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.

Impact of FcRn antagonism on vaccine-induced protective immune responses against viral challenge in COVID-19 and influenza mouse vaccination models

Antagonism of the neonatal Fc receptor through an engineered antibody Fc fragment, such as efgartigimod, results in a decrease in immunoglobulin G levels. This approach is being evaluated as a therapeutic strategy for the treatment of IgG-mediated autoimmune diseases. Our goal was to evaluate the impact of mFc-ABDEG, a mouse-adapted antibody Fc fragment with a mode of action highly similar to efgartigimod, on vaccine-induced protective immune responses against viral infections. Therefore, mouse vaccination models for COVID-19 and influenza were employed, utilizing an mRNA COVID-19 vaccine (COMIRNATY) and an adjuvanted, inactivated quadrivalent influenza vaccine (Seqirus+AddaVax), respectively. In both models, vaccination induced robust humoral responses. As expected, animals treated with mFc-ABDEG had lower levels of virus-specific IgG, while virus-specific IgM responses remained unaffected. The COVID-19 vaccine induced a strong Th1-type T cell response irrespective of mFc-ABDEG treatment. Influenza vaccination resulted in a poor T cell induction, regardless of mFc-ABDEG treatment, due to the Th2-biased response that inactivated influenza vaccines typically induce. Importantly, mFc-ABDEG treatment had no effect on protective immunity against live viral challenges in both models. Vaccinated animals treated with mFc-ABDEG were equally protected as the non-treated vaccinated controls. These non-clinical data demonstrate that FcRn antagonism with mFc-ABDEG did not affect the generation of vaccine-induced protective humoral and cellular responses, or protection against viral challenges. These data substantiate the clinical observations that, although IgG titers were reduced, FcRn antagonism with efgartigimod did not impair the ability to generate new specific IgG responses, regardless of the timing of vaccination.

Predictors of Mortality in Patients Diagnosed With Autoimmune Hepatitis - Insights from a Prospective, 90-day Follow--up Study

Background and aims

The response to corticosteroids and optimal timing for liver transplantation (LT) in patients with autoimmune hepatitis (AIH) remain significant clinical challenges. This study aimed to assess short-term (90-day) mortality in patients with acute AIH (with or without underlying cirrhosis and chronic liver disease) treated with corticosteroids, and to identify factors that predict mortality in this population.

Methods

We conducted a prospective, single-center study between 2022 and 2024, involving patients with histologically confirmed AIH. All patients received corticosteroid treatment and were monitored for various clinical and laboratory parameters on days 3, 7, and 90 after initiating therapy.

Results

A total of 104 patients were included in the study, with a mean age of 46.1 ± 14.3 years; 77% of the patients were female. The 90-day mortality rate following the initiation of corticosteroids was 13.47%. Univariate analysis identified several significant predictors of mortality, including older age, diabetes mellitus, cirrhosis, esophageal varices, hepatic encephalopathy, low serum albumin on day 3, model of end-stage liver disease (MELD) scores on days 3 and 7, and the survival and prognostic factors for acute severe autoimmune hepatitis (SURFASA) score (P < 0.05). Multivariate analysis revealed that MELD score on day 7 (odds ratio [OR] 1.25; 95% confidence interval [CI] {1.09-1.48}; P = 0.00) and SURFASA score (OR 7.46; 95% CI {1.05-53.06}; P = 0.04) were significant. Specifically, a MELD score ≥27.5 on day 7 (area under the receiver operating characteristic curve [AUC] = 0.998) with 100% sensitivity and 97.8% specificity, and a SURFASA score ≥ -2.95 (AUC = 0.969) with 100% sensitivity and 95.6% specificity were highly predictive of mortality.

Conclusion

Despite corticosteroid treatment, mortality rates remain high in the decompensated AIH and acute on chronic liver failure-AIH groups. The SURFASA score, along with MELD scores on days 3 and 7, are strong predictors of mortality and can assist clinicians in making timely decisions regarding referral for early liver transplantation.

Human-genetic variants associated with susceptibility to SARS-CoV-2 infection

SARS-CoV-2, the third major coronavirus of the 21st century, causing COVID-19 disease, profoundly impacts public health and workforces worldwide. Identifying individuals at heightened risk of SARS-CoV-2 infection is crucial for targeted interventions and preparedness. This study investigated 35 SNVs within viral infection-associated genes in SARS-CoV-2 patients and uninfected controls from the Basque Country (March 2020-July 2021). Its primary aim was to uncover genetic markers indicative of SARS-CoV-2 susceptibility and explore genetic predispositions to infection. Association analyses revealed previously unreported associations between SNVs and susceptibility. Haplotype analyses uncovered novel links between haplotypes and susceptibility, surpassing individual SNV associations. Descriptive modelling identified key susceptibility factors, with rs11246068-CC (IFITM3), rs5742933-GG (ORMDL1), rs35337543-CG (IFIH1), and GGGCT (rs2070788, rs2298659, rs17854725, rs12329760, rs3787950) variation in TMPRSS2 emerging as main infection-susceptibility indicators for a COVID-19 pandemic situation. These findings underscore the importance of integrated SNV and haplotype analyses in delineating susceptibility to SARS-CoV-2 and informing proactive prevention strategies. The genetic markers profiled in this study offer valuable insights for future pandemic preparedness.

Immunocompetent tumor-on-a-chip: A translational tool for drug screening and cancer therapy

Tumor is one of the major diseases endangering human health while establishing an efficient in vitro tumor microenvironment (TME) model, which is an effective way to reveal the nature of the tumor and develop therapeutic methods. In recent years, due to the continuous development of lab-on-a-chip technology and tumor biology, various tumor-on-a-chip models applied to oncology research have emerged. Among them, the Immunotherapy-on-a-chip (ITOC) platform stands out with its ability to reflect immunological behavior in the TME. It is a class of in vitro tumor-on-a-chip with immune activity, which has good performance and the ability to reproduce TME. It can highly simulate the complex pathophysiological characteristics of tumors and be used to study various features related to tumor biological behavior. Currently, many advantageous functions and application values of ITOC platforms have been discovered and applied to tumor drug screening and development, tumor immunotherapy, and personalized therapy. In conclusion, the tumor-on-a-chip platform is a highly promising model for medical oncology research. In this review, the background of the ITOC platform, key factors for constructing an ideal ITOC platform, and the specific applications of ITOC platforms in tumor research and treatment are introduced.

Preliminary study on detection and diagnosis of focal liver lesions based on a deep learning model using multimodal PET/CT images

Objectives

To develop and validate a deep learning model using multimodal PET/CT imaging for detecting and classifying focal liver lesions (FLL).

Methods

This study included 185 patients who underwent 18F-FDG PET/CT imaging at our institution from March 2022 to February 2023. We analyzed serological data and imaging. Liver lesions were segmented on PET and CT, serving as the "reference standard". Deep learning models were trained using PET and CT images to generate predicted segmentations and classify lesion nature. Model performance was evaluated by comparing the predicted segmentations with the reference segmentations, using metrics such as Dice, Precision, Recall, F1-score, ROC, and AUC, and compared it with physician diagnoses.

Results

This study finally included 150 patients, comprising 46 patients with benign liver nodules, 51 patients with malignant liver nodules, and 53 patients with no FLLs. Significant differences were observed among groups for age, AST, ALP, GGT, AFP, CA19-9and CEA. On the validation set, the Dice coefficient of the model was 0.740. For the normal group, the recall was 0.918, precision was 0.904, F1-score was 0.909, and AUC was 0.976. For the benign group, the recall was 0.869, precision was 0.862, F1-score was 0.863, and AUC was 0.928. For the malignant group, the recall was 0.858, precision was 0.914, F1-score was 0.883, and AUC was 0.979. The model's overall diagnostic performance was between that of junior and senior physician.

Conclusion

This deep learning model demonstrated high sensitivity in detecting FLLs and effectively differentiated between benign and malignant lesions.

Long-Term Outcomes According to Surgical Margin in Mass-Forming Cholangiocarcinoma: The Role of R1vasc

BACKGROUND

R0 resection is the standard for mass-forming cholangiocarcinoma (MFCCC). R1vasc resection (tumor-vessel detachment) yielded results comparable to R0 and superior to parenchymal-tumor exposure (R1par) for hepatocellular carcinoma and colorectal liver metastases. This study aims to clarify R1vasc outcomes for MFCCC.

PATIENTS AND METHODS

Margin status of patients with MFCCC undergoing resection between 2008 and 2022 was assessed to determine the oncological efficacy of R1vasc regarding survival and hepatic recurrence.

