DAAs), the incidence of adverse clinical outcomes can be reduced but not completely eliminated. This meta-analysis aims at estimating the incidence of clinical outcomes in hepatitis C patients after achieving SVR with DAAs.

METHODS

Literature search was carried out in PubMed, Cochrane Library database, Web of Science, and Embase. The primary endpoint was the incidence of hepatocellular carcinoma (HCC) occurrence, HCC recurrence, decompensated cirrhosis, and liver-related mortality, following DAA-induced elimination of hepatitis C virus (HCV). Subgroup analyses were performed according to age, gender, comorbidities, region, fibrosis stage, presence of decompensation, duration of follow-up, start point of follow-up, and HCC treatment modality. Furthermore, meta-regression was performed to explore sources of high heterogeneity.

RESULTS

Finally, 132 articles were included in our study. The pooled HCC occurrence rate was 1.50/100 person-years (95% CI, 1.35-1.65), HCC recurrence rate was 17.00/100 person-years (95% CI, 13.83-20.42), decompensation rate was 0.30/100 person-years (95% CI, 0.16-0.48), and liver-related mortality was 0.32/100 person-years (95% CI, 0.14-0.56). Meta-regression showed that duration of follow-up and fibrosis grade were important contributors to HCC occurrence. Age, start point of follow-up, and duration of follow-up were important contributors to HCC recurrence rate.

CONCLUSION

Patients with DAA-induced HCV elimination remain at risk for adverse outcomes, particularly those with cirrhosis and HCC history. The exposure to adverse outcomes tended to decrease over time, and the frequency and intensity of follow-up might be reduced in the future, which will require new scoring models to identify these individuals.

Predictive factors for limited health literacy among persons with cirrhosis: A Swedish explorative cross-sectional study

INTRODUCTION

Fatigue and altered cognitive capacity are common symptoms following cirrhosis. Patients consider information about cirrhosis difficult to understand. Health literacy levels vary among persons with chronic illnesses, which can hamper participation in and adaptation to treatment, potential restrictions and recommendations. Limited health literacy might also lead to decreased autonomy.

PURPOSE

The aim was to explore predictors of limited health literacy among adults with cirrhosis.

MATERIALS AND METHODS

This cross-sectional study explored health literacy among 167 Swedish adults with cirrhosis, 94 men and 73 women with a median age of 65 years using the 'Newest Vital Sign' instrument. Predictors of limited health literacy were examined in relation to patient characteristics and cirrhosis disease events. The study is reported following the STROBE guidelines.

RESULTS

The prevalence of limited health literacy was 58%. Low education and covert hepatic encephalopathy were associated with limited health literacy (p < 0.05).

CONCLUSION

Limited health literacy is common among Swedish adults with cirrhosis. Both covert hepatic encephalopathy and low education might be predictors of limited health literacy. Healthcare providers should tailor their patient education based on the patient's literacy level to facilitate understanding, learning and self-management.

Pharmacological and therapeutic effects of natural products on liver regeneration-a comprehensive research

Liver regeneration (LR) refers to the physiological process by which hepatocytes undergo cellular proliferation to restore the structure and function of the liver following significant hepatocyte loss due to injury or partial hepatectomy (PH). While the liver possesses a remarkable regenerative capacity, this process is tightly regulated to ensure appropriate cessation once homeostasis is reestablished. Various strategies, including technological interventions and pharmacological agents, have been explored to enhance LR. Among these, natural products have emerged as promising candidates for promoting LR. For instance, quercetin, a natural compound, has been shown to enhance LR following PH by maintaining redox homeostasis and stimulating hepatocyte proliferation. However, natural products present certain limitations, such as poor solubility and low bioavailability, which may hinder their clinical application. Modifications in the formulation and mode of administration have demonstrated potential in overcoming these challenges and optimizing their pharmacological effects. Recent advancements in research have further highlighted the growing relevance of natural products, including traditional Chinese medicine (TCM), in the context of LR. Despite this progress, a comprehensive and systematic review of their roles, mechanisms, and therapeutic potential remains lacking. This review aims to bridge this gap by summarizing natural products with demonstrated potential to promote LR. Drawing on data from PubMed, Web of Science, and CNKI databases, it elucidates their pharmacological effects and regulatory mechanisms, providing a valuable reference for future research and clinical application in the field of LR.

Size-dependent penetration depth of colloidal nanoparticles into cell spheroids

The penetration of nanoparticle (NP)-based drugs into tissue is essential for their use as nanomedicines. Systematic studies about how different NP properties, such as size, influence NP penetration are helpful for the development of NP-based drugs. An overview of how NPs of different sizes may penetrate three-dimensional cell spheroids is given. In particular different techniques for experimental analysis are compared, including mass spectrometry, flow cytometry, optical fluorescence microscopy, X-ray fluorescence microscopy, and transmission electron microscopy. An experimental data set is supplemented exclusively made for this review, in which the results of different techniques are visualized. Limitations of the analysis techniques for different types of NPs, including carbon-based materials, are discussed.

Photoactivated in-situ engineered-bacteria as an efficient H2S generator to enhance photodynamic immunotherapy via remodeling the tumor microenvironment

Based on the unique biological advantages of bacteria and their derivatives, biosynthetic nanomaterials have been widely used in the field of tumor therapy. Although conventional bacterial treatments demonstrate potential in activating tumor immunity, their efficacy in inhibiting tumor growth remains constrained. In this study, a photoactivated hydrogen sulfide (H2S) generator was successfully prepared by in-situ engineering of bacteria, after Pt/MoS2 nanocomposites were in-situ generated by Escherichia coli (E. coli) and loaded with photosensitizer Ce6. This engineered-bacteria has been proved to have good tumor targeting ability and can enhance the effect of photodynamic therapy in the hypoxic tumor microenvironment. While reactive oxygen species (ROS) is effectively released, the fragmentation of bacteria can accelerate the release of abundant H2S, and promote tumor-specific H2S gas therapy, which can effectively remodel the tumor microenvironment and promote the activation of anti-tumor immunotherapy. This engineered bacteria not only improves the tumor specificity and effectiveness of H2S treatment, but also provides a new idea for nanomaterials in bacterial-mediated synergistic cancer treatment.

Covered TIPS Created with Viatorr Versus Fluency Stent-Grafts for the Refractory Ascites in Patients with Cirrhosis: An Observational Study

RATIONALE AND OBJECTIVES

To compare the long-term clinical efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) created with Fluency versus Viatorr stent-grafts for the treatment of refractory ascites in patients with cirrhosis.

