Deciphering the interplay between SETD2 mediated H3K36me3 and RNA N6-methyladenosine in clear cell renal cell carcinoma (ccRCC)

RNA N6-methyladenosine (m6A) plays diverse roles in RNA metabolism and its deregulation contributes to tumor initiation and progression. Clear cell renal cell carcinoma (ccRCC) is characterized by near ubiquitous loss of VHL followed by mutations in epigenetic regulators PBRM1, SETD2, and BAP1. Mutations in SETD2, a histone H3 lysine 36 trimethylase (H3K36me3), are associated with reduced survival, greater metastatic propensity, and metabolic reprogramming. While m6A and H3K36me3 deregulation are separately implicated in renal tumorigenesis, H3K36me3 may participate directly in m6A targeting, but the m6A-H3K36me3 interplay has not been investigated in the context of ccRCC. Using RCC-relevant SETD2 isogenic knockout and rescue cell line models, we demonstrate a dynamic redistribution of m6A in the SETD2 depleted transcriptome, with a subset of transcripts involved in metabolic reprogramming demonstrating SETD2 dependent m6A and expression level changes. Using a panel of six histone modifications we show that m6A redistributes to regions enriched in gained active enhancers upon SETD2 inactivation. Finally, we demonstrate a reversal of transcriptomic programs involved in SETD2 loss mediated metabolic reprogramming, and reduced cell viability through pharmacologic inhibition or genetic ablation of m6A writer METTL3 specific to SETD2 deficient cells. Thus, targeting m6A may represent a novel therapeutic vulnerability in SETD2 mutant ccRCC.

Association between early antibiotic treatment after admission and mortality of acute-on-chronic liver failure patients with bacterial infection: A multicenter retrospective study

Bacterial infection is a significant risk factor in the onset and development of acute-on-chronic liver failure (ACLF). Although early broad-spectrum antibiotic treatment is recommended, the optimal time to initiate antibiotic therapy remains unclear. This study aimed to investigate the relationship between the timing of antibiotic treatment and the prognosis of ACLF patients with bacterial infection. Patients with ACLF and bacterial infections upon admission were retrospectively evaluated. The predictors of 28-day mortality were identified using univariate, least absolute shrinkage and selection operator regression analysis, and multivariate logistic regression analyses. The "survminer" R package was used to categorize patients into two groups based on a 6-h threshold: early antibiotic administration (<6 h of admission) and later antibiotic administration (≥6 h after admission). A total of 295 patients were evaluated. The lungs were the most common site of infection (61.7% of patients had lung infections), followed by the peritoneum (25.4% of patients had spontaneous bacterial peritonitis). The time to first antibiotic administration was an independent predictor of 28-day mortality, and the odds of mortality increased by 2% for each hourly delay in antibiotic administration after admission. In Kaplan-Meier survival analysis, both 28-day and 90-day mortality rates were significantly lower in the early antibiotic group than in the later antibiotic group (both p < 0.0001). In conclusion, early antibiotic treatment is an independent predictor of 28-day mortality in ACLF patients with bacterial infections. Patients who received antibiotics less than 6 hours after admission exhibited lower 28- and 90-day mortality rates.

Nicotinamide N-methyltransferase in cardiovascular Diseases: Mechanistic insights and therapeutic potential

Cardiovascular diseases (CVDs), including conditions like ischemic heart disease, heart failure (HF), and atherosclerosis (AS), have complex pathogenesis that involves both behavioral and metabolic factors. Nicotinamide N-methyltransferase (NNMT) is an enzyme involved in the methylation of nicotinamide (NAM), and its increased activity is associated with disruptions in the NAD+ and methionine cycles. These disruptions are considered significant risk factors for cardiovascular diseases, though the specific mechanisms of NNMT remain unclear. This review discusses the role of NNMT in cardiovascular diseases by modulating NAD+ and methionine metabolism, including mechanisms such as NAD+ depletion, mitochondrial energy crisis, SIRTs deactivation, PARP hyperactivation, as well as hyperhomocysteinemia and epigenetic dysregulation. NNMT is linked to diseases such as atherosclerosis, pulmonary arterial hypertension, heart failure, and coronary heart disease, playing a critical role in their progression. Moreover, the potential of NNMT as a therapeutic target for cardiovascular diseases is explored. RNAi therapies, NNMT small-molecule inhibitors, and exercise therapies are promising treatment approaches, but there are limitations in current research, including discrepancies between animal models and human tissue expression, the dual role of NNMT, and the dose-dependent effects of NNMT inhibitors. Future studies should further clarify NNMT's mechanisms and assess its feasibility as a therapeutic target, aiming to develop more effective treatments and enhance prevention and treatment strategies for cardiovascular diseases.

Indian National Association for the Study of Liver (INASL) Guidance Statements for Determining Futility in Liver Transplantation

Liver transplantation (LT) is a life-saving procedure for patients with end-stage liver disease; however, with the growing shortage of organ donors, the need to identify futile transplants has become increasingly urgent. Futility in liver transplantation refers to situations where the expected post-transplant survival or quality of life is poor, making the procedure unlikely to yield a meaningful benefit. Various definitions of futility are used across different countries and transplant centers, with criteria often based on clinical factors such as age, comorbidities, MELD score, and functional status. For hepatologists and transplant surgeons, clearer guidelines are essential to make informed decisions and avoid unnecessary transplants that may place patients at risk without improving their prognosis. While some studies have proposed futility scores, there is currently no universal consensus on a standardized definition or set of criteria. This highlights the need for further prospective trials to evaluate the predictors of futility in liver transplantation, aiming to refine decision-making processes, optimize organ allocation, and improve patient outcomes. Future research should focus on the development of universally accepted futility criteria and explore interventions to mitigate the factors contributing to transplant futility.

SLC27A5 inhibits cancer stem cells by inducing alternative polyadenylation of METTL14 in hepatocellular carcinoma

Solute carrier family 27 member 5 (SLC27A5/FATP5) is a liver-specific metabolic enzyme that plays a crucial role in fatty acid transport and bile acid metabolism. Deficiency of SLC27A5 promotes the progression of hepatocellular carcinoma (HCC) and is strongly associated with a poor prognosis. SLC27A5 exhibits noncanonical functions beyond its metabolic role; however, its specific mechanisms in hepatocarcinogenesis remain elusive and are therefore investigated in this study. Immunoprecipitation-mass spectrometry analysis showed that SLC27A5-interacting proteins were significantly enriched in alternative polyadenylation (APA). RNA-sequencing data provided evidence that SLC27A5 plays a global role in regulating APA events in HCC. Mechanistically, SLC27A5 facilitates the usage of the proximal polyadenylation site of METTL14 by downregulating the expression of the APA-associated factor PABPC1, resulting in the shortening of the METTL14-3'UTR and the conversion of METTL14-UL to METTL14-US. In contrast to METTL14-UL, METTL14-US escapes the inhibitory effect of miRNA targeting, leading to increased METTL14 expression. METTL14-US upregulation by SLC27A5 suppressed the stemness of HCC. Therefore, low levels of SLC27A5 and METTL14 may serve as reliable biomarkers for identifying poor prognosis in patients with HCC. In conclusion, SLC27A5/PABPC1 inhibits HCC stemness via APA-regulated expression of METTL14, providing potential avenues for the development of novel therapeutic strategies.