RESULTS

The study analyzed 125 patients: 68 (54.4%) R0, 18 (14.4%) R1vasc, 24 (19.2%) R1par, and 15 (12.0%) R1vasc + par. Tumor size was similar between R0 (4.4 cm, range 1.5-19.0) and R1vasc (4.3 cm, range 2.3-14.5, p = 0.754) but larger for R1par (8.2 cm, range 2.5-15.0, p = 0.005) and R1vasc + par (9.0 cm, range 5.0-17.0, p < 0.001). The median overall survival (OS) was comparable for R0 [64.8 months; 95% confidence interval (CI): 50.0-79.6], R1vasc (54.4 months; 95% CI 19.6-89.2; p = 0.932), and R1vasc + par (62.0 months; 95% CI 35.6-88.5; p = 0.989). R1par showed lower OS (26.8 months; 95% CI 16.1-37.6; p = 0.134). Local recurrence was higher for R1par (45.8%, p < 0.0001) compared with R0 (10.3%) and similar for R1vasc (16.6%) and R1vasc + par (20.0%). Survival after hepatic recurrence was higher for R1vasc compared with R1par (p = 0.041).

CONCLUSIONS

R1vasc is a valid option for increasing resectability in patients with MFCCC, with OS being comparable to R0. R1vasc + par may be necessary for larger tumors.

Quality Measures to Enhance the Management and Treatment of Primary Biliary Cholangitis: A Delphi Consensus Study

BACKGROUND & AIMS

Primary Biliary Cholangitis (PBC) is a chronic autoimmune liver disease characterised by bile duct destruction, leading to cholestasis and fibrosis. Despite therapeutic advancements, gaps remain in diagnostic standardisation, treatment response evaluation, and patient-centred care. This study aimed to develop consensus-driven quality measures to optimise PBC management.

METHODS

Using the Delphi methodology, 92 clinicians participated in two rounds of surveys addressing diagnostic protocols, therapeutic strategies, follow-up standards, and patient-reported outcomes (PROs). Appropriateness ratings were analysed using the RAND/UCLA method to achieve consensus on key quality measures.

RESULTS

Strong consensus was reached on the appropriateness of non-invasive diagnostic tools such as Vibration-Controlled Transient Elastography (VCTE) and abdominal ultrasound for staging and monitoring fibrosis in chronic cholestasis. Different treatment options were evaluated in patients with inadequate response to UDCA, including compensated cirrhosis (Child-Pugh A), with early initiation deemed appropriate in cases of UDCA intolerance or partial response. Genetic studies and liver biopsy showed variability in consensus, particularly for patients without biochemical cholestasis, reflecting areas needing further research.

CONCLUSIONS

This study establishes actionable quality measures for PBC care, offering specific recommendations on diagnostic protocols, therapeutic benchmarks, and follow-up standards. These measures go beyond guidelines by addressing gaps in patient stratification, follow-up protocols, and strategies. Future research should address cost-effectiveness, access to non-invasive tools, and implementation challenges such as clinician training and resource availability.

Association of sarcopenia assessed by CT/MRI with treatment response and clinical outcomes in noncirrhotic primary biliary cholangitis patients

BACKGROUND AND OBJECTIVE

Sarcopenia is a common complication in patients with cirrhosis. However, research on sarcopenia in patients with noncirrhotic primary biliary cholangitis (PBC) is limited. This study aimed to investigate the prevalence of sarcopenia and the associations between concomitant sarcopenia and the biochemical response to ursodeoxycholic acid (UDCA) treatment and clinical outcomes in patients with noncirrhotic PBC.

METHODS

This retrospective study enrolled consecutive patients whose baseline visits occurred between January 2009 and December 2023. Sarcopenia was assessed via pretreatment CT or MRI at the mid-L3 level through the skeletal muscle index (SMI). Baseline characteristics, response rate after UDCA administration, liver-related events were compared. And baseline liver and plasma C-reactive protein (CRP) and IL-6 levels in a subset of patients were also evaluated.

RESULTS

A total of 164 patients were included and sarcopenia was identified in 66 (40.2 %) patients. The median duration of follow-up was 4.75 (1.71, 6.40) years. The PBC patients with sarcopenia had a lower biochemical response rate (45.9 % vs. 65.9 %; P = 0.014) after 12 months of UDCA treatment and a higher incidence of liver-related events (24.2 % vs. 11.2 %, P = 0.027) during follow-up. Furthermore, higher levels of baseline CRP and IL-6 in the plasma and liver were also observed(P < 0.05).

CONCLUSIONS

Sarcopenia was highly prevalent in patients with noncirrhotic PBC. Concomitant sarcopenia may adversely affect the biochemical response to UDCA treatment and the occurrence of liver-related adverse events in PBC patients without cirrhosis.

cPLA2α on the influence of Th17 and its role in the formation of liver fibrosis

This study primarily investigated the mechanism and pathways of the cPLA2α signaling pathway on Th17-mediated HSC activation and liver fibrosis, providing insights for clinical strategies to target HSC activation and delay the rapid progression of liver fibrosis. In vitro and in vivo model were established, and different concentrations of the cPLA2α inhibitor AACOCF3 were administered respectively for intervention. The expression of IL- 17 was detected by ELISA, and the expression of cPLA2α protein and HSC activation protein α-SMA index were detected by Western blot and immunofluorescence. In addition, observe the changes in the degree of liver fibrosis in mice through the pathological staining of mouse livers. In an in vitro system, Th17 could induce HSC activation. And after intervention, the results showed that the inhibitor could inhibit Th17 activation of HSC. Next, in an in vivo model, Th17 could also induce HSC activation. And after intervention, the results showed that the inhibitor could also inhibit HSC activation by Th17. Observation under liver pathological staining showed that the inflammation and staining were significantly reduced in the intervention group, suggesting a therapeutic effect of AACOCF3. Using in vitro and in vivo approaches, these data suggest that Th17 cells can promote the activation and proliferation of HSCs, which further exerts a role in promoting liver fibrosis. These data also suggest that the cPLA2α pathway may be involved in the activation of HSCs by Th17 cells and induce liver fibrosis mechanisms.

The role of TNF in metabolic disorders and liver diseases

Tumor necrosis factor (TNF) is identified as a pro-inflammatory cytokine critical to the pathology of liver disease. In the carbohydrate metabolism, TNF has been demonstrated to impede the insulin signaling pathway, thereby precipitating glucose intolerance and insulin resistance. In lipid metabolism, TNF upregulates genes implicated in fatty acid synthesis, resulting in increased lipid accumulation within the liver. In amino acid metabolism, TNF has shown to promote the gene expression for amino acid catabolism, leading to decreased protein synthesis. Additionally, TNF stimulates the production of other chemokines and inflammatory cytokines that can further exacerbate liver injury. Overall, TNF is crucial in developing liver diseases by disrupting various metabolic pathways in the liver, causing insulin resistance, lipid accumulation, and decreased protein synthesis. This review summarizes the present understanding of TNF's role in the regulation of carbohydrate, lipid and amino acid metabolism in liver disease together with its potential therapeutic implications.

Dissecting the genetic basis and mechanisms underlying the associations between multiple extrahepatic factors and autoimmune liver diseases

Background

Autoimmune liver diseases (AILDs) encompass autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC). The onset of these diseases is fundamentally influenced by genetic susceptibility. Although various extrahepatic factors are potentially linked to AILDs, the genetic underpinnings and mechanisms of these associations remain unclear.

Methods

Utilizing large-scale genome-wide association study (GWAS) data, this study systematically investigated the relationships between extrahepatic autoimmune diseases (EHAIDs), immune cells, and various triggering factors with AILDs. Mendelian randomization (MR) was employed to assess the causal effects of these extrahepatic factors on AILDs, complemented by linkage disequilibrium score (LDSC) regression to uncover shared genetic architecture and causal effects underlying the associations between autoimmune diseases. We employed colocalization, enrichment analysis, and protein-protein interaction (PPI) network to identify the functions of shared loci. Additionally, we proposed that activated immune cells in the circulation may contribute to liver and biliary tract inflammation via migration, mediating the impact of extrahepatic factors on AILDs. This hypothesis was tested using two mediation analysis methods: two-step MR (TSMR) and multivariable MR (MVMR).