MATERIALS AND METHODS

A retrospective analysis was conducted on 118 cirrhotic patients with refractory ascites undergoing TIPS with Fluency stent-grafts (Fluency group, n=83) or Viatorr stent-grafts (Viatorr group, n=35) at two centers from January 2017 to December 2021. Competing risk analysis was used to compare the incidence of clinical outcomes between groups after adjusting for confounders.

RESULTS

During a median of 30.9 months follow-up, 31 patients (26.3%) developed portal hypertension complications (11 cases of recurrent ascites, 16 cases of variceal bleeding, and four cases of both ascites and variceal bleeding), 15 patients (12.7%) developed shunt dysfunction, 58 patients (49.15%) developed overt hepatic encephalopathy (OHE), and 74 patients (62.7%) died. After adjusting for confounding factors, the Viatorr stent was associated with a reduced OHE risk (38% vs 54% at 5 years, p=0.004) but a comparable incidence of portal hypertension complications (27% vs 27%, p=0.536), shunt dysfunction (14% vs 12%, p=0.401), and mortality (41% vs 37%; p=0.064) compared to the Fluency stents. These findings were consistent across most relevant subgroups.

CONCLUSION

In cirrhotic patients with refractory ascites undergoing TIPS, Viatorr stent-grafts were associated with lower risk of OHE while no significant differences in clinical efficacy compared to the Fluency stent-grafts.

High Global Prevalence of Steatotic Liver Disease and Associated Subtypes: a Meta-analysis

BACKGROUND & AIMS

Steatotic liver disease (SLD) encompasses various forms of hepatic steatosis and has become a significant global health concern. Despite its growing burden, a comprehensive understanding of its prevalence is lacking. Thus, this meta-analysis aims to provide a detailed estimation of the global prevalence of SLD and its subtypes.

METHODS

A systematic review and meta-analysis was conducted, examining studies published between January 2023 and August 2024 from MEDLINE and EMBASE that reported on the prevalence of SLD and its subtypes.

RESULTS

A total of 44 studies encompassing 11,282,575 participants were included. Among them, 3,826,283 individuals were diagnosed with SLD. The pooled global prevalence of SLD was 37.5% (95% confidence interval [CI], 31.4%-44.1%; I2 = 99.8%). Subtype analysis showed a prevalence of 33.6% (95% CI, 28.1%-39.5%; I2 = 99.9%) for metabolic dysfunction-associated steatotic liver disease, 4.1% (95% CI, 3.1%-5.3%; I2 = 100%) for metabolic alcohol-related liver disease, and 2.2% (95% CI, 1.5%-3.1%; I2 = 98.0%) for alcohol-related liver disease in the population. Prevalence was notably elevated in individuals with type 2 diabetes (70.2%; 95% CI, 66.1%-73.9%; I2 = 65.4%) and in overweight/obese populations (70.7%; 95% CI, 43.2%-88.4%; I2 = 99.0%).

CONCLUSION

The high prevalence of SLD shows that there remains an urgent need for targeted public health interventions and policies to address the modifiable risk factors contributing to the global burden of SLD.

Double reflex testing improves the efficacy and cost effectiveness of hepatitis delta diagnosis in southern Spain

This study aims to evaluate the prevalence of undiagnosed hepatitis delta in southern Spain (Andalusia) and assess the effectiveness and cost-efficiency of implementing reflex testing for hepatitis D detection in HBsAg-positive patients. A multicenter ambispective study was conducted in 17 Andalusian hospitals. The retrospective phase (January 2018-June 2022) analyzed diagnostic processes for hepatitis delta in HBsAg-positive patients. The prospective phase (October 2022-March 2023) implemented reflex testing, performing anti-HDV serology on all HBsAg-positive patients without prior testing. HDV RNA testing followed for those who tested anti-HDV-positive. In the retrospective phase, out of 18,583 HBsAg-positive patients, anti-HDV tests were performed on 3,436 (18%), identifying 205 (6%) positive cases. HDV RNA was tested in 158 (77%) anti-HDV-positive patients, with 69 (44%) testing positive. In the prospective phase, out of 2,384 HBsAg-positive patients without prior anti-HDV testing, 2,293 (96%) were tested, identifying 109 (4.7%) positive cases. HDV RNA was analyzed in 97 (89%) anti-HDV-positive patients, with 30 (31%) testing positive. Reflex testing increased anti-HDV detection by 77%, resulting in a fourfold increase in detecting anti-HDV-positive patients and a threefold increase in detecting HDV RNA-positive patients, reducing undiagnosed HDV RNA-positive cases to 4% compared to 45% with clinical practice. Cost analysis indicated a saving of €265,954 with reflex testing. Reflex testing improves HDV detection, reduces costs, and simplifies diagnosis, making it an efficient strategy for managing chronic hepatitis D patients.

Plasma exchange improves survival with native liver in Wilson disease with new Wilson's index ≥ 11 & early hepatic encephalopathy

BACKGROUND AND AIM

Decision about liver transplant is difficult in Wilson disease (WD) with liver failure, especially with conflicting reports about new Wilson index (NWI). Therapeutic plasma exchange (TPE) can provide survival with native liver (SNL) in WD. This study was done to see the effect of TPE on outcome and identify factors for SNL.

METHODS

All cases of WD with liver failure (INR. ≥ 2.5) from prospectively maintained data were included for propensity score matching (PSM) to select TPE (n = 48) and no-TPE (n = 48) groups. Three sessions of TPE on three consecutive days were given to TPE group.

RESULTS

One hundred fifty-nine cases were included in the PSM with NWI & hepatic encephalopathy (HE) grading as predictors. SNL was comparable (26 vs. 17 cases (OR 1.45, p = 0.05) when the analysis was done in the whole cohort of 96 patients. SNL significantly improved when performed in those with no to early HE: TPE group (24/37) versus no-TPE group (14/34) (OR = 1.70, p = 0.03). Kaplan-Meier survival curves were significantly (log rank 0.019) improved in the TPE group when analyzing in no to early HE. Lower INR (adjusted OR 0.47, 95%CI 0.28-0.79, p = 0.005) and TPE administration (adjusted OR 3.12, 95%CI 1.10-9.4, p = 0.032) at enrollment were independently associated with SNL. Lower NWI (adjusted OR 0.686, 95%CI 0.53-0.89, p = 0.005) at 96 h was independently associated with SNL.