Fibrogenic Gene Signature as Early Prediction for the Efficacy of Pharmacological Interventions for MASH-Associated Fibrosis

The incidence of metabolic dysfunction-associated steatohepatitis (MASH) and associated liver fibrosis is rapidly increasing, while pharmacological treatment options remain limited. Despite great efforts in developing novel MASH therapeutics, many investigative therapeutics that reduced fibrosis in preclinical models ultimately failed in clinical trials. To this end, we explored the possibility of predicting the efficacy of therapeutics by evaluating changes in the expression of a fibrogenic gene signature in the early stages of disease development and before effects on pathology become evident. Ldlr-/-.Leiden mice were fed a high-fat diet (HFD) to induce obesity and MASH. Mice were subsequently treated for 4 weeks with various therapeutics with established efficacy (obeticholic acid) or lack of efficacy (cenicriviroc and pioglitazone) to study their anti-fibrotic potential. Expression of a fibrogenic gene signature was evaluated, which predicts profibrotic processes before histopathologic fibrosis develops. The predictions were compared with a long-term experiment reaching histological fibrosis endpoints. Cenicriviroc and pioglitazone did not affect HFD-induced fibrosis signature, indicative of no effect of these treatments on active fibrosis processes. Consistently, in the long-term treatment study, both cenicriviroc and pioglitazone did not affect HFD-induced histologically measured fibrosis. In contrast, obeticholic acid improved the fibrogenic gene signature to a healthier state compared to untreated HFD controls. These early gene expression changes aligned with long-term histological fibrosis endpoints and clinical data on these investigative therapeutics. This study highlights the potential of using short-term studies and applying a fibrogenic gene signature as an early screening tool to investigate the efficacy of investigative drugs on MASH-associated fibrosis. This signature, which is based on the active fibrosis processes in humans, may allow rapid screening of therapeutics, or combinations thereof, when used in a translational mouse model.

Upper limit of normothermic machine preservation of liver grafts from donation after circulatory death yet to be defined

BACKGROUND

The normothermic machine perfusion pump (NMPP) could shape the future of transplantation. Providing ex-vivo optimization, NMPP attenuates ischemic insult while replenishing energy. An understanding of machine perfusion time (MPT) impact and potential clinical benefits is paramount and necessitates exploration.

AIM

To investigate the relationship between MPT and post-transplant graft function.

METHODS

Retrospective review of the first 50 donation after circulatory death (DCD) grafts preserved using NMPP in a tertiary institution was performed. Essential preservation time points, graft parameters, recipient information, and postoperative outcomes were prospectively recorded. Early allograft dysfunction (EAD), L-Graft₇ score and 90-day outcomes were collected for all grafts. The first 20 recipients were allocated into the early group, considered the learning curve population for the center. The subsequent 30 were allocated into the late group. Recipients were also stratified into cohorts depending on MPT, i.e., short (< 8 hours), medium (8-16 hours) and long (> 16 hours).

RESULTS

NMPP operational parameters were not predictive of EAD, L-GrAFT₇ or 90-day outcomes. The early group had significantly less MPT and cold ischemia time than the late group (553 minutes vs 850 minutes, P < 0.001) and (127.5 minutes vs 154 minutes, P = 0.025), respectively. MPT had no impact in either group.

CONCLUSION

Increased MPT of DCD liver grafts had no adverse recipient results for the times utilized in this population, indicating its upper limits, likely beyond 24 hours, are not demonstrated within this study. Future studies are necessary to determine whether longer MPT is beneficial or detrimental to graft function and, if the latter, what is the maximum safe duration. Further studies of the effect of normothermic machine perfusion pump duration on long-term outcomes are also needed.

Exploring the mechanisms of Yinchenhao decoction against ANIT-induced cholestatic liver injury by lipidomics, metabolomics and network pharmacology

Yinchenhao decoction (YCHD) has been used for the treatment of cholestasis for more than 1000 years with clear clinical efficacy. However, its active compounds and pharmacological mechanism against cholestasis are unclear. In this study, an integrated strategy of network pharmacology, lipidomics, metabolomics, and molecular docking were performed to elucidate the mechanism of YCHD's anti-cholestasis effect. Network pharmacology demonstrated YCHD mainly modulated lipid and atherosclerosis signaling pathways with the involvement of NF-κB, TNF, MAPK, and PI3K/AKT signaling pathways. In vivo experiments, male C57BL/6 J mice model of cholestasis was established by alpha-naphthyl isothiocyanate (ANIT), and were treated with different dosages (3 g/kg and 9 g/kg) of YCHD for one week. Ursodeoxycholic acid (UDCA) was used as a positive control. The in vivo experiments verified the ameliorative effect of YCHD on inflammation, hepatocellular injury and cholestasis. Furthermore, lipidomics and metabolomics research showed that YCHD could improve the metabolism disorder of glycerolipid, glycerophospholipid and amino acids. Subsequently, further WB and molecular docking validation experiments showed that the active compounds in YCHD have regulatory effects on the PPARγ/NF-κB/JNK pathway, the core pathway in lipid and atherosclerosis pathways, thereby inhibiting inflammatory response and improving lipid metabolism disorders. This study could provide evidence of the molecular mechanism and material basis of YCHD in treating cholestasis. This study also provided new research ideas for the discovery of active ingredients in traditional Chinese medicine formulas for the treatment of cholestasis.

Pig bile powder maintains blood glucose homeostasis by promoting glucagon-like peptide-1 secretion via inhibiting farnesoid X receptor

BACKGROUND

Traditional Chinese medicine offers many valuable remedies for maintaining blood glucose homeostasis in patients with type 2 diabetes mellitus. Bile powder (BP) is a powdered form of bile derived from pigs. It has been used historically in various medicinal applications. Currently, the therapeutic potential of BP in regulating glucose homeostasis remains unclear. Bile acids (BAs) are increasingly recognized for their role in glucose metabolism particularly through the modulation of glucagon-like peptide-1 (GLP-1).