Results

Causal associations between multiple extrahepatic factors and AILDs were identified. Notably, CD27+ B cells were found to be a risk factor for PBC, while PSC progression was associated with CD28+ CD8+ T cells exhaustion and increased levels of CD28- CD8+ T cells. Mediation analyses revealed 64 pathways via TSMR and 15 pathways via MVMR, indicating that the effects of extrahepatic factors on AILDs may be mediated by circulating immune cells. The shared genetic architecture also contributed to these associations. Analysis of shared loci and gene functions identified ATXN2 as being shared between PBC and 9 EHAIDs, while SH2B3 and PSMG1 were shared with 6 and 5 EHAIDs, respectively, in PSC.

Conclusions

Our research compared three distinct AILDs, enhancing the understanding of their etiology and providing new evidence on risk factors, diagnostic markers, and potential therapeutic targets.

A placebo-controlled Phase 2 trial of E6011, anti-human fractalkine monoclonal antibody, in primary biliary cholangitis

BACKGROUND

While ursodeoxycholic acid (UDCA) remains the first-line therapy for primary biliary cholangitis (PBC), the autoimmune nature of PBC underscores the need for treatments targeting immunological pathways that may achieve a cure. E6011, a novel humanized anti-fractalkine monoclonal antibody, has emerged as a potential therapeutic option for PBC. We conducted a randomized, placebo-controlled, double-blind study to evaluate the efficacy and safety of E6011 in patients with PBC with an incomplete response to UDCA.

METHODS

The study was composed of 12-week Double-Blind Phase (placebo, E6011 10 mg/kg/month, 15 mg/kg/month, or 10 mg/kg/every other week [eow]) followed by a 52-week Open-Label Phase. The primary endpoint was the percent change in alkaline phosphatase (ALP) at Week 12.

RESULTS

A total of 29 patients were enrolled. Histological evaluation at screening revealed that 83 % of the enrolled patients were classified as Stage 4 according to the Nakanuma Classification. The mean percent changes in ALP at Week 12 were +0.45 % in the placebo, +0.65 % in the 10 mg/kg/month, +1.23 % in the 15 mg/kg/month and +1.19 % in the 10 mg/kg/eow, with no observed trends toward ALP reduction in the E6011 treatment. Based on the interim analysis, the study was discontinued due to a lack of the efficacy. E6011 was generally safe and well tolerated.

CONCLUSION

This study of E6011 failed to meet the primary endpoint in patients with PBC with an incomplete response to UDCA. The advanced histological severity present in more than 80 % of patients at baseline may have contributed to these findings.

Metabolic dysfunction-associated steatotic liver disease (MASLD) in children with obesity: An Obesity Medicine Association (OMA) and expert joint perspective 2025

Introduction

This Obesity Medicine Association (OMA) Expert Joint Perspective examines steatotic liver disease (SLD), which is composed of metabolic dysfunction-associated steatotic liver disease (MASLD), and metabolic dysfunction-associated steatohepatitis (MASH) in children with obesity. The prevalence of obesity is increasing, rates have tripled since 1963 from 5 % to now 19 % of US children affected in 2018. MASLD, is the most common liver disease seen in children, can be a precursor to the development of Type 2 Diabetes (T2DM) and is the primary reason for liver transplant listing in young adults. We must be vigilant in prevention and treatment of MASLD in childhood to prevent further progression.

Methods

This joint clinical perspective is based upon scientific evidence, peer and clinical expertise. The medical literature was reviewed via PubMed search and appropriate articles were included in this review. This work was formulated from the collaboration of eight hepatologists/gastroenterologists with MASLD expertise and two physicians from the OMA.

Results

The authors who are experts in the field, determined sentinel questions often asked by clinicians regarding MASLD in children with obesity. They created a consensus and clinical guideline for clinicians on the screening, diagnosis, and treatment of MASLD associated with obesity in children.

Conclusions

Obesity and the comorbidity of MASLD is increasing in children, and this is a medical problem that needs to be addressed urgently. It is well known that children with metabolic associated chronic disease often continue to have these chronic diseases as adults, which leads to reduced life expectancy, quality of life, and increasing healthcare needs and financial burden. The authors of this paper recommend healthy weight reduction not only through lifestyle modification but through obesity pharmacotherapy and bariatric surgery. Therefore, this guidance reviews available therapies to achieve healthy weight reduction and reverse MASLD to prevent progressive liver fibrosis, and metabolic disease.

Innovative construction and application of bile duct organoids: Unraveling the complexity of bile duct diseases and potential therapeutic strategies

The biliary system is crucial for liver function, regulating bile production, secretion, and transport. Dysfunctions within this system can lead to various diseases, such as cholangiopathies and biliary fibrosis, which may progress from benign to malignant states like cholangiocarcinoma. While liver organoid research is well-established and technologically advanced, bile duct organoids (BDOs) offer significant potential. BDOs can accurately simulate the physiological structure and function of bile ducts, making them valuable tools for in-vitro biliary disease research. Here, we review the development of BDO models, focusing on stem cell-derived organoids and tissue-derived organoids. We also illustrate the role of cultivation strategies and extracellular scaffolds in supporting organoid growth and stability, including the influence of cellular components of the microenvironment and physicochemical factors. Furthermore, we discuss the applications of BDOs in biliary development, disease modeling, regenerative medicine, and drug screening. Additionally, we emphasize the transformative potential in BDO biobanks and personalized medicine, which helps to pave the way for innovative therapeutic strategies and personalized medicine. Finally, we summarize the current and prospective advancements in BDO technologies, highlighting the integration of emerging technologies such as artificial intelligence, 3D bioprinting, and organoid-on-chip systems. These technologies hold great promise for significantly enhancing both clinical and research applications in the field of biliary diseases.

Multi-Organ-on-Chip approach to study the impact of inter-organ communication on the efficacy and side effects of cancer therapy

Cancer is one of the pathological conditions of the human body, which, due to its tissue diversity, is not fully understood. Currently used preclinical in vitro cell or animal models do not reflect the complexity and functional features of the human body, including its pathological conditions such as cancer. This fact is related to poor predictions of the effectiveness of newly developed drugs. Therefore, in our work, we focused on creating a tool that allows the reproduction of important morphological and biochemical features of the tumor in vivo, such as three-dimensional (3D) structure, heterogeneity, the presence of extracellular matrix (ECM), and the appropriate scale (volume to surface ratio). Moreover, the presented Multi-Organ-on-Chip (MOC) tool allows us to evaluate the effects of anticancer therapy, considering hepatic metabolism (liver model) and the assessment of its side effects on a selected organ (skin model). Our research shows that incorporating multiple organ models in one in vitro tool affects the viability and metabolic activity of the cells that constitute them. Moreover, we have shown how important it is to consider hepatic metabolism when evaluating the therapeutic effectiveness of two selected chemotherapy drugs, 5-Fluorouracil (5-FU) and its prodrug Capecitabine (CAP).

Preoperative total bile acid can be used as a prognostic biomarker in patients with operable biliary tract cancers

BACKGROUND

Biliary tract cancers (BTCs) are highly invasive malignancies with poor prognoses. However, reliable biomarkers for survival prediction remain lacking. Notably, abnormal lipid metabolism has elicited increasing interest in digestive tract tumors, with the liver playing an important role in lipid metabolism.

OBJECTIVE

To explore the relationship between hepatic lipid metabolism-related indicators, assessed through routine clinical biochemical testing and survival prognosis in patients with BTCs.

METHODS

Overall, 109 patients with a pathological diagnosis of BTC from 2017 to 2023 were included in this study. Univariate and multivariate Cox regression analyses were performed using R Studio software, and survival curves were plotted.

RESULTS

Univariate analysis revealed that tumor location and preoperative total bile acid (TBA), carcinoembryonic antigen, cancer antigen (CA)125, and CA19-9 levels were correlated with patient survival (P < 0.05). Multivariate Cox regression analysis identified increased TBA level [hazard ratio (HR) = 0.445, P = 0.004] as an independent prognostic factor for longer survival. Conversely, tumor location [intrahepatic cholangiocarcinoma (iCCA) and/or extrahepatic cholangiocarcinoma (eCCA)] (HR = 2.463, P = 0.036) and increased CA125 and CA19-9 levels (HR = 2.549, P = 0.008 and HR = 2.100, P = 0.019) were independent prognostic factors for shorter survival. Additionally, Kaplan‒Meier survival curves revealed significantly longer survival in patients with increased TBA levels than those in the normal group (P = 0.012). Conversely, patients with iCCA and/or eCCA tumor location and increased CA125 and CA19-9 levels had significantly shorter median survival (P = 0.044, P = 0.013, and P = 0.012, respectively).

CONCLUSION

TBA may be a biomarker for predicting survival in patients with operable BTC, highlighting its clinical significance and application potential.