CONCLUSIONS

TPE is independently associated with improvement in SNL by threefold in patients with NWI ≥ 11 and no to early HE. Patients with advanced HE should be offered immediate liver transplant. After 3 sessions of TPE, NWI < 11 increases SNL by 32%. Hence, NWI should be maintained below 11 with more sessions of TPE.

Efficacy of probiotics in patients with cognitive impairment: A systematic review and meta-analysis

OBJECTIVE

To conduct an in-depth exploration of the specific impacts of probiotics and prebiotic supplements on cognitive impairment, it is imperative to also investigate pertinent factors, including the optimal dosage of probiotics for enhancing cognitive function. This investigation is essential for optimizing probiotic interventions to prevent and treat cognitive decline, aimed at preventing and aiding in the treatment of cognitive decline among patients with cognitive impairment.

METHODS

A comprehensive computerized search was conducted across the Embase, PubMed, Web of Science, Cochrane Library, SinoMed, CNKI, Wanfang and WeiPu Data. Studies targeting randomized controlled trials (RCTs) were included. This search covered a timeframe extending from the inception of each database to September 2024. Following an independent process of literature screening, data extraction, and rigorous quality assessment conducted by two investigators, a meta-analysis was performed using Stata 15.0 software.

RESULTS

A total of ten studies, involving 778 patients, were included in the analysis. The meta-analysis revealed that probiotics were effective in enhancing cognitive function among patients with cognitive impairment, with a standardized mean difference (SMD) of 0.52 (95% CI: 0.07, 0.98; P < 0.001). Subgroup analysis further demonstrated that the largest effect size was observed for studies utilizing the Mini-Mental State Examination (MMSE) scale as the outcome measure (SMD = 0.88). Additionally, the greatest efficacy was associated with single-strain probiotics (SMD = 0.81), and interventions lasting ≤12 weeks exhibited the most pronounced effect (SMD = 0.61).

CONCLUSION

Probiotics have been shown to enhance cognitive function, with a probiotic intervention program featuring a single probiotic strain and a duration of ≤12 weeks demonstrating particularly robust efficacy in improving cognitive function, as assessed by the MMSE scale.

Serum Interleukin-6 Levels may be a Key Determinant of 6-week Further Decompensation Risk in Patients With Cirrhosis and Acute Variceal Bleed: A Proof of Concept Study

Background and aims

Limited data exist on the role of systemic inflammation and gut barrier dysfunction in acute variceal bleed (AVB). We studied inflammatory markers and changes in the intestinal barrier in patients with AVB and assessed if these can be used to identify a higher risk subgroup with regard to outcomes.

Methods

In this prospective observational study, patients with cirrhosis and AVB presenting at a tertiary care center were stratified by whether or not they developed acute decompensation (AD) over 6 weeks follow-up. Utility of systemic inflammatory markers (interleukin-6 [IL-6], C-reactive protein), endotoxinemia (serum IgM/IgG anti-endotoxin antibodies), and duodenal epithelial tight junction proteins (TJPs) by immunohistochemistry (IHC) for tight-junction proteins (claudin-2,-4, zonula occludens-1(ZO-1), junctional adhesion molecule (JAM)) was assessed to predict the outcomes. These parameters were compared with a pre-existing cohort of patients with cirrhosis and no recent variceal bleed and with those without cirrhosis (dyspepsia with no endoscopic pathology). A nomogram was developed from multivariate model to predict 6-wk AD in patients with AVB.

Results

Patients with AVB(n = 66) (age:46.4 ± 11.7 years; etiology: alcohol/NASH/HBV/HCV [48.5%/12.1%/12.1%/7.6%]) were included. Twenty-four (36.3%) patients developed 6-wk AD. Patients with 6-wk AD had higher serum IL-6 (median: 156.14 pg/ml [IQR: 136.12-170.52] vs 58.28 pg/ml [31.70-110.67]; P < 0.001) and Child score (median: 9 [6.75-10.25] vs 7 [6-9]; P = 0.042) at baseline. Serum endotoxinemia and duodenal epithelial TJP were similar. A nomogram combining CTP and IL-6 was generated that predicted 6-wk AD with optimism-corrected c-statistic of 0.87. Comparison with non-bleeder cirrhosis (n = 52) (7.57 [5.48-9.87]) and dyspepsia controls (n = 53) (5.72 [4.40-6.45]; P < 0.001) also identified significant elevation of serum IL-6, not entirely explainable by derangements in TJP and bacterial translocation markers.

Conclusion

6-wk AD rates in patients with cirrhosis and AVB can be predicted using combination of Child score and serum IL-6.

Novel Mutation at Cys225 in GNAO1-Associated Developmental and Epileptic Encephalopathies: Clinical, Molecular, and Pharmacological Profiling of Case Studies

GNAO1-associated disorders have a large spectrum of neurological symptoms, from early-onset developmental and epileptic encephalopathies (DEE) to late-onset movement disorders. First reported in 2013 and now identified in around 400 cases worldwide, this disease is caused by dominant, mostly de novo missense mutations in GNAO1, the gene encoding the major neuronal G protein Gαo. Being the immediate transducer of a number of neuronal G protein-coupled receptors, Gαo plays crucial functions in brain development and physiology. Here, we discover a novel mutation site in GNAO1, Cys225 mutated to Tyr or Arg in pediatric individuals from France and China (p.(Cys225Tyr) and p.(Cys225Arg), respectively), leading to severe early-onset DEE. Molecular investigations characterize the novel pathogenic variants as deficient in the interactions with guanine nucleotides and physiological cellular partners of Gαo, with reduced stability and plasma membrane localization and a strong neomorphic interaction with the chaperone Ric8A. Salts of zinc, emerging as a promising targeted therapy for GNAO1-associated disorders, impose a previously unseen effect on the mutant Gαo, accelerating the loss of its ability to interact with guanine nucleotides. Our study, combining clinical, cellular, molecular, and modeling approaches, describes deep insights into molecular etiology and treatment perspectives of the novel form of GNAO1-associated disorders.

The clinical challenge of managing patients after sustained virological response with direct-acting antivirals for Hepatitis C

PURPOSE OF REVIEW

This review highlights the critical considerations for monitoring patients who achieve sustained virological response (SVR) after direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) infection. Despite the remarkable success of DAAs, challenges persist in managing long-term risks, including hepatocellular carcinoma (HCC), liver decompensation, and extrahepatic manifestations, necessitating a tailored follow-up approach.