AIM

To investigate BP effects on glucose homeostasis and elucidate its mechanistic role through GLP-1 and farnesoid X receptor (FXR) signaling.

METHODS

A diabetic mouse model was established using a high-fat diet and streptozotocin administration. Mice were treated with BP at doses of 25, 50, or 75 mg/kg/day for 45 days. Glucose homeostasis was assessed via the oral glucose tolerance test and insulin tolerance test. Serum GLP-1 levels were measured by enzyme-linked immunosorbent assay. A GLP-1 receptor antagonist and an FXR agonist were used to clarify the underlying mechanisms. In vitro STC-1 murine enteroendocrine cells were treated with a BP-mimicking BA mixture to assess GLP-1 secretion and proglucagon gene expression.

RESULTS

BP treatment significantly improved glucose homeostasis in the diabetic mouse model as indicated by lower blood glucose (P < 0.05) and improved insulin sensitivity. BP enhanced GLP-1 secretion (P < 0.05), which was an effect abolished by the GLP-1 receptor antagonist. This observation confirmed its dependence on GLP-1 signaling. In STC-1 cells, BP-derived BA mixtures stimulated GLP-1 secretion and upregulated proglucagon expression (P < 0.05). Mechanistically, BP inhibited FXR signaling as evidenced by the reversal of its effects upon fexaramine administration. In addition, long-term BP treatment suppressed FXR signaling, resulting in elevated GLP-1 levels and preventing glucose dysregulation.

CONCLUSION

BP improved glucose homeostasis by promoting GLP-1 secretion via FXR inhibition, highlighting its potential as a therapeutic strategy for metabolic disorders.

Innovative nanomedicine approaches for the management of nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent liver disorder globally. The prevalence of NAFLD in the general population is estimated to be 25-30 %, making it the most common chronic liver condition in China as well as worldwide. Given the escalating disease burden and the scarcity of effective therapeutic interventions, there is a pressing unmet clinical need. Consequently, the development of novel pharmaceuticals has emerged as a pivotal research focus in recent years. Moreover, the advent of nano-delivery technology offers innovative solutions for NAFLD drug therapy. This paper presents a comprehensive examination of the pathogenesis and therapeutic targets of NAFLD. It critically reviews the latest advancements in nanomedicine research pertinent to NAFLD treatment. The review synthesizes a broad range of research findings to bridge the gap between current knowledge and emerging therapeutic strategies, and aims to inform and guide future research directions in NAFLD management.

Advancing care in primary biliary cholangitis: emerging insights and novel therapies

INTRODUCTION

- Primary biliary cholangitis (PBC) is a chronic, cholestatic liver disease, is associated with fatigue and pruritus and can progress to cirrhosis if left untreated. Ursodeoxycholic acid (UDCA) has been the mainstay of therapy for over 40 years. However, 30-40% of PBC patients do not adequately respond to UDCA or have risk factors for disease progression and require second-line treatment.

AREAS COVERED

- Recent international cohort analyses have provided new insights that enable early identification of high-risk PBC patients and suggest that stricter treatment goals may lower mortality and reduce the need for liver transplantation. Alongside established second-line agents, several promising substances have progressed to phase 2 and 3 trials. Notably, seladelpar and elafibranor, two selective agonists of peroxisome proliferator-activated receptors, achieved high rates of biochemical response and good tolerability, leading to their recent approval for second-line treatment of PBC. Moreover, dedicated clinical trials addressed fatigue and pruritus, the two main symptoms of PBC.

EXPERT OPINION

- Personalized treatment approaches for PBC are both feasible and essential to improve biochemical response, extend transplant-free survival and alleviate symptom burden. Well-tolerated novel therapies are poised to reshape the treatment landscape in the near future.

Sepsis in liver failure patients: Diagnostic challenges and recent advancements

Acute liver failure (ALF) and acute-on-chronic LF (ACLF) are prevalent hepatic emergencies characterized by an increased susceptibility to bacterial infections (BI), despite significant systemic inflammation. Literature indicates that 30%-80% of ALF patients and 55%-81% of ACLF patients develop BI, attributed to immunological dysregulation. Bacterial sepsis in these patients is associated with adverse clinical outcomes, including prolonged hospitalization and increased mortality. Early detection of bacterial sepsis is critical; however, distinguishing between sterile systemic inflammation and sepsis poses a significant challenge due to the overlapping clinical presentations of LF and sepsis. Conventional sepsis biomarkers, such as procalcitonin and C-reactive protein, have shown limited utility in LF patients due to inconsistent results. In contrast, novel biomarkers like presepsin and sTREM-1 have demonstrated promising discriminatory performance in this population, pending further validation. Moreover, emerging research highlights the potential of machine learning-based approaches to enhance sepsis detection and characterization. Although preliminary findings are encouraging, further studies are necessary to validate these results across diverse patient cohorts, including those with LF. This article provides a comprehensive review of the magnitude, impact, and diagnostic challenges associated with BI in LF patients, focusing on novel advancements in early sepsis detection and characterization.

Mechanisms and therapeutic potential of multiple forms of programmed cell death in renal fibrosis

Programmed cell death (PCD), particularly necroptosis, ferroptosis, and pyroptosis alongside classical apoptosis has attracted considerable attention in recent years in the context of renal fibrosis (RF). Accumulating evidence indicates that these regulated cell death pathways contribute substantially to renal tissue damage and fibrosis progression by promoting inflammation and extracellular matrix (ECM) accumulation. Renal fibrosis, a common pathological process to various chronic kidney diseases (CKD), is closely intertwined with diverse forms of cell death. Elucidating the underlying molecular mechanisms is critical for identifying effective therapeutic targets. This review systematically summarizes the signaling mechanisms of apoptosis, necroptosis, ferroptosis, and pyroptosis, detailing their roles in the pathogenesis of RF. We analyze recent advances in pharmacological treatment and emerging therapies targeting these pathways, and explore potential therapeutic targets for clinical implementation. Targeting multiple forms of regulated cell death pathways concurrently may offer a promising avenue for the precision treatment of RF.

Natural bioactive compounds reprogram bile acid metabolism in MAFLD: Multi-target mechanisms and therapeutic implications

Metabolic-associated fatty liver disease (MAFLD) has become an increasingly prevalent liver disorder worldwide, being closely associated with obesity, metabolic syndrome, and insulin resistance. Bile acids (BAs), beyond their traditional role in lipid digestion, play a pivotal part in regulating lipid and glucose metabolism as well as inflammatory responses. Recent investigations have recognized BAs as key factors in the onset and progression of MAFLD, mainly via their interactions with nuclear receptors such as the farnesoid X receptor (FXR) and the G protein-coupled bile acid receptor (TGR5). Additionally, active compounds derived from traditional Chinese medicine (TCM) have shown promising potential in the treatment of MAFLD. This study systematically reviews and analyzes the molecular mechanisms and recent progress in the application of TCM active ingredients for MAFLD treatment, with a focus on their regulation of BAs. These active ingredients, including saponins, flavonoids, polysaccharides, and sterols, exert therapeutic effects through diverse mechanisms, such as modulating BA synthesis and mediating receptor-signaling pathways, and are expected to restore metabolic homeostasis.