Diabetes Mellitus in Patients With Autoimmune Hepatitis: Frequency, Risk Factors and Effect on Outcome

BACKGROUND

Treatment for autoimmune hepatitis (AIH) includes corticosteroids, which are associated with the development of diabetes mellitus (DM). Reported new-onset DM rates in patients with AIH have varied, and predisposing factors and prognostic implications are inadequately characterised.

AIM

To identify the frequency and predisposing factors for DM in AIH and its association with disease progression and mortality.

METHODS

Retrospective/prospective single-centre study of 494 patients with AIH presenting 1987-2023, 466 receiving corticosteroids (454 prednisolone, 12 budesonide) and followed for (median (range) 9 (0-36) years).

RESULTS

Forty-seven patients (10%) already had DM at AIH diagnosis. New-onset DM subsequently developed in another 59 (13%). In those receiving prednisolone, new-onset DM incidence was 8% ± 1% after 1 year and 14% ± 2% after 10 years (14- and 3-fold higher than expected population rate), and was independently associated with older age, non-Caucasian ethnicity, higher initial prednisolone dose, higher BMI at diagnosis and more weight gain after 2 years of follow-up. New-onset DM usually persisted despite stopping prednisolone. New-onset DM and DM at any time were independently associated with all-cause death/transplantation rate, along with previously established risk factors (older age, cirrhosis, lower ALT at diagnosis and failure of early ALT normalisation). New-onset DM and DM at any time were also independently associated with cirrhosis development. Similar associations of new-onset DM and DM at any time with liver-related death/transplantation were significant on univariate but not multivariate analysis.

CONCLUSION

New-onset DM occurred in 13% of patients with AIH, was related to older age, non-Caucasian ethnicity, higher prednisolone dose, higher BMI at diagnosis and weight gain; and was an independent predictor of all-cause death/transplantation and of cirrhosis development, underlining the need to minimise steroid burden in AIH.

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.

Association of alkaline phosphatase to albumin ratio with all-cause mortality in critically ill patients with cirrhosis: a retrospective study

BACKGROUND

Cirrhosis is the end stage of many chronic liver diseases, which seriously affects the quality of life of patients. The alkaline phosphatase to albumin ratio (APAR) index is a new indicator related to the prognostic risk of many diseases. This study was aimed at exploring the association between the APAR index and the risk of all-cause mortality in patients with cirrhosis.

METHODS

Patients with cirrhosis who were 18 years of age or older and admitted to the intensive care unit were included from the Medical Information Mart for Intensive Care IV (MIMIC-IV) - Version 3.0 database in this study. The primary endpoint of this study was all-cause mortality at 365- days, with secondary endpoints at 90-days and 28-days after admission. The hazard ratio (HR) and 95% CI between the APAR index and endpoints were calculated using the Cox proportional hazards model. A restricted cubic spline (RCS) regression model was created to explore the relationship between the APAR index and cirrhosis. Furthermore, we explored the predictive value of the APAR index in different populations of cirrhosis through subgroup analysis.

RESULTS

A total of 2,109 patients with cirrhosis were included from the MIMIC-IV database. After adjusting for potential covariates, APAR as a continuous variable was significantly positively associated with all-cause mortality at 28-days (HR: 2.007, 95% CI: 1.369, 2.948; P < 0.001), 90-days (HR: 2.392, 95% CI: 1.642, 3.495; P < 0.001), and 365-days (HR: 2.418, 95% CI: 1.660, 3.534; P < 0.001) in cirrhotic patients. When APAR was a categorical variable, compared with patients in the lower APAR group, the risk of 365-days all-cause mortality in patients of the higher APAR group significantly increased (HR: 1.451, 95%CI: 1.197, 1.758). APAR was linearly related to all-cause mortality at 28-days, 90-days and 365-days after admission (P for non-linearity = 0.221, 0.390, and 0.344, respectively). Subgroup analysis indicated that among patients with cirrhosis complicated with hepatorenal syndrome, those without spontaneous peritonitis or portal hypertension/esophageal varices, and those receiving human albumin infusion, elevated APAR levels were significantly associated with an increased risk of long-term death.

CONCLUSIONS

A higher APAR index is significantly associated with the risk of all-cause mortality in cirrhosis. APAR may be a potential biomarker for evaluating the long-term prognosis of critically ill patients with cirrhosis.

Genome-wide association study of post COVID-19 syndrome in a population-based cohort in Germany

If health impairments due to coronavirus disease 2019 (COVID-19) persist for 12 weeks or longer, patients are diagnosed with Post-COVID Syndrome (PCS), or Long-COVID. Although the COVID-19 pandemic has largely subsided in 2024, PCS is still a major health burden worldwide, and identifying potential genetic modifiers of PCS remains of great clinical and scientific interest. We therefore performed a case-control type genome-wide association study (GWAS) of three recently developed PCS (severity) scores in 2,247 participants of COVIDOM, a prospective, multi-centre, population-based cohort study of SARS-CoV-2-infected individuals in Germany. Each PCS score originally represented the weighted sum of the binary indicators of all, or a subset, of 12 PCS symptom complexes, assessed six months or later after the PCR test-confirmed SARS-CoV-2 infection of a participant. For various methodical reasons, however, the PCS scores were dichotomized along their respective median values in the present study, prior to the GWAS. Of the 6,383,167 single nucleotide polymorphisms included, various variants were found to be associated with at least one of the PCS scores, although not at the stringent genome-wide statistical significance level of 5 × 10- 8. With p = 6.6 × 10- 8, however, the genotype-phenotype association of SNP rs9792535 at position chr9:127,166,653 narrowly missed this threshold. The SNP is located in a region including the NEK6, PSMB7 and ADGRD2 genes which, however, does not immediately suggest an etiological connection to PCS. As regards functional plausibility, variants of a possible effect mapped to the olfactory receptor gene region (lead SNP rs10893121 at position chr11:123,854,744; p = 2.5 × 10- 6). Impairment of smell and taste is a pathognomonic feature of both, acute COVID-19 and PCS, and our results suggest that this connection may have a genetic basis. Three other genotype-phenotype associations pointed towards a possible etiological role in PCS of cellular virus repression (CHD6 gene region), activation of macrophages (SLC7A2) and the release of virus particles from infected cells (ARHGAP44). All other gene regions highlighted by our GWAS did not relate to pathophysiological processes currently discussed for PCS. Therefore, and because the genotype-phenotype associations observed in our GWAS were generally not very strong, the complexity of the genetic background of PCS appears to be as high as that of most other multifactorial traits in humans.

The common genetic variant rs1278960 determining expression of Interferon-lambda predicts inflammatory response in critically ill COVID-19 patients

The single nucleotide polymorphism rs12979860 is associated with the production of IFNλ4, a type III interferon, which offers protection from viral infection via its proinflammatory properties. We investigated if a genetically determined increase in IFNλ4 affects disease progression in SARS-CoV-2. This prospective, single-center study involved critically ill SARS-CoV-2 patients admitted to the intensive care unit. We performed genotyping for rs12979860 and analyzed daily laboratory data. Genotype frequencies were compared with an external validation cohort. Critically ill individuals with COVID-19 (n = 184; 29.3% women) were included. Median age was 63 years. The TT genotype was present in 11%, CT in 48% and CC in 41%. At baseline, CRP, ferritin, transferrin and neopterin did not differ significantly between groups. Longitudinal analysis revealed significant genotype-dependent differences in CRP, ferritin and neopterin with the highest peak in TT patients after 10-15 days. A higher need for renal replacement therapy (31.6% vs. 11.7%, p = 0.044) and mechanical ventilation (22 days vs. 15 days, p = 0.018) was observed in the TT group. The SNP rs12979860 near IFNL4 is associated with distinct inflammatory trajectories in critically ill COVID-19 patients. Genetic determinants of the immune response influence the severity of inflammation and clinical outcomes in severe COVID-19.

New platinum derivatives selectively cause double-strand DNA breaks and death in naïve and cisplatin-resistant cholangiocarcinomas

BACKGROUND & AIMS

Patients with cholangiocarcinoma (CCA) have poor prognosis. Current cisplatin-based first-line chemotherapy offers limited survival benefits. Cisplatin induces single-strand DNA breaks, activating DNA repair mechanisms that diminish its effectiveness. Here, we present the design, chemical synthesis, and therapeutic evaluation of a new generation of chemotherapeutic agents (Aurkines) with unique polyelectrophilic properties. These agents cause a high frequency of double-strand DNA breaks, bypassing DNA repair, and promoting cancer cell death.

METHODS

Two novel compounds, Aurkine 16 and Aurkine 18, were designed and evaluated for their antitumor effects in both naïve and cisplatin-resistant CCA cells, cancer-associated fibroblasts (CAFs), healthy cholangiocytes, and in vivo models.