RECENT FINDINGS

Recent studies emphasize that SVR does not eliminate risks for complications, particularly in patients with advanced fibrosis or cirrhosis. Advances in noninvasive tools, such as transient elastography and blood-based markers, have improved assessment of portal hypertension and liver function dynamics post-SVR. HCC surveillance remains critical for high-risk groups. Additionally, SVR improves extrahepatic conditions like mixed cryoglobulinemia and non-Hodgkin lymphoma, though careful monitoring for recurrence or associated risks is advised. Reinfection in high-risk populations underscores the importance of structured prevention and retreatment strategies.

SUMMARY

Tailored follow-up of post-SVR patients remains essential. Future research should focus on refining predictive tools for late complications and optimizing surveillance strategies, balancing cost-effectiveness with clinical outcomes.

Free Water MRI of White Matter in Wilson's Disease

BACKGROUND

Diffusion tensor imaging (DTI) is susceptible to partial volume effects from free water, which can be corrected by using bi-tensor free water imaging (FWI). This approach may improve the evaluation of microstructural changes associated with Wilson's disease (WD).

PURPOSE

To investigate microstructural changes in white matter of WD using DTI and FWI.

STUDY TYPE

Prospective.

SUBJECTS

Nineteen neurological WD (7 female, 31.68 ± 7.89 years), 10 hepatic WD (3 female, 29.67 ± 13.37 years), and 25 healthy controls (13 female, 29.5 ± 7.7 years).

FIELD STRENGTH/SEQUENCE

3-T, spin-echo echo-planar imaging diffusion-weighted imaging, T1-weighted, T2-weighted, fluid-attenuated inversion recovery.

ASSESSMENT

Various diffusion metrics, including mean diffusivity (MD), radial diffusivity (RD), fractional anisotropy (FA), axial diffusivity (AD), free water, and free water-corrected metrics (MDT, RDT, FAT, and ADT) were estimated and compared across entire white matter skeleton among neurological WD, hepatic WD, and controls. Voxel-wise tract-based spatial statistics and region of interest (ROI) analysis based on white matter atlas were performed. Additionally, partial correlation analysis was conducted to assess the relationship between FWI indices in ROIs and clinical indicators.

STATISTICAL TESTS

One-way analysis of variance, family-wise error correction for multiple comparisons, and Bonferroni correction for post hoc comparisons. A P-value <0.05, corrected for multiple comparisons, was considered statistically significant.

RESULTS

Our study found significantly lower FA and higher MD, AD, and RD across most of white matter skeleton in neurological WD. Decreased FAT and increased MDT, ADT, and RDT were observed only in limited white matter areas compared to DTI indices. Additionally, a significant relationship was found between Unified WD Rating Scale neurological subscale of neurological WD and free water (r = 0.613) in middle cerebellar peduncle, ADT (r = -0.555) in superior cerebellar peduncle, RDT (r = 0.655), and FAT (r = -0.660) in posterior limb in internal capsule.

DATA CONCLUSION

FWI may allow a more precise evaluation of microstructural changes in WD than conventional DTI, with FWI metrics potentially correlating with clinical severity scores of WD patients.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: Stage 2.

HBcrAg and cirB-RNA Do Not Predict Clinical and Virological Outcomes in Patients With HBeAg-Negative Chronic Infection

BACKGROUND & AIMS

Predicting clinical and virological outcomes in HBeAg-negative (HBeAg-neg) chronic infection often requires long-term monitoring. Our study explored whether a single measurement of quantitative HBsAg (qHBsAg), HBV core-related antigen (HBcrAg), and circulating HBV RNA (cirB-RNA) can define the natural course of untreated HBeAg-neg chronic infection patients.

METHODS

To this aim, we included 128 naïve HBeAg-neg chronic infection patients, stratified according to qHBsAg levels in: (1) 10-1000 IU/mL, (2) 1000-10 000 IU/mL, and (3) > 10 000 IU/mL.

RESULTS

HBcrAg and cirB-RNA were detected in 27% and 19% of patients with qHBsAg > 1000 IU/mL but rarely detected in patients with qHBsAg < 1000 IU/mL. After a median follow-up of 5.1 years, 9.4% of patients lost HBsAg, and 8.5% experienced an increase in HBV DNA > 2000 IU/mL. qHBsAg < 1000 IU/mL was the only factor independently associated with functional cure.

CONCLUSIONS

In untreated HBeAg-neg chronic infection patients, single-point cirB-RNA and HBcrAg do not offer additional predictive value over qHBsAg < 1000 IU/mL for spontaneous HBsAg loss.

Optimal Management of the Inpatient With Decompensated Cirrhosis

Over the past several years, there has been a wealth of new data pertaining to the management of complications of cirrhosis, resulting in several important updates to best practices and consensus guidelines. Despite these advancements and numerous recent targeted quality initiatives, hospitalizations resulting from complications of cirrhosis remain frequent, costly and associated with poor patient outcomes. An emphasis on evidence-based management of hospitalized patients with decompensated cirrhosis has the potential to decrease readmission rates and length of stay while improving overall patient outcomes. Herein, we provide an updated, evidence-based overview of the optimal inpatient management of the most frequently encountered complications associated with cirrhosis.

Cerebral Edema in Acute Liver Failure: Insights From Autopsy

Acute liver failure (ALF) is a rare critical illness with a high mortality, characterised by the abrupt loss of hepatic function associated with altered consciousness from hepatic encephalopathy. In some patients, the further development of cerebral edema (CE) and intracranial hypertension (ICH) with cerebral herniation (CH) can be fatal. The current prevalence of CE and CH is unknown, and the utility of clinical physical signs and cerebral computed tomography (CT) imaging to assess the presence of CE and ICH has had limited evaluation. We investigated these issues in a large ALF patient series, evaluating cerebral findings at autopsy. The prevalence of CE and CH was markedly lower than previously reported, present in only a minority of cases studied. Younger age, more severe HE, and vasopressor requirement were closely associated with CE and CH, and manifestations were present early after transfer to a transplantation centre. External clinical signs were specific for CE but lacked sensitivity, failing to identify the majority of autopsy-proven cases. Cerebral CT showed high specificity, sensitivity, and accuracy.

Longitudinal Evolution of the Brain Microstructure in Cirrhotic Patients on Diffusion Kurtosis Imaging

BACKGROUND

Although improvement of cognitive function after liver transplantation has been demonstrated in several neuropsychological studies, there is limited research on longitudinal changes in the cirrhotic patients' brain structure before and after transplantation.