Immune Dysfunction and Infection Risk in Advanced Liver Disease

The risk of microbial infections is increased in cirrhosis and other forms of advanced liver disease such as alcohol-associated hepatitis. Such infections may precipitate new or further decompensation and death, especially in patients with clinical features of acute-on-chronic liver failure. The severe immune dysfunction or "immune paralysis" caused by advanced liver disease is associated with high short-term mortality. However, the pathogenic mechanisms underlying immune dysfunction and immunodeficiency are incompletely understood. Evidence to date suggests a complex, dynamic process that perturbs the physiological roles of the liver as a master regulator of systemic immunity and protector against noxious effects of exogenous molecules in the portal vein flowing from the gut. Thus, in cirrhosis and severe alcohol-associated hepatitis, the ability of hepatocytes and intrahepatic immune cells to balance normal context-dependent dichotomous responses of tolerance vs immune activation is lost. Contributing factors include loss of the gut barrier with translocation of microbial products through the portal vein, culminating in development of functional defects in innate and adaptive immune cells, and generation of immune-regulatory myeloid cells that permit microbial colonization and infection. This review addresses key evidence supporting the paradigm of immune dysfunction as a risk for microbial infections and identifies potential therapeutic targets for intervention. The primary focus is on cirrhosis-associated immune dysfunction and alcohol-associated liver disease, because the bulk of available data are from these 2 conditions.

Insights into medication-induced liver injury: Understanding and management strategies

Drug-induced liver injury (DILI) has increasingly become a major concern in Western countries since the late 1960s, with an estimated annual incidence of 13.9-19.1 cases per 100,000 people. DILI is a significant cause of acute liver failure, exhibiting a high mortality rate of 10-50 %. Its etiology includes medications, herbal products, and dietary supplements, exacerbated by pre-existing liver conditions, sonorities, pregnancy, and nutritional deficiencies. It is categorized into intrinsic and idiosyncratic reactions. Intrinsic DILI, dose-dependent and predictable, is primarily caused by substances like paracetamol, which leads to liver toxicity through direct metabolic pathways. In contrast, idiosyncratic DILI is less common, unpredictable, and affects susceptible individuals, with non-steroidal anti-inflammatory drugs, antibiotics, and cardiovascular agents frequently implicated in hospitals. Oxidative stress, mitochondrial dysfunction, bile salt export inhibition, and stress on the endoplasmic reticulum are some DILI-related pathophysiology. Diagnosis relies on biochemical tests, serological markers, radiological investigations, and liver biopsy. Management strategies emphasize the identification and cessation of the offending drugs, supportive care, and specific treatment options targeted to the culprit drugs. Management depends on the severity and nature of the injury.

Metabolic Dysfunction-Associated Steatotic Liver Disease in the MENA Region: Setting a Research and Action Priority Agenda

BACKGROUND & AIMS

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a growing health challenge, particularly in Middle East and North Africa (MENA) countries. This study aimed to establish a consensus-driven research and action agenda to address MASLD within the MENA region.

METHODS

Following a global MASLD research and action agenda setting study, over two Delphi rounds (Rs), MENA region experts (R1 n = 112, R2 n = 104) indicated their level of agreement with and provided feedback on MASLD research and action priorities via Qualtrics XM. In R2, panellists also ranked the priorities, which were categorised across six domains: (1) the human and economic burden, (2) defining and implementing care models, (3) disease management, (4) education and awareness, (5) patient and community perspectives, and (6) leadership and policies for the MASLD public health agenda.

RESULTS

The consensus-built MASLD research and action priority agenda for the MENA region comprises 52 priorities. Combined agreement (i.e., 'agree' + 'somewhat agree') increased from 97.6% and 98.1% in R1 to 98.2% and 98.5% in R2 with the research (n = 30) and action (n = 22) priorities, respectively. The highest ranked research priorities included developing regional MASLD databases and validating non-invasive diagnostic tools. The highest ranked action priorities included taking steps to enhance the adoption of lifestyle interventions among people living with MASLD and improving disease knowledge among healthcare providers.

CONCLUSIONS

This region-specific agenda can help to guide research and optimise clinical practice, thereby improving the understanding, prevention, and management of MASLD, enhancing health outcomes and reducing its burden within the MENA region.

A nomogram for predicting early biliary complications in adult liver recipients of deceased donor grafts: Integrating artery resistive index and clinical risk factors

BACKGROUND

This study aimed to identify predictors of biliary complications within 90 days after liver transplantation in adult recipients of deceased donor grafts.

METHODS

The study retrospectively analyzed adult patients who underwent liver transplantation from January 2016 to December 2021 using deceased donor grafts in our center. Patients were randomly divided into training and validation cohorts (7:3 ratio). A nomogram was developed using least absolute shrinkage and selection operator logistic regression for feature selection, followed by a 2-way stepwise approach in multivariate logistic regression. Model performance was assessed with the C-index, receiver operating characteristic area under the curve, calibration curves, and decision curve analysis.

RESULTS

A total of 757 patients were included, of whom 76 developed early biliary complications. Least absolute shrinkage and selection operator binary logistic analysis showed that postoperative day 1 arterial resistance index, acute rejection, acute-on-chronic liver failure, hepatic artery thrombosis, recipient body mass index, and donor age were independent predictors of biliary complications within 90 days. A nomogram was established on the basis of these factors. The C-index for the final nomogram was 0.822. The area under the curve in the training cohort was 0.837 (95% confidence interval, 0.780-0.893) and 0.771 (95% confidence interval, 0.677-0.865) in the validation cohort. Calibration curves demonstrated good agreement between predicted and actual outcomes. Decision curve analysis confirmed the clinical utility of the nomogram.

CONCLUSION

Low arterial resistance index (≤0.57) on the first postoperative day is a predictor of biliary complications within 90 days after liver transplantation in adult recipients of deceased donor grafts. The nomogram provides a practical tool for predicting complications and guiding clinical decisions.

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.