RESULTS

Aurkines effectively induced double-strand DNA breaks, leading to increased DNA damage and elevated levels of reactive oxygen species, resulting in greater cytotoxicity than cisplatin in CCA cells. Phosphoproteomic and molecular analysis revealed that cisplatin activates DNA repair pathways, while Aurkines primarily induce apoptosis. Importantly, Aurkines also triggered apoptosis in cisplatin-resistant CCA cells and CAFs without harming healthy cholangiocytes. Additionally, Aurkines demonstrated cytotoxicity in other cisplatin-resistant cancers, such as breast and ovarian cancer. This tumor selectivity results from reduced uptake, increased efflux, and compact chromatin structure in normal cells, limiting Aurkine-DNA interactions. In vivo, Aurkines inhibited the growth of subcutaneous naïve and cisplatin-resistant CCA tumors, as well as orthotopic tumors in immunocompetent mice promoting antitumor immune cell recruitment, without any adverse events. Transport studies revealed that Aurkines were selectively taken up by OCT1, OCT3, CTR1, and OATP1A2, whereas only CTR1 transported cisplatin.

CONCLUSIONS

Aurkines represent promising therapeutic drugs for both naïve and cisplatin-resistant cancers due to their unique polyelectrophilic properties and selective targeting of malignant cells.

IMPACT AND IMPLICATIONS

This study introduces a novel therapeutic strategy designed to induce frequent double-strand DNA breaks selectively in both naïve and cisplatin-resistant cancer cells, without evident toxic side effects at therapeutic doses. This approach may settle the basis for new strategies to overcome the critical challenge of drug resistance in cancer treatment, and has the potential to be a breakthrough not only for the treatment of biliary tumors but also for other cancers.

Characteristics and Outcomes of Hepatocellular Carcinoma in Patients with Autoimmune Hepatitis

BACKGROUND

The incidence of HCC in patients with autoimmune hepatitis (AIH) is low and, due to the paucity of data in the literature, a thorough characterization of these patients is missing.

AIM

To describe the main characteristics and outcome of patients with AIH and HCC.

METHODS

Among patients with HCC included in the Italian Liver Cancer (ITA.LI.CA) database during the period 2009-2022, we selected those with AIH, and we described their liver disease characteristics, modality of HCC diagnosis, tumor stage, treatment, and outcome.

RESULTS

Among 10,026 patients with HCC, we identified 23 patients (0.2%) with AIH (43.5% males, 69.6% aged > 65 years, 91.0% with cirrhosis). Fifteen patients (65.2%) had co-factors of liver disease [8 patients (34.8%) metabolic dysfunction-associated steatotic liver disease, 4 patients (17.4%) alcohol abuse, 3 patients (13.0%) AIH/Primary Biliary Cholangitis overlap syndrome]. Tumors diagnosed under surveillance (60.9%) were more frequently uninodular (85.7% vs 66.6%, p = 0.146) and Milan-in (85.7% vs 44.4%, p = 0.066) than those diagnosed outside surveillance. Treatment with curative intent was more frequent among patients under surveillance (78.6% vs 33.3%, p = 0.077). Median overall survival was 41.7 months and was remarkably longer in patients under surveillance than in those diagnosed outside surveillance (68.2 vs 27.4 months, p = 0.032).

CONCLUSION

AIH accounts for a minimal fraction of patients with HCC, and in most patients, risk co-factors for HCC are present. In patients with AIH, too, surveillance is associated with better tumor stage, higher access rate to potentially curative treatments, and improved survival.

A nationwide study of primary biliary cholangitis prevalence, geographic distribution, and health care providers

BACKGROUND

Prevalence estimates of primary biliary cholangitis (PBC) in the United States have evolved with the introduction of newer real-world data capture approaches. Little is known about the geographic distribution of PBC in the United States and the health care provider (HCP) landscape for patients with PBC. This real-world study aimed to estimate the prevalence of PBC in the United States, assess regional variability in its prevalence, and describe HCPs for patients with PBC.

METHODS

Patients with PBC were identified using Komodo's Healthcare Map, a large national administrative claims database. PBC prevalence per 100,000 adults was adjusted by age and gender at the 3-digit ZIP Code tabulation area level. Patients' PBC-related medical or pharmacy claims were used to determine HCP specialties and affiliations (academic vs. nonacademic); the latest claim and all claims were examined.

RESULTS

The adjusted 2021 PBC prevalence was 40.9 per 100,000 adults. The highest absolute number of patients with PBC in the United States was in heavily populated urban areas, but prevalence adjusted for population size was highest in some rural areas. Among all claims, most (83.2%) patients received care from a specialist (gastroenterologist/hepatologist) at one time. However, only approximately half (53.5%) of patients with PBC, irrespective of therapy use, were most recently treated for PBC by a specialist.

CONCLUSIONS

This is the most comprehensive and contemporary estimation of PBC prevalence in the United States to date. The pockets of high prevalence of PBC located in some rural areas highlight the need to better evaluate PBC risk factors and potential barriers in access to specialist care once patients are diagnosed. Greater awareness of PBC and its management are needed.

Update in clinical science: Autoimmune hepatitis

Autoimmune hepatitis (AIH) is an enigmatic, relatively rare disease with a variable spectrum of presentation whose pathogenesis, diagnosis and management remain a major challenge. We have performed a review of recent developments in basic science, epidemiology, clinical science, therapeutics, and regulatory science, evaluating the challenges associated with the application of translational research and clinical trial design to a condition that is a chameleon in nature, where outcomes range from relatively benign disease through cirrhosis and acute liver failure. This review is focused on developments from 2020 onwards so we can present a forward-looking view on the challenges and remaining questions that must be addressed to improve patient care and outcomes in AIH. We also outline areas of debate and offer insights into these areas.

Risk factors and prediction for DILI in clinical practice

INTRODUCTION

Drug-induced liver injury is an important adverse effect and can be caused by various medications, including novel therapeutic agents. The risk stratification of patients susceptible to DILI is a growing field.

AREAS COVERED

The current article highlights new studies on risk stratification regarding risk factors of DILI, prediction of liver injury, and predictors of severe outcomes. Studies on patient demographic and genetic risk factors are discussed, in addition to the potential role of concomitant medications that may affect the risk of DILI.

EXPERT OPINION

Although much is known about patient risk factors for DILI, a better combination of these factors into risk scores is needed to predict which patients are particularly susceptible. Knowledge of these risk factors might determine drug treatment in the near future, as well as the need for routine monitoring of liver tests.

Long-Term Survival and Prognostic Factors of Stereotactic Body Radiotherapy Following Transarterial Chemoembolization for Hepatocellular Carcinoma

BACKGROUND/AIMS

This study presents a detailed analysis of long-term survival and critical factors influencing the outcomes of hepatocellular carcinoma patients treated with stereotactic body radiotherapy (SBRT) and transarterial chemoembolization (TACE). Our findings provide reassurance about the potential of the combination of TACE and SBRT as an effective treatment strategy for patients with large liver tumors due to HCC.

METHODS

A prospective study was conducted on 42 patients with intermediate-stage hepatocellular carcinoma (HCC) at 108 Military Central Hospital between December 2018 and June 2024. Following a single session of TACE, each patient underwent SBRT 1 month later. The SBRT dose ranged from 27.5 to 48 Gy, delivered in 3-5 fractions. The patient survival analysis was conducted using the Kaplan-Meier method while examining prognostic factors influencing survival, which involved log-rank tests and Cox proportional hazards regression analysis.

RESULTS

Among the 42 patients (83.3% male), 34 patients (81.0%) had tumors measuring ≥ 5 cm. The median follow-up period was 32.2 months (4.5-65.1 months). The median overall survival (OS) was 32.6 months, with the respective 1-, 3-, and 5-year OS rates reported as 73.8%, 24.5%, and 19.6%. Furthermore, the median progression-free survival (PFS) was 16.6 months, with corresponding 1- and 3-year PFS rates of 71.4% and 19.0%. Factors linked to improved OS and PFS included AFP levels and treatment response based on Modified RECIST criteria. Additionally, multivariate analysis identified patient age, EQD2, and BED10 as significant predictors of better survival outcomes.

CONCLUSIONS

Our study provides evidence supporting the effectiveness and safety of combining TACE and SBRT as a treatment strategy for patients with large liver tumors due to HCC, instilling confidence in the future of HCC treatment. Positive prognostic factors included patient age, EQD2, and BED10.