PURPOSE

To investigate longitudinal changes of brain microstructure in cirrhotic patients using diffusion kurtosis imaging (DKI).

STUDY TYPE

Prospective.

SUBJECTS

A total of 153 cirrhosis patients, comprising 60 hepatic encephalopathy (HE) patients (16 females/44 males) and 93 no-HE patients (35 females/58 males), along with 93 healthy controls (HCs) (53 females/40 males) were enrolled. Subsequently, 58 recipients completed 1-month postoperative follow-up, 29 patients completed 1-, 3-months, and 17 patients completed 1-, 3-, 6-month follow-up.

SEQUENCE

Spin-echo single-shot echo-planar sequence using a 3.0 T scanner.

ASSESSMENT

Diffusion kurtosis estimator software was used to estimate the DKI parameter maps by a MR imaging physicist (Y.-Y.C. with 12 years of experience).

STATISTICAL TESTS

The diffusion metrics (eg, radial kurtosis [RK], mean kurtosis, fractional anisotropy, mean diffusivity) of the patients before transplantation were compared with those of the HCs using voxel-wise analysis of variance (ANOVA), along with t tests for post hoc analysis. Linear mixed-effects models were applied to the longitudinal data. We imposed a cluster level Family Wise Error (FWE) correction rate of PFWE = 0.05 with voxel-wise cutoff of P = 0.001 together with a cluster-size cutoff of N ≥ 56, and generated smoothness estimates from the preprocessed data using the mixed-model autocorrelation function.

RESULTS

The RK metrics of the patients decreased significantly in the anterior cingulate cortex (HE/no-HE < HC, ANOVA-F = 21.91). After transplantation, the RK of the pallidum showed a continuous upward trend (time effect T = 11.26); whereas the RK of the right postcentral gyrus showed a continuous downward trend (time effect T = -9.56). In addition, the RK in superior longitudinal fasciculus showed new-onset decrease after transplantation.

DATA CONCLUSION

Longitudinal changes in DKI metrics reveal the course of brain microstructural changes before and after transplantation in cirrhotic patients, potentially associated with cognitive alterations after surgery.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY: Stage 4.

Extracellular vesicles from Lacticaseibacillus paracasei reduce neuroinflammation in hippocampus and restore some cognitive functions in hyperammonemic rats

Cirrhotic patients may show minimal hepatic encephalopathy (MHE) which impairs life quality and span. There is a need of new safe treatments for MHE. Hyperammonemia is a main contributor to MHE. Hyperammonemic rats reproduce the cognitive impairment present in patients with MHE, which is mediated by neuroinflammation and altered glutamatergic neurotransmission in hippocampus. Probiotics induce positive effects in MHE patients, which could be mediated by bacterial extracellular vesicles (EVs). The aims of this work were to evaluate in hyperammonemic rats: 1) if intravenous administration of EVs from L. paracasei improves memory and learning and 2) reduces neuroinflammation in hippocampus and 3) to study the mechanisms involved using an ex vivo approach. It is shown that intravenous injection of EVs from L. paracasei reverses glial activation in hippocampus and cognitive impairment in hyperammonemic rats. Ex vivo studies in hippocampal slices show that hyperammonemia increases TNFα and TNFR1 and S1PR2 membrane expression and activation, leading to increased IL-1β content and activation of IL-1 receptor and of Src. This increases CCL2 and BDNF and TrkB activation. This leads to increased membrane expression of the NR2B subunit of the NMDA receptor and of the GluA2 subunit of AMPA receptors and reduced membrane expression of the GluA1 subunit, leading to cognitive impairment. EVs from L. paracasei reduce neuroinflammation in hyperammonemic rats and restore the function of the TNFα-TNFR1-S1PR2-IL-1β-CCL2-BDNF-TrkB pathway, glutamatergic neurotransmission and cognitive function in rats with hyperammonemia and MHE. This suggests that these EVs could also improve cognitive function in cirrhotic patients with MHE.

Differences between hepatocellular carcinoma caused by alcohol and other aetiologies

Alcohol-related liver disease is the third leading cause of hepatocellular carcinoma worldwide and the leading cause in Europe. Additionally, the recent definition of metabolic dysfunction-associated steatotic liver disease with increased alcohol intake (MetALD) will enrich this population with a more nuanced phenotype, reflecting recent epidemiological trends. In these patients, the hepatocellular carcinoma diagnosis is often delayed and less frequently detected through screening programmes. Moreover, at the time of diagnosis, patients with alcohol-related hepatocellular carcinoma tend to have a poorer general condition, more severely impaired liver function, and a higher prevalence of comorbidities, leading to increased competitive mortality. However, when hepatocellular carcinoma is diagnosed during surveillance programmes in patients with alcohol-related liver disease or MetALD, the rate of allocation to first-line curative treatments is high (56%) and comparable to that of patients with virus-related hepatocellular carcinoma. As a consequence, the aetiology of the underlying cirrhosis cannot be considered an independent prognostic factor in patients with hepatocellular carcinoma. Instead, prognosis is driven by liver function, general condition, and tumour burden. This underscores the crucial role of early diagnosis through periodic surveillance in patients with alcohol- or MetALD-related cirrhosis.

ACG Clinical Guideline: Malnutrition and Nutritional Recommendations in Liver Disease

Malnutrition, defined as deficiency, excess, or imbalance of nutrients, is a common complication in patients with liver disease, especially those with cirrhosis. Malnutrition may present as an isolated micronutrient deficiency, such as zinc deficiency, and it commonly presents as frailty and/or sarcopenia in patients with advanced liver disease. Patients with cirrhosis and/or alcohol-associated hepatitis should be assessed for malnutrition because it adversely affects patient outcomes including mortality, as well as waitlist and posttransplant outcomes among liver transplant candidates. The prevalence of malnutrition varies based on the method of assessment and disease severity, being higher in those with advanced liver disease. Among stable outpatients with cirrhosis, counseling should be done to eat small frequent meals, a night-time snack between 7 PM and 10 PM, and 2 or more cups of coffee daily. In selected patients with metabolic dysfunction-associated steatohepatitis, vitamin E 800 IU/d should be provided. Among hospitalized patients with cirrhosis, nutritional supplementation preferably by enteral route should be implemented in those with poor oral intake of daily requirements of proteins and/or calories. Protein intake should not be restricted including patients with decompensated cirrhosis and hepatic encephalopathy. A vegetable source of protein seems to be better tolerated than an animal source of protein in patients with hepatic encephalopathy. Branched chain amino acids augment the efficacy of lactulose and rifaximin in the treatment of hepatic encephalopathy. Level of evidence and strength of recommendations were evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations system. This guideline was developed under the auspices of the American College of Gastroenterology Practice Parameters Committee.