Insights into Clinical Trials for Drugs Targeting MASLD: Progress, Challenges, and Future Directions

The transition in terminology from fatty liver disease to metabolic dysfunction-associated steatotic liver disease (MASLD) marks a considerable evolution in diagnostic standards. This new definition focuses on liver fat accumulation in the context of overweight/obesity, type 2 diabetes, or metabolic dysfunction, without requiring the exclusion of other concurrent liver diseases. The new definition also provides clear guidelines for defining alcohol consumption in relation to the disease. MASLD is currently acknowledged as the most widespread liver disorder globally, affecting ~25% of the population. Despite the extensive array of clinical trials conducted in recent years, the number of approved treatments for metabolic dysfunction-associated fatty liver disease is very limited. In the review critically evaluates the results of clinical trials of related drugs and assesses the future directions for drug development trials. The renaming of MASLD presents new challenges and opportunities for the design of clinical trials and the selection of target populations for drug development.

Disparity landscapes of viral-induced structural variations in HCC: Mechanistic characterization and functional implications

BACKGROUND AND AIMS

HCC is the most common type of primary liver cancer and is a common malignancy worldwide. About half of all new liver cancers worldwide each year occur in China, including Hong Kong, due to a high prevalence of HBV infection. HBV DNA integrates into the human genome, disrupting the endogenous tumor suppressors/regulatory genes or enhancing the activity of proto-oncogenes. It would be useful to examine the different NGS-based databases to provide a more unbiased and comprehensive survey of HBV integration.

APPROACH AND RESULTS

We aimed to take advantage of publicly available data sets of different regional cohorts to determine the disparity landscapes of integration events among sample cohorts, tissue types, chromosomal positions, individual host, and viral genes, as well as genic locations. By comparing HCC tumors with non tumorous livers, the landscape of HBV integration was delineated in gene-independent and gene-dependent manners. Moreover, we performed mechanistic investigations on how HBV-TERT integration led to TERT activation and derived a score to predict patients' prognostication according to their clonal disparity landscape of HBV integration.

CONCLUSIONS

Our study uncovered the different levels of clonal enrichment of HBV integration and identified mechanistic insights and prognostic biomarkers. This strengthens our understanding of HBV-associated hepatocarcinogenesis.

Is the FIB-4 score a prognostic factor in acute ischemic stroke patients receiving intravenous thrombolytic therapy?

BACKGROUND

Liver dysfunction is recognized as a risk factor for poor outcome after. stroke. The FIB-4 index, a laboratory test for predicting liver fibrosis, has been shown to be. associated with poor prognosis in cardiovascular and cerebrovascular diseases. The aim of. this study was to explore the relationship between FIB-4 score and hemorrhagic. transformation, mortality, and prognosis in patients with acute ischemic stroke who received. intravenous thrombolytic therapy (IV tPA).

METHODS

The records of 255 consecutive patients who received IV tPA for acute. ischemic stroke were retrospectively reviewed. Patients were divided into two groups. according to their FIB-4 scores: group 1 (FIB-4 ≤ 2.67) and group 2 (FIB-4 > 2.67). The. demographic data, NIHSS scores at admission, THRIVE scores, intracranial bleeding rates, (using the Heidelberg Bleeding Classification, NINDS and ECASS criteria for symptomatic. intracranial hemorrhage), stroke etiology subtypes (using the automated Causative. Classification System), and mRS scores at the third month were recorded.

RESULTS

On logistic regression analysis, group 2 patients were older, had higher mRS. scores at the third month and had increased mortality within 3 months when compared with. group 1 (p ≤ 0.05). Although group 2 patients had a higher rate of intracranial hemorrhage, the difference was not statistically significant.

CONCLUSIONS

The FIB-4 index may serve as a a useful predictor of poor prognosis in patients with acute ischemic stroke who received IV tPA. Large-scale prospective studies are needed to confirm this relationship and provide valuable insights for clinical practice.

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).

The present and the future of immunotherapy in hepatocellular carcinoma and biliary tract cancers

Hepatobiliary malignancies encompass a spectrum of invasive carcinomas arising in the liver [hepatocellular carcinoma (HCC), bile ducts [intrahepatic cholangiocarcinoma (ICC), and extrahepatic cholangiocarcinoma (EHC)] and the gallbladder. These malignancies represent a growing global health burden, with rising incidence and mortality rates and their overall prognosis remains poor because many patients present with advanced unresectable disease at diagnosis. In recent years, significant advancements in understanding HCC immunogenicity have reshaped the therapeutic scenario of advanced HCC with the immunotherapy revolutionizing the current HCC treatment landscape and patients' prognosis. Moreover, the addition of immunotherapy to chemotherapy has recently established a new standard of care first-line treatment for patients with biliary tract cancers (BTCs) who had historically few therapeutic options. Currently, immunotherapy and immune checkpoint inhibitor (ICI)-based regimens stand as a valuable and practice-changing options in both HCC and BTC management. The mounting recent evidence supporting immunotherapy's survival benefit demands clinicians to stay updated with a rapidly evolving treatment landscape as well as gain knowledge about patient selection, response rate compared with other systemic treatments and immune-mediated adverse events (imAEs) management. A panel of international Experts, comprising hepatologists and oncologists, gathered to explore the challenges in effectively integrating immunotherapy in routine clinical practice. The aim of this review is to present the Experts' insights to inform treatment choice in HCC and BTC with a special emphasis on the role of currently available ICI-based therapies in shifting treatment paradigms and potentially reversing the natural course of these two deadly malignancies.

The hepatoprotective effects of the polyphenol-enriched n-butanol fraction of Cnicus benedictus against carbon tetrachloride-induced liver fibrosis in rats: In vivo study

Liver fibrosis is a continuous wound-healing response to chronic injury caused by various chemical, virus, and pathological disorders; the lack of approved drugs or methods to reverse or prevent liver fibrosis makes it an interesting area of research. This study investigates the potential hepatoprotective effects of the phenolic extract of Cnicus benedictus in rat's module of liver fibrosis. Liver fibrosis was induced by intraperitoneal injection of carbon tetrachloride (CCl4) for six consecutive weeks; the butanol fraction of Cnicus and silymarin was administered orally concurrently with CCl4. After six weeks, all animals were euthanized. Rat liver tissue levels of malondialdehyde (MDA) and glutathione (GSH) were measured, and serum liver enzymes and protein were measured using the ELISA technique. Histopathological study and immunohistochemistry of liver tissue for transforming growth factor (TGF-β1), alpha-smooth muscle actin (α-SMA), and hydroxyproline were assessed. In HPLC analysis, Cnicus extract showed several components, including quercetin, gallic acid, rutin, kaempferol, silibinin, and apigenin. Treatment with Cnicus butanol extract reduces serum ALT, AST, bilirubin, and albumin levels compared to induction. Additionally, Cnicus extract increases liver GSH levels and decreases liver MDA levels compared to induction. Liver tissue of TGF-β1, α-SMA, and hydroxyproline expression was downregulated in rats receiving Cnicus extract. Liver tissue histopathology showed improvement in its features compared to the induction group. In conclusion, oral administration of the polyphenol-enriched n-butanol fraction of Cnicus benedictus showed a protective effect on liver fibrosis caused by CCl4, possibly through antioxidant and anti-inflammatory mechanisms.