Iqirvo for primary biliary cholangitis - efficacy, safety, and future directions

Primary biliary cholangitis (PBC) is a chronic autoimmune liver disease characterized by progressive bile duct destruction, leading to cirrhosis and liver failure. Recent advancements in treatment have focused on targeting specific molecular pathways involved in the disease's pathogenesis. Iqirvo, a dual peroxisome proliferator-activated receptor alpha and delta agonist, has shown promise in addressing the unmet medical needs of PBC patients. This review examines the clinical development and efficacy of Iqirvo, which recently received accelerated approval from the U.S. Food and Drug Administration. The approval was based on data demonstrating improvements in biochemical markers associated with liver function and bile acid metabolism. We also discuss the safety profile, potential side effects, and future implications for the management of PBC. The expedited approval of Iqirvo represents a significant advancement in PBC therapy, offering new hope for patients unresponsive to existing treatments.

Correlation of METTL4 genetic variants and severe pneumonia pediatric patients in Southern China

BACKGROUND

Pneumonia is a major cause of mortality and health burden in children under five, yet its genetic etiology remains poorly understood. Methyltransferase 4, N6-adenosine (METTL4), is a methyltransferase enzyme responsible for RNA and DNA methylation and is known to be activated under hypoxic conditions. However, its potential link to susceptibility to pneumonia has not been evaluated. This study aimed to explore candidate regulatory single nucleotide polymorphisms (SNPs) within the METTL4 gene and their association with the development of severe pneumonia.

RESULTS

In this study, we recruited a cohort of 1034 children with severe pneumonia and 8426 healthy controls. We investigated the associations of candidate regulatory single nucleotide polymorphisms (SNPs) within METTL4 polymorphisms with severe pneumonia. Our results indicated that the C allele of rs9989554 (P = 0.00023, OR = 1.21, 95% CI: 1.09-1.34) and the G allele of rs16943442 (P = 0.0026, OR = 1.22, 95% CI: 1.07-1.38) were significantly associated with an increased risk of severe pneumonia. The regulatory potential of these two SNPs in the lung was investigated using tools such as expression quantitative trait loci (eQTLs), RegulomeDB, and FORGEdb.

CONCLUSIONS

This study represents the first investigation elucidating the role of genetic variations in the METTL4 gene and their influence on susceptibility to severe pneumonia in pediatric populations. METTL4 is identified as a novel predisposing gene for severe pneumonia and a potential therapeutic target. Further research is warranted to validate this correlation and to comprehensively elucidate the biological role of the METTL4 gene in severe pneumonia.

Molecular mimicry-driven autoimmunity in chronic rhinosinusitis with nasal polyps

BACKGROUND

The pathogenesis of chronic rhinosinusitis with nasal polyps (CRSwNP) remains a subject of discussion. Although both microbial infection and autoimmunity have been proposed as potential contributors to CRSwNP pathobiology, their respective roles and intricate interactions in disease progression remain unclear owing to the limited knowledge regarding dysregulated humoral immunity in CRSwNP.

OBJECTIVE

To deepen understanding of CRSwNP, we sought to identify the precise humoral antigens targeted by dominant B-cell clones within the disease environments.

METHODS

Immunoglobulin repertoire sequencing was performed to identify dominant B-cell clones in CRSwNP tissues. These immunoglobulin clones were reconstructed as antibodies, which were then used in immunoprecipitation and antigen array experiments for hypothesis-free global antigen profiling of autogenous and exogenous antigens.

RESULTS

From analysis of 13 patients with CRSwNP, 31 antibodies were reconstructed from dominant B-cell clones identified in 9 patients. Seven novel protein autoantigens were identified, 5 of which were nucleic acid-binding proteins, and all were associated with autoimmune diseases. Additionally, 9 microbial antigens, including various viruses, bacteria, and fungi, were discovered. Notably, 2 antibodies demonstrated dual reactivity, simultaneously recognizing both microbial and human proteins. For example, 1 antibody targeted cytomegalovirus, Clostridium tetani, and human PLEC, whereas another recognized Aspergillus niger and human DLAT, through molecular mimicry of shared amino acid homologies.

CONCLUSION

Our data indicate the possibility that the pathobiology of CRSwNP involves autoreactive humoral immunity, with a subset of cases potentially exhibiting molecular mimicry-driven autoimmune features triggered by microbial infections. Nevertheless, this hypothesis requires further investigation.

Pemafibrate improves liver biochemistry and GLOBE scores in patients with primary biliary cholangitis: Nationwide, multicenter study by the Japanese Red Cross Liver Study Group

AIM

We aimed to evaluate the effect of pemafibrate, a selective peroxisome proliferator-activated receptor-α modulator, on patients with primary biliary cholangitis (PBC) complicated by dyslipidemia.

METHODS

In total, 61 patients with PBC (Add-on group: 33 patients on ursodeoxycholic acid [UDCA] + pemafibrate combination therapy; Switch group: 28 patients who switched from UDCA + other fibrates to UDCA + pemafibrate combination therapy) were included in the study. Changes in aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT), alkaline phosphatase (ALP), and GLOBE scores were retrospectively analyzed from 6 months before to 12 months after treatment. The POISE criteria were also used to evaluate the treatment efficacy after 12 months.

RESULTS

After 12 months of UDCA + pemafibrate combination therapy, AST significantly decreased from 45 ± 3 to 28 ± 3 U/L (p < 0.05), ALT from 49 ± 5 to 32 ± 5 U/L (p < 0.005), GGT from 155 ± 223 to 91 ± 182 U/L (p < 0.005), and ALP from 1.4 ± 0.9 to 0.9 ± 0.8 × upper limit of normal (p < 0.0005) in all patients. ALT, GGT, and ALP levels were significantly lower after 12 months of UDCA + pemafibrate combination therapy in both the Add-on and Switch groups. After 12 months of combination therapy, the mean GLOBE score of all patients significantly decreased from 0.37 to 0.01 (p < 0.05) and the percentage of patients with a GLOBE score of 0.3 or higher decreased.

CONCLUSIONS

In patients with PBC who showed an inadequate response to prior therapy, pemafibrate add-on or switch therapy improved liver biochemistry and GLOBE scores. Pemafibrate may be useful as a second-line drug when UDCA alone is inadequate, or as an alternative after combination therapy with other fibrates.

Uncovering shared genetic features between inflammatory bowel disease and systemic lupus erythematosus

Inflammatory bowel disease (IBD) is an autoimmune disease (AD) characterized by chronic, relapsing intestinal inflammation. Systemic lupus erythematosus (SLE) is a complex autoimmune disease with multisystem involvement and overactivation of both innate and adaptive immunity. The extra intestinal manifestations (EIMs) that commonly occur in IBD include many of the organ sites that are affected by SLE. ADs are often comorbid with one another and may have shared underlying genetic features and architectures contributing to their pathogenesis and disease course. We performed both epidemiological and post-genome wide association study (GWAS) analyses to investigate the shared genetic features between IBD and systemic lupus erythematosus (SLE). Specifically, we performed epidemiological association analysis in the All of Us Research Program (AoURP) and genome-wide/local genetic correlation analysis and cell-type specific SNP heritability enrichment analysis using previously published summary level data. A significant epidemiologic association exists between IBD and SLE with an adjusted odds ratio (aOR) of 2.94 (95% CI: 2.45-3.53; P < 0.001) in a multivariable model accounting for confounders in the AoURP data. Genome-wide genetic correlation analysis in previously published summary level data demonstrated a significant genetic correlation between IBD, CD, and UC with SLE, and local genetic correlation analysis demonstrated several positive and significant correlations in local genomic regions harboring disease variants in genes common to both SLE and IBD etiology, including variants in ELF1, CD226, JAZF1, WDFY4, and JAK2. Cell-type SNP heritability enrichment analysis identified both overlapping and distinct functional categories contributing to SNP heritability across IBD phenotypes. Notably, IBD-related phenotypes demonstrated significant enrichment in T-lymphocyte functional groups while SLE signal appeared in distinct categories, such as B-lymphocytes (along with CD). Gene-level collapsing analysis of rare variants in the United Kingdom BioBank (UKBB) identified overlapping nominally-significant genes between SLE and IBD, CD, and UC. By leveraging several post-GWAS methods, the present study identifies shared genetic features between IBD and SLE, highlighting similarities and differences in the genetic features that contribute to the pathogenesis of each disease.