Enhancing Liver Nodule Visibility and Diagnostic Classification Using Ultrasound Local Attenuation Coefficient Slope Imaging

OBJECTIVE

B-mode ultrasound (US) presents challenges in accurately detecting and distinguishing between benign and malignant liver nodules. This study utilized quantitative US local attenuation coefficient slope (LACS) imaging to address these limitations.

MATERIALS AND METHODS

This is a prospective, cross-sectional study in adult patients with definable solid liver nodules at US conducted from March 2021 to December 2023. The composite reference standard included histopathology when available or magnetic resonance imaging. LACS images were obtained using a phantom-free method. Nodule visibility was assessed by computing the contrast-to-noise ratio (CNR). Classification accuracy for differentiating benign and malignant lesions was assessed with the area under the receiver operating characteristic curve (AUC), along with sensitivity and specificity.

RESULTS

The study enrolled 97 patients (age: 62 y ± 13 [standard deviation]), with 57.0% malignant and 43.0% benign observations (size: 26.3 ± 18.9 mm). LACS images demonstrated higher CNR (12.3 dB) compared to B-mode (p < 0.0001). The AUC for differentiating nodules and liver parenchyma was 0.85 (95% confidence interval [CI]: 0.79-0.90), with higher values for malignant (0.93, CI: 0.88-0.97) than benign nodules (0.76, CI: 0.66-0.87). A LACS threshold of 0.94 dB/cm/MHz provided a sensitivity of 0.83 (CI: 0.74-0.89) and a specificity of 0.82 (CI: 0.73-0.88). LACS mean values were higher (p < 0.0001) in malignant (1.28 ± 0.27 dB/cm/MHz) than benign nodules (0.98 ± 0.19 dB/cm/MHz).

CONCLUSION

LACS imaging improves nodule visibility and provides better differentiation between benign and malignant liver nodules, showing promise as a diagnostic tool.

Early living donor liver transplantation for alcohol-associated hepatitis: Status in the era of increasing demand, unmet needs, and future considerations

Hazardous alcohol consumption is the leading cause of liver disease worldwide. Alcohol-associated hepatitis (AH) is an acute and serious presentation of alcohol-associated liver disease that is associated with high short-term mortality. Medical management remains limited to corticosteroid therapy and intensive nutrition but improves survival in <50% of individuals. Liver transplantation (LT) is increasingly recognized as a treatment option for many patients with AH and may lead to greater survival benefits than medical management alone. The rate of waitlistings and LTs for AH has doubled in recent years, especially in the United States. Several studies from the West have reported early LT for AH to be successful, where deceased donor LT is the norm. The challenges of LT in living donor centers, particularly for those with AH, are unique and have previously not been discussed in depth. In this review, we aim to discuss the challenges unique to LDLT with respect to candidate and donor selection, ethical considerations, disparities in LDLT, post-LT alcohol relapse, and measures to prevent them while also addressing the definitions and outcomes of early-living donor liver LT for AH.

Alpha-1 antitrypsin deficiency-associated liver disease: From understudied disorder to the poster child of genetic medicine

Alpha-1 antitrypsin deficiency (AATD) constitutes an inborn disorder arising due to mutations in alpha-1 antitrypsin (AAT), a secreted protease inhibitor produced primarily in hepatocytes. It leads to diminished serum AAT levels, and this loss-of-function predisposes to chronic obstructive pulmonary disease and lung emphysema. The characteristic Pi*Z mutation results in hepatic Z-AAT accumulation. In its homozygous form (Pi*ZZ genotype), it is responsible for the majority of severe AATD cases and can cause both pediatric and adult liver disease, while the heterozygous form (Pi*MZ) is considered a disease modifier that becomes apparent primarily in the presence of other comorbidities or risk factors. In the current review, we collate conditions associated with AATD, introduce typical AAT variants, and discuss our understanding of disease pathogenesis. We present both cross-sectional and longitudinal data informing about the natural disease history and noninvasive tools that can be used for disease stratification as well as a basis for disease monitoring. Given that AATD-associated liver disease is highly heterogeneous, we discuss the risk factors affecting disease progression. While the loss-of-function lung disease is treated by weekly intravenous administration of purified AAT, recombinant modified AAT and oral protease inhibitors are currently in clinical trials. Among the liver candidates, small interfering RNA fazirsiran efficiently suppresses AAT production and is currently in phase 3 clinical trial, while several other genetic approaches, such as RNA editing, are at earlier stages. In summary, AATD represents a systemic disorder increasingly seen in the hepatologic routine and requiring thorough interdisciplinary care, since the currently ongoing clinical trials often address only one of the organs it affects.

MetALD: New Perspectives on an Old Overlooked Disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) and alcohol-associated liver disease (ALD) are the major contributors to the liver disease burden globally. The rise in these conditions is linked to obesity, type 2 diabetes, metabolic syndrome and increased alcohol consumption. MASLD and ALD share risk factors, pathophysiology and histological features but differ in their thresholds for alcohol use, and the ALD definition does not require the presence of metabolic dysfunction. A recent multi-society consensus overhauled the nomenclature of liver steatosis and introduced the term MetALD to describe patients with metabolic dysfunction who drink more than those with MASLD and less than those with ALD. This new terminology aims to enhance the understanding and management of liver disease but poses challenges, such as the need to accurately measure alcohol consumption in research and clinical practice settings. Recent studies show that MetALD has significant implications for patient management, as it is associated with increased mortality risks and more severe liver outcomes compared to MASLD alone. MetALD patients face increased risks of liver disease progression, cancer and cardiovascular disease. The diagnosis of MetALD involves the adequate quantification of alcohol use through standardised questionnaires and/or biomarkers as well as proper assessment of liver disease stage and progression risk using non-invasive tools including serologic markers, imaging, elastography techniques and genetic testing. Effective management requires addressing both metabolic and alcohol-related factors to improve outcomes. This review intends to provide a comprehensive overview of MetALD, covering pathogenesis, potential diagnostic approaches, management strategies and emerging therapies.