High Hospitalization Rates and Risk Factors Among Frail Patients With Cirrhosis: A 10-year Population-based Cohort Study

BACKGROUND & AIMS

Cirrhosis-related inpatient hospitalizations have increased dramatically over the past decade. We used a longitudinal dataset capturing a large metropolitan area in the United States from 2011 to 2021 to evaluate contemporary hospitalization rates and risk factors among frail patients with cirrhosis.

METHODS

We conducted a retrospective, longitudinal cohort study using the Chicago Area Patient-Centered Outcomes Research Network (CAPriCORN) database, an electronic health record repository that aggregates de-duplicated data across 7 health care systems in the Chicago metropolitan area, from 2011 to 2021. The primary outcome of our study was the rate of hospitalization encounters. Frailty was defined by the Hospital Frailty Risk Score. Hospitalization rates were reported per 100 patients per year, and a multivariable logistic regression analysis identified predictors of annual hospitalization probability.

RESULTS

During the study period, of 36,971 patients, 16,265 patients (44%) were hospitalized (compensated, 18.4%; decompensated, 81.6%). Hospitalization rates were highest in patients with decompensated cirrhosis, reaching nearly 77.3 hospitalizations/100 patients per year. Hospitalization rates among patients with compensated cirrhosis were also high (14.2 vs 77.3 hospitalization/100 patients per year), with odds of annual hospitalization 3 times (odds ratio, 3.1; 95% confidence interval, 2.9-3.4) as high among compensated patients with intermediate frailty and 5 times (odds ratio, 5.2; 95% confidence interval, 4.5-6.0) as high among those with severe frailty (compared with compensated patients with low frailty).

CONCLUSION

Compensated and decompensated cirrhosis patients with intermediate to severe frailty face a substantially increased odds of annual hospitalizations compared with those with low frailty. Future work should focus on targeted interventions to incorporate routine frailty screenings into cirrhosis care and to ultimately minimize high hospitalization rates.

Mitochondrial Membrane Potential of CD8+ T Cells Predicts Bacterial Infection and Rapid Development of Acute-on-chronic Liver Failure in Cirrhotic Patients

Background and Aims

Patients with cirrhosis are at an increased risk of bacterial infection (BI), which is the most common precondition for acute-on-chronic liver failure (ACLF). In this study, we aimed to evaluate the ability of mitochondria-related indicators (mitochondrial mass and mitochondrial membrane potential (MMP)) of T cells in peripheral blood to predict BI and ACLF within 90 days in cirrhotic patients.

Methods

We prospectively studied mitochondria-related indicators in various T cells from 235 cirrhotic patients at the Second Hospital of Nanjing. The outcomes of interest were BI and ACLF.

Results

The restricted cubic spline analysis showed that the MMP of CD8+ T cells had a linear relationship with the risk of BI and ACLF (both P < 0.001). Multivariable Cox regression analysis demonstrated that the MMP of CD8+ T cells was an independent risk factor for both BI and ACLF (BI: hazard ratio 0.96, 95% confidence interval 0.94-0.98; P < 0.001; ACLF: hazard ratio 0.94, 95% confidence interval 0.90-0.97; P < 0.001). The MMP of CD8+ T cells exhibited better diagnostic efficacy than traditional indices in predicting BI (C index: 0.75). The MMP of CD8+ T cells, when combined with traditional models (Child-Turcotte-Pugh and model for end-stage liver disease score), improved their diagnostic efficiency in predicting both BI and ACLF. Additionally, the MMP of CD8+ T cells showed a significant negative correlation with inflammation-related markers (P < 0.05). Mitochondrial damage and abnormally activated mitochondrial autophagy were observed in CD8+ T cells from cirrhotic patients with low MMP.

Conclusions

The MMP of CD8+ T cells could serve as a valuable predictor of BI and ACLF within 90 days in cirrhotic patients.

Liver transplantation for combined hepatocellular cholangiocarcinoma: Current evidence, selection criteria, and therapeutic controversies

Combined hepatocellular cholangiocarcinoma (cHCC-CCA) is a rare and aggressive primary liver malignancy characterized by features of both HCC and CCA. Preoperative diagnosis remains challenging because of overlapping imaging and histopathological features, which often lead to misclassification. Although liver resection is the primary curative therapy, the efficacy of liver transplantation (LT) remains controversial. Historically, LT has been considered contraindicated owing to the poor prognosis, high recurrence rate of cHCC-CCA, and the potential for organ wastage. Recent studies have suggested that LT may benefit carefully selected patients, particularly those with early-stage tumors or cirrhosis. However, there is no consensus on the criteria for LT in patients with cHCC-CCA. Lymphadenectomy and vascular resection strategies were discussed along with locoregional and systemic therapies. This review synthesized the current evidence on surgical strategies for cHCC-CCA, focusing on evolving LT criteria and outcomes.

Infection risk and management in patients with cirrhosis: A critical overview

In this paper, we analyze the article published by El Labban et al, which explores the impact of cirrhosis on patients with necrotizing fasciitis. The authors conclude that cirrhosis is a significant risk factor for increased in-hospital morbidity and mortality in this patient population. Building upon their final observation regarding the importance of understanding this association, we will delve into the topic of infections in patients with liver cirrhosis. These patients exhibit intrinsic characteristics that make them particularly susceptible to infections, both bacterial and fungal. This heightened risk not only increases the likelihood of severe infections but also makes them a common trigger for acute decompensations, including the development of acute-on-chronic liver failure, which markedly worsens prognosis and mortality. Infections in patients with cirrhosis often require a more aggressive and rapid diagnostic and therapeutic approach due to the higher risk of nosocomial infections, multidrug-resistant organisms, and atypical clinical presentations. Delayed or inadequate management can lead to unfavorable outcomes, further complicating the course of their underlying liver disease. The aim of this article is to emphasize the importance of early and appropriate management in patients with cirrhosis with infections. Evidence supports that timely and tailored interventions not only improve clinical outcomes but also reduce mortality. By raising awareness among clinicians about the complexity of these cases, we hope to contribute to optimizing the care of this high-risk population.