Conceptual Contextualization of Neutrophilic Dermatoses

ABSTRACT

Neutrophilic dermatoses are defined as inflammatory skin diseases characterized by sterile infiltration of polymorphonuclear neutrophils into various cutaneous layers. Although, in many cases, neutrophilic dermatoses represent the cutaneous counterpart of autoinflammatory diseases, this is not always the case, and there are other causes associated with this group of diseases, such as the administration of certain drugs or an underlying tumor. However, understanding the autoinflammatory context in which most of these entities develop, as well as their close relationship with autoimmunity, is key to comprehending their pathogenesis. In addition, understanding the mechanisms by which neutrophils migrate to the dermis and become activated is fundamental for interpreting the morphological findings of these biopsies. Finally, the description of a new group of neutrophilic dermatoses in recent years, in relation to keratinization disorders, has been crucial for understanding the best therapeutic approach for these difficult-to-manage entities.

Cancer immune evasion, immunoediting and intratumour heterogeneity

Cancers can avoid immune-mediated elimination by acquiring traits that disrupt antitumour immunity. These mechanisms of immune evasion are selected and reinforced during tumour evolution under immune pressure. Some immunogenic subclones are effectively eliminated by antitumour T cell responses (a process known as immunoediting), which results in a clonally selected tumour. Other cancer cells arise to resist immunoediting, which leads to a tumour that includes several distinct cancer cell populations (referred to as intratumour heterogeneity (ITH)). Tumours with high ITH are associated with poor patient outcomes and a lack of responsiveness to immune checkpoint blockade therapy. In this Review, we discuss the different ways that cancer cells evade the immune system and how these mechanisms impact immunoediting and tumour evolution. We also describe how subclonal antigen presentation in tumours with high ITH can result in immune evasion.

Global trends and disparities in gallbladder and biliary tract cancers: insights from the global burden of disease study 2021

BACKGROUND

Gallbladder and biliary tract cancers (GBC and BTC) are highly malignant, with poor prognoses and substantial regional variability in the disease burden. Although advances in medical science have improved outcomes in high-income regions, low- and middle-income regions continue to face rising incidence and mortality rates owing to delayed detection and treatment. Understanding the global trends and risk factors of GBC and BTC is essential for targeted interventions to reduce disease burden.

METHODS

A retrospective analysis of GBC and BTC was conducted using the 2021 Global Burden of Disease study. Data from 204 countries and territories between 1990 and 2021 were analyzed for incidence, mortality, and disability-adjusted life years stratified by age, sex, and sociodemographic index (SDI). Trends were quantified using age-standardized rates and estimated annual percentage changes.

RESULTS

In 2021, 216,768 new cases and 171,961 deaths were reported globally, with age-standardized incidence and mortality rates of 2.6 and 2.0 per 100,000, respectively. The high-income Asia-Pacific and Latin American regions exhibited the highest disease burdens. While global age-standardized rates declined estimated annual percentage changes for incidence: -0.44; mortality: -0.97), low-SDI regions experienced increases. High BMI emerged as the leading risk factor, contributing to 12% of the disability-adjusted life years. Projections indicate a stable incidence but rising mortality by 2036.

CONCLUSION

Although the global age-standardized rates of GBC and BTC are decreasing, disparities persist, with low-SDI regions experiencing increasing burdens. Targeted interventions addressing modifiable risk factors such as obesity, along with improved healthcare infrastructure and early detection, are critical for mitigating this global health challenge.

Conversion Surgery Performed Following Durvalumab Combined With Gemcitabine and Cisplatin in Cholangiocarcinoma: A Case Report

BACKGROUND/AIM

Immunotherapy using immune checkpoint inhibitors (ICIs) has been widely approved for many cancers. ICI therapy has also been performed for unresectable bile duct cancer in recent years. However, there are few reports of conversion surgery following ICI therapy for unresectable or borderline resectable bile duct cancer. Herein, we present a case of conversion surgery following immune checkpoint ICI therapy for unresectable cholangiocarcinoma, focusing on the cancer immune microenvironment of this case.

CASE REPORT

A 77-year-old man was diagnosed with borderline resectable, distal bile duct cancer and hilar cholangiocarcinoma. The patient underwent four courses of durvalumab combined with gemcitabine and cisplatin (Dur+GC) therapy. Evaluation of disease progression showed stable disease (SD), and considering the patient's surgical risk, a pancreaticoduodenectomy was performed. Adenocarcinoma components remained, and detailed pathological examinations using immunohistochemistry were performed. Marked infiltration of lymphocytes was observed in both the cancer core area and the margin area. The lymphocytes were positive for CD3 and CD8, with a subset also expressing CD103. PD-L1 expression was weakly positive in the stromal area, and positive cells were likely to be infiltrating macrophages in morphological features. Cancer cells were positive for HLA-A/B/C and beta-2.

CONCLUSION

CD103+ CD8+ T cells, recently referred to as tissue-resident memory T cells, might be a critical immune cell population involved in ICI-induced anticancer immune responses in cholangiocarcinoma.

Drug Induced Liver Injury: Highlights and Controversies in the 2023 Literature

Drug-induced liver injury (DILI) remains an active field of clinical research and investigation with more than 4700 publications appearing in 2023 relating to hepatotoxicity of all causes and injury patterns. As in years past, we have attempted to identify and summarize highlights and controversies from the past year's literature. Several new and novel therapeutic agents were approved by the US Food and Drug Administration (FDA) in 2023, a number of which were associated with significant hepatotoxicity. Updates in the diagnosis and management of DILI using causality scores as well as newer artificial intelligence-based methods were published. Details of newly established hepatotoxins as well as updated information on previously documented hepatotoxic drugs is presented. Significant updates in treatment of DILI were also included as well as reports related to global DILI registries.

The effects of loss of Y chromosome on male health

Loss of Y chromosome (LOY) is the most commonly occurring post-zygotic (somatic) mutation in male individuals. The past decade of research suggests that LOY has important effects in shaping the activity of the immune system, and multiple studies have shown the effects of LOY on a range of diseases, including cancer, neurodegeneration, cardiovascular disease and acute infection. Epidemiological findings have been corroborated by functional analyses providing insights into the mechanisms by which LOY modulates the immune system; in particular, a causal role for LOY in cardiac fibrosis, bladder cancer and Alzheimer disease has been indicated. These insights show that LOY is a highly dynamic mutation (such that LOY clones expand and contract with time) and has pleiotropic, cell-type-specific effects. Here, we review the status of the field and highlight the potential of LOY as a biomarker and target of new therapeutics that aim to counteract its negative effects on the immune system.

Metabolic restoration: Rhubarb polysaccharides as a shield against non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) accounts for remarkable burden of death and costs worldwide with no recommended pharmacological intervention for the clinical management. This study aimed to investigate the efficacy and underlying mechanisms of rhubarb-derived polysaccharides (RP) in mitigating high-fat diet (HFD)-induced NAFLD and to analyze the primary monosaccharide components of RP. Forty male C57BL/6 mice were subjected to a dietary intervention consisting of either a high fat or chow diet for a duration of 12 weeks. RP (270, 540 mg·kg-1·d-1) was administered to the mice for 4 consecutive weeks from the 9th week. Various assessments were conducted, including histopathological examination, liver transcriptome analysis, non-targeted metabolomics analysis, and evaluation of protein expressions related to lipid and bile acid metabolism. This study found RP demonstrate a protective effect on the livers of NAFLD mice by inhibiting lipid accumulation and reducing hepatocyte inflammatory damage. The metabolomics analysis of multi-tissues revealed that the RP exert a hepatoprotective effect against NAFLD by restoring the altered bile acids (BAs) and fatty acids (FFAs) metabolism through the improvement of BA transporter, nucleus hormone receptor, lipogenesis protein, FFA transporter, and lipolysis proteins. Hence, RP may serve as a potential therapeutic agent for NAFLD.

High galectin expression in Helicobacter pylori-infected gastric mucosa in childhood

BACKGROUND

Mild Th1 and Th17 immune responses in childhood against Helicobacter pylori are presumed to be responsible for H. pylori colonization and mucosal atrophy reduction. However, the mechanism remains unclear. In this study, we aimed to investigate the childhood-specific immune responses observed after H. pylori infection by analyzing galectin expression in the gastric mucosa. We focused on galectin-1 (Gal-1) and galectin-9 (Gal-9), which function to suppress Th1 and Th17 immune responses.

METHODS

We analyzed changes in the expression of Gal-1 and Gal-9 in the gastric mucosa of pediatric patients with H. pylori infection. Ten pediatric patients with and ten patients without H. pylori infection who underwent biopsy to assess the cause of chronic abdominal symptoms using esophagogastroduodenoscopy were evaluated. Gal-1 and Gal-9 expression in the biopsy tissues of the gastric antrum and corpus was analyzed by immunohistochemical staining.