Relative Exchangeable Copper, Exchangeable Copper and Total Copper in the Diagnosis of Wilson Disease

BACKGROUND AND AIMS

Diagnosing Wilson disease (WD) remains challenging. The exchangeable copper (CuEXC) methodology measures the non-ceruloplasmin-bound copper fraction in serum. Relative exchangeable copper (REC), the ratio of CuEXC to total serum copper (Total Cu), has been proposed as a potential diagnostic biomarker. This study aimed to evaluate the diagnostic performance of these three copper biomarkers in WD.

METHODS

CuEXC and Total Cu levels were measured in newly diagnosed treatment-naïve patients with WD (n = 13), treated WD (n = 91), non-Wilsonian hepatic disease (n = 206) and non-Wilsonian acute liver failure (n = 22). REC, CuEXC and Total Cu were compared among groups. Receiver-operating characteristic analyses were performed.

RESULTS

Median REC was significantly elevated among patients with WD compared to all other groups combined (23.6% vs. 4.9%, p < 0.001). The opposite was found for Total Cu (3.5 μmol/L vs. 17.2 μmol/L, p < 0.001). In newly diagnosed patients with WD, median REC was significantly higher than in treated patients (29.1% vs. 21.6%, p = 0.008). The optimal diagnostic cut-off value for REC was ≥ 13.8% (sensitivity 100% and specificity 99.6%) for newly diagnosed patients versus those with non-Wilsonian hepatic disease. For Total Cu, the optimal cut-off was ≤ 7.1 μmol/L (sensitivity 61.5% and specificity 99.1%) for newly diagnosed patients with WD versus those with non-Wilsonian hepatic disease.

CONCLUSION

Our data support the diagnostic value of REC in WD. The more broadly available Total Cu also demonstrates a strong diagnostic performance and may be useful in initial work-up. We suggest including REC and/or Total Cu in a future revision of the Leipzig score.

Endoscopy Sedation Challenges in Patients With Hepatic Encephalopathy: A Focused Review on Propofol and Selective Use of Benzodiazepines

BACKGROUND

Hepatic encephalopathy (HE) presents a significant challenge in gastrointestinal endoscopy sedation due to impaired liver function, which alters drug metabolism and increases the risk of adverse effects. In the absence of clear guidelines and specific biomarkers for diagnosis and assessment of HE, there is insufficient evidence to formulate standardized protocols for management, diagnosis, and sedation during endoscopy.

AREAS OF UNCERTAINTY

Rigid protocols for sedation are difficult to implement due to wide variation in patient age, comorbidities, and disease severity, which creates a "gray zone." This leaves decisions heavily reliant on the clinician's preference or experience, patient characteristics, and institutional protocols. This review highlights the strengths and limitations of propofol, midazolam, and remimazolam in efforts to improve sedation strategies for endoscopic procedures in patients with HE.

DATA SOURCES

A review was conducted using PubMed and Scopus databases, keeping in view recent publications. Only primary research studies were considered for this review. Inclusion was based on the relevance of patient side effects, sedation outcomes, and safety profiles, with a particular focus on gastrointestinal endoscopy procedures and their implications in HE.

RESULTS

Propofol remains preferred in patients with HE, demonstrating manageable cardiovascular and respiratory events without worsening encephalopathy. However, its safety requires careful consideration in this high-risk population. The combination of propofol with adjuncts, such as esketamine, has shown potential in mitigating adverse effects and optimizing sedation protocols in challenging cases. Midazolam, though historically used, is not recommended in HE due to exacerbation of encephalopathy and unfavorable safety profiles. While remimazolam shows promise, no evidence in HE populations precludes definitive conclusions about its efficacy and safety.

CONCLUSIONS

Future research should focus on optimizing sedation protocols according to the needs of HE patients, including tools for risk stratification and guidelines considering individual patient profiles. Furthermore, studies must be performed to evaluate remimazolam's outcomes and safety profiles, both as a standalone sedative and in combination with other agents.

The physiological role of copper: Dietary sources, metabolic regulation, and safety concerns

Copper plays an important physiological role in the body, with both deficiency and excess potentially impacting overall health. The body maintains a stringent copper metabolism mechanism to oversee absorption, utilization, storage, and elimination. Dietary consumption serves as the principal source of copper. The dietary factors may interfere with the absorption and metabolism of copper, leading to fluctuation of copper levels in the body. However, these dietary factors can also be strategically employed to facilitate the precise regulation of copper. This paper delved into the advancements in research concerning copper in food processing, including dietary sources of copper, the regulatory processes of copper metabolism and health implications of copper. The safety and its underlying mechanisms of excess copper were also highlighted. In particular, the paper examines the influence of dietary factors on the absorption and metabolism of copper, aiming to provide direction for accurate copper regulation and the creation of functional foods and pharmaceuticals.

The Eradication of Hepatitis C Virus after Liver Transplantation Improved Liver Function and Maintained the Health-related Quality of Life

BACKGROUND

The outcomes of hepatitis C virus eradication and health-related quality of life in the patients treated with direct-acting antivirals (DAAs) after liver transplantation were examined.

METHODS

Thirty-five patients with HCV infection treated with sofosbuvir/ledipasvir after liver transplantation were enrolled in the study. The achievement rate of sustained viral response (SVR), liver function and health-related quality of life based on Short-Form-36 version 2 were evaluated.

RESULTS

All 35 patients achieved SVR and liver function was improved to a level comparable to that of non-transplanted cases by the DAA treatment. As to health-related quality of life, the scores of general health, vitality and mental health were comparable to Japanese national standard scores among 8 subscales of Short-Form-36 version 2.

CONCLUSION

HCV eradication after liver transplantation is useful for not only improving liver function but maintaining health-related quality of life.

N,N'-bis(2-mercaptoethyl)isophthalamide (NBMI) as a novel chelator for Wilson's disease