Prognostic challenges in alcoholic hepatitis: From scoring systems to clinical predictors

In this article, we discuss the recently published article by Yang et al. This retrospective analysis, which was conducted at a large urban tertiary care center, focused on comparing Lille model scores at days 3 and 7 with established scoring systems and identifying critical clinical predictors, such as renal dysfunction, nutritional status, and underlying cirrhosis. Alcoholic hepatitis (AH), a severe manifestation of alcohol-related liver disease, is associated with high morbidity and mortality, necessitating accurate prognostic tools and comprehensive clinical assessments. Prognostic tools are invaluable for early risk stratification, but they must be contextualized within the multifactorial nature of AH. Acute renal dysfunction and poor nutritional status, for example, are not just complications but pivotal markers of disease severity and systemic impact. Addressing these factors requires a holistic approach that extends beyond scoring systems to include targeted interventions and comprehensive patient care. This editorial emphasizes the need for a paradigm shift in AH management, where prognostic models are complemented by a deeper understanding of patient-specific factors. Such an approach can guide clinicians in tailoring therapies and improving outcomes for this high-risk population.

Mechanism-guided drug development and treatment for liver fibrosis: a clinical perspective

Liver fibrosis is a common response to chronic liver injury due to multiple etiologies and plays a crucial in the progression of chronic liver disease to cirrhosis, hepatocellular carcinoma, and other liver-related clinical outcomes. Currently, available treatments to block liver fibrosis are designed to eliminate the underlying causes of liver disease. The lack of truly effective drugs to regress or reverse fibrosis is a major unmet clinical need. In this context, this article briefly describes the pathological process of hepatic fibrosis and focuses on reviewing the progress of clinical studies on mechanism-based anti-fibrotic drug development and therapy, highlighting that the positive effect of thyroid hormone receptor-β (THR-β) analogs, fibroblast growth factor 21 (FGF21) analogues, Glucagon-like peptide 1 receptor (GLP-1R) agonists, pan-peroxisome proliferator-activated receptor (pan-PPAR) agonists, fatty acid synthase (FASN) inhibitors, and hydronidone in reducing liver fibrosis caused by specific etiologies. Moreover, multi-pathway guided combination therapy or traditional Chinese medicine demonstrate significant advantages in combating liver fibrosis. Finally, new technologies and approaches affecting the clinical development of anti-hepatic fibrosis drugs were discussed.

The bile acid-gut microbiota axis: A central hub for physiological regulation and a novel therapeutic target for metabolic diseases

Bile acids are a family of signaling molecules synthesized in the liver and metabolized by gut bacteria. As metabolites of the intestinal microbiota, bile acids bind to various receptors, and affect the metabolism and immune function of the host, including glucose and lipid metabolism, energy homeostasis, and inflammatory response. Conversely, bile acids also shape the composition of the gut microbiota. Given their critical role in physiological regulation, disrupted bile acid signaling is closely linked to metabolic diseases. Consequently, therapeutic strategies targeting bile acids are increasingly being explored. The size, composition, and function of the bile acid pool can be modulated through direct treatments (e.g., bile acid replacement therapy, administration of bile acid receptor agonists/antagonists) or indirect treatments (e.g., gut microbiota modulation, probiotic supplementation), providing new ideas for preventing and treating metabolic diseases.

Cardiovascular, Kidney, Liver, and Metabolic Interactions in Heart Failure: Breaking Down Silos

Over the past few decades, the rising burden of metabolic disease, including type 2 diabetes, prediabetes, obesity, and metabolic dysfunction-associated steatotic liver disease, has corresponded with fundamental shifts in the landscape of heart failure (HF) epidemiology, including the rising prevalence of HF with preserved ejection fraction. It has become increasingly important to understand the role of extracardiac contributors and interorgan communication in the pathophysiology and phenotypic heterogeneity of HF. Whereas traditional epidemiological strategies have separately examined individual contributions of specific comorbidities to HF risk, these approaches may not capture the shared mechanisms and more complex, bidirectional relationships between cardiac and noncardiac comorbidities. In this review, we highlight the cardiac, kidney, liver, and metabolism multiorgan interactions and pathways that complicate HF development and progression and propose research strategies to further understand HF in the context of multiple organ disease. This includes evolving epidemiological approaches such as multiomics and machine learning which may better capture common underlying mechanisms and interorgan crosstalk. We review existing preclinical models of HF and how they have enhanced our understanding of the role of multiorgan disease in the development of HF subtypes. We suggest recommendations as to how clinical practice across multiple specialties should screen for and manage multiorgan involvement in HF. Finally, recognizing the advent of novel combinatorial therapeutic agents that may have multiple indications across the cardiac-kidney-liver metabolism continuum, we review the current clinical trials landscape. We specifically highlight a pressing need for the design of more inclusive trials that examine the contributions of multimorbidity and incorporate multiorgan end points, which we propose may lead to outcomes that are evermore clinically relevant today.

Enhancing the potency of in vivo lentiviral vector mediated gene therapy to hepatocytes

In vivo gene therapy to the liver using lentiviral vectors (LV) may represent a one-and-done therapeutic approach for monogenic diseases. Increasing LV gene therapy potency is crucial for reducing the effective doses, thus alleviating dose-dependent toxicities and facilitating manufacturing. LV-mediated liver transduction may be enhanced by positively selecting LV-transduced hepatocytes after treatment (a posteriori) or by augmenting the initial fraction of LV-targeted hepatocytes (a priori). We show here that the a posteriori enhancement increased transgene output without expansion of hepatocytes bearing LV genomic integrations near cancer genes, in mouse models of hemophilia, an inherited coagulation disorder. Furthermore, we enhanced hepatocyte transduction a priori in mice by transiently inhibiting antiviral pathways and/or through a fasting regimen. The most promising transduction-enhancer combination synergized with phagocytosis-shielded LV, resulting in a remarkable 40-fold increase in transgene output. Overall, our work highlights the potential of minimally invasive, cost-effective treatments capable of improving the potency of in vivo LV gene therapy to hepatocytes, in order to expand its applicability and ease clinical translation.

Challenges and needs in the management of non-alcoholic fatty liver disease from the perspective of gastroenterology and hepatology specialists: a qualitative study

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease worldwide, and it poses a significant threat to public health. There is insufficient documented evidence about the problems and needs of patients and physicians in managing NAFLD. This study aimed to explore the challenges and needs in managing NAFLD from the perspective of gastroenterology and hepatology (GH) specialists.

METHODS

This qualitative study was conducted from January to September 2023. Fifteen Iranian GH specialists selected by purposive sampling. Data were collected through semi-structured interviews. The interviews were analyzed inductively using the Elo and Kyngas content analysis approach. The criteria proposed by Guba and Lincoln were used to ensure the study's validity.