RESULTS

Gal-1 expression was significantly increased in the stromal cells of the corpus owing to H. pylori infection. No alterations in Gal-1 expression due to H. pylori infection were observed in the antral tissue. Helicobacter pylori infection considerably increased Gal-9 expression in all tissues. According to previous reports, the increased expression of Gal-9 associated with H. pylori infection is not observed in adults. Therefore, the increased expression of Gal-9 associated with H. pylori infection is specific to pediatric patients.

CONCLUSION

The increased expression of Gal-1 and Gal-9 may suppress Th1 and Th17 immune responses against H. pylori infection during childhood, promote H. pylori colonization, and reduce inflammation in the gastric mucosa of pediatric patients.

Recurrence of autoimmune hepatitis cholestatic variant syndromes after liver transplantation affects graft and patient survival

Background & Aims

A significant proportion of patients with variant syndromes (VSs), namely autoimmune hepatitis/primary biliary cholangitis or autoimmune hepatitis/primary sclerosing cholangitis, require liver transplantation (LT) despite treatment. The frequency of disease recurrence and the effect on graft survival are yet to be clarified. The aim of this international, multicentric, retrospective study is to evaluate the risk factors associated with recurrence and the impact of the disease recurrence after LT on graft and patient survival.

Methods

We evaluated 166 patients undergoing LT for VS in 33 centers in North America, South America, Europe, and Asia. Clinical data before and after LT, biochemical data within the first 12 months after LT, and immunosuppression after LT were analyzed to identify patients with a higher risk of recurrence of autoimmune disease based on a histological and radiological diagnosis. Cumulative probabilities of graft and overall survival after LT were calculated using a semi-Markov model.

Results

The autoimmune pattern of recurrence resembled the original VS in 19 cases (61%). Recurrence of autoimmune liver disease (rALD) after LT was observed in 23% and 33% of patients after 5 and 10 years, respectively. Increased alkaline phosphatase (hazard ratio [HR] 1.60, 95% confidence interval [CI] 1.13-2.25, p <0.01) and alanine aminotransferase (HR 1.25, 95% CI 1.01-1.53, p = 0.03) at 12 months after LT and acute rejection (HR 3.58, 95% CI 1.60-7.73, p <0.01) were associated with a higher risk of VS recurrence, whereas the use of predniso(lo)ne was associated with a reduced risk (HR 0.30, 95% CI 0.14-0.64, p <0.01). After adjusting for alanine aminotransferase and alkaline phosphatase at 12 months, the use of predniso(lo)ne was found to be independently and negatively associated with recurrent disease. The rALD was found to be significantly associated with graft loss and patient survival in the multivariate Cox regression analysis with a time-dependent covariate. The 5- and 10-year probabilities of graft survival were 68% and 41% in patients with recurrent VS compared with 83% and 60% in patients without recurrent disease, respectively (p = 0.01). The overall survival was significantly reduced in patients with recurrent disease (p = 0.01), with event probability at 5 and 10 years of 75% and 49% vs. 84% and 60% in patients without recurrence, respectively.

Conclusions

rALD after LT is frequent and is associated with elevation in liver enzymes within the first year after LT and rejection episodes. According to our data, VS recurrence appears to be associated with poorer graft and patient survival. Further studies are needed to explore strategies that can prevent VS recurrence or mitigate its potential impact.

Impact and implications

This study investigated the recurrence of autoimmune liver diseases (rALD) in patients transplanted for variant syndromes (VSs) and its effect on graft and patient survival. The findings reveal a significant association between rALD and poorer graft and overall survival, highlighting the need for preventive strategies. This research is crucial for transplant physicians and healthcare providers, as it underscores the impact of early liver enzyme monitoring and tailored immunosuppressive therapy on long-term outcomes. These insights can inform more effective post-LT management protocols, potentially improving patient prognosis.

Benign biliary conditions with increased risk of malignant lesions

Numerous conditions and pathologies affect the biliary system, many of which have underlying benign courses. However, these overall benign conditions can predispose the patient to malignant pathologies, often due to malignancy arising from abnormal biliary ducts (such as with cholangiocarcinoma) or due to malignancy arising from end-stage liver disease caused by the biliary condition (such as with hepatocellular carcinoma). While these malignancies can at times be obvious, some pathologies can be very difficult to detect and distinguish from the underlying benign biliary etiology. This paper discusses various benign biliary pathologies, with discussion of epidemiology, imaging features, malignant potential, and treatment considerations, with the goal of educating radiologists and referring clinicians to the risk and appearance of hepatobiliary malignancies associated with benign biliary conditions.

Challenges in interpreting Mendelian randomization studies with a disease as the exposure: Using COVID-19 liability studies as an exemplar

Mendelian randomization (MR) studies using diseases as exposures are increasingly prevalent although any observed associations do not necessarily imply effect of diseases. To illustrate this challenge, we conducted a systematic review of MR studies focusing on COVID-19 consequence. We hypothesized if outcome genome-wide association studies (GWAS) were conducted before COVID-19 pandemic in late 2019, any observed associations in these studies were unlikely to be driven by COVID-19. We systematically searched PubMed, EMBASE, and MEDLINE for all MR studies published between 1 January 2019 and 20 May 2023. Inclusion criteria included MR studies which used COVID-19 as the exposure and designed to assess COVID-19's impact on health outcomes. We extracted relevant information, such as result interpretation and relevance assumption assessment. This review was registered at PROSPERO (CRD42023421079). Amongst 57 included studies, 45 studies used outcome GWAS published prior to 2019 whilst the remaining studies likely used outcome GWAS containing data collected before 2019. Relevance assumption was assessed mainly by p values. A total of 35 studies showed an association of COVID-19 liability with health outcomes. Regardless of the results, 45 studies attributed these as evidence (or lack of evidence) of COVID-19 consequence. In MR studies using disease liability as exposure, relevance assumption should consider the prevalence of the disease in the outcome GWAS in the context of 2 sample Mendelian randomization study rather than p values/F-statistic alone. Even when these are verified, these studies likely suffered from pleiotropy, making corresponding interpretation as effect of disease challenging.

Precision oncology in biliary tract cancer: the emerging role of liquid biopsy

Liquid biopsy has already proven effective in aiding diagnosis, risk stratification and treatment personalization in several malignancies, and it could represent a practice-changing tool also in biliary tract cancer, even though clinical applications are currently still limited. It is promising for early diagnosis, especially in high-risk populations, and several studies on circulating free DNA (cfDNA), circulating tumour cells and differential microRNA (miRNA) profiles in this setting are ongoing. Circulating tumour DNA (ctDNA) also appears as a feasible noninvasive biomarker in the curative setting, in detecting minimal residual disease after resection and in monitoring disease recurrence. As of today, it can be particularly valuable in biliary tract cancer for genomic profiling, with a good concordance with tissue samples for most molecular alterations. CtDNA analysis may especially be considered in clinical practice when the tumour tissue is not sufficient for next-generation sequencing, or when urgent therapeutic decisions are needed. Moreover, it offers the possibility of providing a real-time picture to monitor treatment response and dynamically identify resistance mutations, potentially representing a way to optimize treatment strategies.

Screening Biomarkers and Risk Factors for COVID-19 Progression in a Border Population Between Brazil-Bolivia

Background

The performance and genetic role in host response delineate investigative points of polymorphisms as potential biomarkers in viral infections.

Methods

Thus, this research aimed to map biomarkers and risk factors in the severity of COVID-19 in individuals in Western Amazon (n = 243).

Results

Patients aged 40 to 59 years showed an association with clinical progression (P = .003), also evidencing the relationship for individuals >60 years (P < .001), besides the non-vaccination influenced the pathology (P = .023). qPCR for human genotyping of the targets rs2070788, rs4702, rs76635825, rs540856718, rs35803318, rs12979860, and rs16899066, as well as for gene expression of ACE2, HLA-A, HLA-B, IFNL-3/2, IL-6, and TMPRSS2 was used. The rs12979860 (C > T) and rs2070788 (A > G) showed association among the analyzed groups (P < .05) with the allelic and genotypic frequency of rs12979860 (x 2 < 3.84) and evolutionary pointing of rs2070788G allele among infected people, including deaths.

Conclusion

Gene expression showed high levels between the moderate and severe groups, with emphasis on TMPRSS2 and IL-6 genes that performed better. Thus, there is possibly an association regarding the role of the TMPRSS2 gene and rs2070788G, as well as age and IL-6 levels for COVID-19, pointing in parallel to the considerable influence of the vaccine on the SARS-CoV-2 pathway.