Wilson's Disease (WD) is a rare autosomal recessive disorder caused by mutations in the ATP7B gene. These mutations lead to defective copper (Cu) transport and to accumulation of Cu in tissues, primarily in the liver and brain. Current treatment options such as D-penicillamine, trientine, and zinc salts focus on increasing Cu excretion or reducing Cu absorption, but often cause debilitating side effects. N,N'-bis(2-mercaptoethyl)isophthalamide (NBMI) is a lipophilic thiol-based compound originally developed for environmental decontamination. It has been shown to chelate toxic metals such as mercury, lead, and cadmium. This study was designed to evaluate the efficacy of NBMI to mitigate Cu overload using both in vitro and in vivo models of WD. HepG2 cells with the ATP7B gene knocked down had increased sensitivity to copper sulfate (CuSO4) compared to wild-type (WT) cells, validating the cell model for WD. Pretreatment with NBMI (2.5-50 μM) improved cell viability, reduced Cu-induced oxidative stress, decreased metallothionein levels, mitigated resulting DNA damage, and reduced overall levels of free intracellular Cu. In an established toxic milk mouse (tx-J) model of WD, 1% dietary NBMI effectively lowered hepatic, cerebral, and renal Cu levels. Treatment with 1% NBMI also improved liver function, as evidenced by reduced ALT levels and normalized hepatocyte morphology. Tx-J mice displayed higher liver-to-body weight ratios compared to WT mice, and treatment with 1% NBMI effectively reduced this ratio. While NBMI did not impact the elevated white blood cell counts and low platelet levels characteristic of tx-J mice, it also did not cause any detrimental effects on red blood cell, hemoglobin, and hematocrit levels. This dose of NBMI also restored homeostasis of other dysregulated essential metal ions in tx-J mice. These findings suggest that dietary administration of NBMI effectively chelates excess free Cu, ameliorates WD symptoms and offers a promising alternative to existing chelators.

Clinical and biochemical footprints of inherited metabolic diseases: Ia. Movement disorders, updated

Movement disorders are a common manifestation of inherited metabolic diseases (IMDs), categorized into hyperkinetic movement disorders, hypokinetic-rigid syndromes, ataxia, and spasticity. We reviewed and updated the list of known metabolic disorders associated with movement disorders, identifying a total of 559 IMDs. We outlined the more common and treatable causes, sorted by the dominant movement disorder phenomenology, and provided a practical clinical approach for suspected IMDs presenting with movement disorders. This work represents an updated catalog in a series of articles aimed at creating and maintaining a comprehensive list of clinical and metabolic differential diagnoses based on system involvement.

Sex-specific differences in NAFLD development: effect of a high-sucrose diet on biochemical, histological, and genetic markers in C57bl/6N mice

Sucrose intake is a potential risk factor for non-alcoholic fatty liver disease (NAFLD). Individual characteristics such as sex, play arole in the biological variation of the disease, potentially related to genetic regulation. This research evaluated sex differences in biochemical, histopathological, and gene expression responses associated with NAFLD in C57bl/6N mice on a high sucrose diet. Female and male mice were assigned to control or high sucrose diets (50% sucrose solution) for 20 weeks. After sacrifice, blood and hepatic tissue were collected for analysis. Female mice revealed moderate-to-high NAFLD, whereas male mice showed mild-to-moderate NAFLD. Sex-specific variations were observed in Cd36 gene expression, an upregulation in females compared with the male group, and Adipor1 gene expression showed significant downregulation in the female group in response to high sucrose diet compared with the control group. These findings highlight the importance of considering gender disparities in the treatment and management of NAFLD.

Novel hypothesis and therapeutic interventions for irritable bowel syndrome: interplay between metal dyshomeostasis, gastrointestinal dysfunction, and neuropsychiatric symptoms

Irritable bowel syndrome is a gastrointestinal disorder due to multiple pathologies. While patients with this condition experience anxiety and depressed mood more frequently than healthy individuals, it is unclear how gastrointestinal dysfunction interacts with such neuropsychiatric symptoms. Data suggest that irritable bowel syndrome patients predominantly display a lower zinc intake, which presumably impairs enterochromaffin cells producing 5-hydroxytryptamine, gut bacteria fermenting short-chain fatty acids, and barrier system in the intestine, with the accompanying constipation, diarrhea, low-grade mucosal inflammation, and visceral pain. Dyshomeostasis of copper and zinc concentrations as well as elevated pro-inflammatory cytokine levels in the blood can disrupt blood-cerebrospinal fluid barrier function, leading to locus coeruleus neuroinflammation and hyperactivation with resultant amygdalar overactivation and dorsolateral prefrontal cortex hypoactivation as found in neuropsychiatric disorders. The dysregulation between the dorsolateral prefrontal cortex and amygdala is likely responsible for visceral pain-related anxiety, depressed mood caused by anticipatory anxiety, and visceral pain catastrophizing due to catastrophic thinking or cognitive distortion. Collectively, these events can result in a spiral of gastrointestinal symptoms and neuropsychiatric signs, prompting the progression of irritable bowel syndrome. Given that the negative feedback mechanism in regulation of the hypothalamic-pituitary-adrenal axis is preserved in a subset of neuropsychiatric cases, dorsolateral prefrontal cortex abnormality accompanied by neuropsychiatric symptoms may be a more significant contributing factor in brain-gut axis malfunction than activation of the hypothalamic corticotropin-releasing hormone system. The proposed mechanistic model could predict novel therapeutic interventions for comorbid irritable bowel syndrome and neuropsychiatric disorders.

Chemoprevention of Gastrointestinal Cancers: An Umbrella Review of Meta-Analyses of Randomized Controlled Trials and Cohort Studies

Several meta-analyses have investigated the association between chemopreventive agents (CPAs) and the risk of gastrointestinal cancers, but syntheses of the quality of evidence in aggregate are lacking. This umbrella review aimed to assess the quality of evidence from meta-analyses of randomized controlled trials (RCTs) and cohort studies that examine inverse associations between CPAs and the risk of gastrointestinal cancers or any premalignant conditions. Summary effect sizes from random-effects models, between-study heterogeneity, 95% prediction interval, small-study effect, excess significance, and credibility ceilings were devised to classify the credibility of evidence from meta-analyses of cohort studies, whereas the GRADE approach was used for meta-analyses of RCTs. From 20,296 publications, 577 full-text articles were evaluated for eligibility, and 69 articles that provided 194 unique meta-analyses were included. Among meta-analyses of RCTs (N = 93), 26 reached statistical significance (p < 0.05). Seven inverse associations were graded as either high quality (celecoxib and colorectal adenomas, (N = 4)) or moderate (aspirin and colorectal adenomas, (N = 2) and H-pylori eradication and gastric cancer (N = 1)). Among meta-analyses of cohort studies (N = 101), 60 reached statistical significance. Four inverse associations were graded as either convincing (antivirals with hepatocellular carcinoma (HCC); N = 1) or highly suggestive (aspirin with HCC (N = 2) and colorectal cancer (N = 1)). This review suggests that the associations with the most consistent empirical evidence were confined to those targeting the well-established risk factors of gastrointestinal cancer progression. Despite the limited established evidence, the inverse associations observed between metformin and colorectal, esophageal, and gastric cancers, as well as between statins and HCC and gastric cancer, merit further research.