RESULTS

The identified challenges were divided into thirteen main categories (34 subcategories and 117 primary codes), and the identified needs were divided into eight main categories (21 subcategories and 97 primary codes). The main categories of the challenges were chronic nature and time-consuming differential diagnosis, complex treatment process, defects in the patient management process, shortcomings of the healthcare system, the effect of unhealthy eating and cultural and social factors on the diet, incorrect attitude of patients, lack of knowledge and awareness of patients, lack of comprehensive treatment plans based on patients' conditions, defect in knowledge and awareness of physicians, inadequate cooperation of patients, defects in the process of recording and monitoring information and providing feedback, insufficient policies and plans in the prevention of NAFLD, and economic problems. The main categories of needs included developing a comprehensive treatment plan, updating physicians' knowledge and creating standard treatment protocols, changing attitudes and empowering patients, informing and educating patients, establishing multi-specialty clinics for NAFLD treatment, establishing peer support groups and facilitating communication, utilizing digital technology to track patient information and monitor their progress, and supportive, educational, prevention, and management policies in the treatment of NAFLD.

CONCLUSIONS

This study showed that managing NAFLD involves physical, psychological, nutritional, sports, economic, and social aspects and requires multidisciplinary clinical approaches, digital technologies, and supportive and educational policies. These findings have important implications that can help patients, physicians, and policymakers design better lifestyle prescriptions to manage NAFLD.

Acute kidney injury incidence and clinical features: Refractory versus non-refractory ascites

INTRODUCTION AND OBJECTIVES

Outpatients with cirrhosis, ascites and minor acute serum creatinine (sCr) changes could have been missed as having acute kidney injury (AKI). This study aims to assess the incidence, clinical features of all AKI stages amongst patients with cirrhosis and various ascites severities.

MATERIALS AND METHODS

Retrospective study of patients with cirrhosis and ascites from April 2020 to March 2021. Data collected included demographics, clinical features, medications, AKI development, and 6-month follow-up outcomes. Multivariate analysis for factors predicting AKI development and resolution was done.

RESULTS

115 (38 % of 306) with refractory ascites (RA) were compared to 191 with non-refractory ascites (n-RA), 86 % were outpatients. RA patients had higher baseline MELD-Na (18.1 ± 4.7 vs. 17.2 ± 6.8 in n-RA, p = 0.01) but had similar cirrhosis complications. 98 % RA patients required regular large volume paracenteses (LVP) (p < 0.001 vs. n-RA). AKI occurred in 39 % of RA and 19 % of n-RA patients (p<0.001). Most were stage 1 AKI, treated with albumin ± vasoconstrictor with similar response. 27 % of AKI in n-RA were classified as type 1 HRS (vs.20 % in RA, p < 0.001). Baseline MELD-Na (p = 0.01) predicted AKI development; lower peak sCr predicted AKI resolution (p = 0008). 11 (3.6 %) n-RA and 22 (19 %) RA patients developed acute-on-chronic liver failure (ACLF), with 86 % RA patients having renal failure as part of the ACLF syndrome (p < 0.001 vs. n-RA patients). Both groups had similar 6-month survival.

CONCLUSIONS

AKI occurs not infrequently in n-RA patients who are mostly treated as outpatients. Therefore, patients with n-RA need to be monitored closely so to allow prompt diagnosis and treatment of AKI.

Evaluation of the Stability of Organ Procurement Organization Performance Metrics

In 2020, the Centers for Medicare and Medicaid Services (CMS) updated the Organ Procurement Organization (OPO) Conditions for Coverage, redefining deceased donor potential (DDP) as all inpatient deaths among patients 75 or younger with a primary cause of death consistent with organ donation, also called CALC (Cause, Age, and Location Consistent with donation). This study evaluates CALC performance metrics using 2018-20201 data from Centers for Disease Control (CDC) mortality data (currently used by CMS) and Agency for Healthcare Research and Quality's State Inpatient Databases (SID). We analyzed yearly performance variability, compared data sources, and examined the impact of CALC versus CALC-adjusted, which excludes donors with potential contraindications. There was significant year-to-year variability in CDC CALC tiers, with up to 40% of OPOs changing tiers annually. Between 20-43% of OPOs changed CALC performance tiers using SID compared to CDC. Additionally, while CALC and CALC-adjusted rates were correlated, 11-29% of OPOs changed performance tiers with adjustment. These differences identify opportunities for potential changes to create more stable and consistent OPO performance measures. Future research to refine these metrics to ensure they support the goal of continuing improvement in OPO performance to maximize organ donation and transplant rates is important.

LEADS - a comprehensive human liver-on-a-chip for non-alcoholic steatohepatitis (NASH) drug testing

Metabolic dysfunction associated steatohepatitis (MASH), also known as non-alcoholic steatohepatitis (NASH), is a progressive form of steatotic liver disease (SLD). It is an emerging healthcare threat due its high prevalence, accelerated and non-linear progression, and final culmination as decompensated liver failure and/or hepatocellular carcinoma (HCC). The pathogenesis of NASH is complex with strong ethnic influences and genetic predispositions, underscoring the need for preclinical models that utilize patient-derived cells to enhance our understanding of the disease. Current models face three major limitations: (i) reliance on primary cells with limited reproducibility, high cost, short culture duration and ethical considerations, (ii) failure to recapitulate all key features of NASH, and (iii) inadequate drug testing data and/or data did not correlate with clinical responses. Therefore, there is a pressing need for robust and relevant preclinical models that faithfully recapitulate human NASH, allow generation of patient-specific models and provide quantitative responses for mechanistic studies and drug testing. We have developed a functional liver tissue-on-a-chip by co-culturing human adult liver stem cell (haLSC)-derived hepatobiliary organoids, induced pluripotent stem cell (iPSC)-derived Kupffer cells (iKCs) and iPSC-derived hepatic stellate cells (iHSCs). We simulated the metabolic microenvironment of hyper nutrition and leaky gut by treating the cells with a concoction of free fatty acids (FFAs), fructose, gut-derived lipopolysaccharides (LPS) and a gut-derived metabolite, phenyl acetic acid (PAA). Through optimization of co-culture media and induction regimens, we were able to stably induce steatosis, hepatocellular ballooning, inflammation, and activation of iHSC and fibrosis-all key hallmarks of NASH. Our LEADS (liver-on-a-chip for NASH drug testing) model also recapitulated the pathological types of steatosis and allowed for quantification of the key features via microscopic evaluation and secretome profiling to score for disease severity. Notably, treatment with saroglitazar, pioglitazone, cenicriviroc (CVC), obeticholic acid (OCA) and resmetirom produced responses similar to those observed in clinical trials. Taken together, our LEADS model is the first model developed using patient-derived hepatic stem cells which recapitulated all key features used for comprehensive drug testing, with results matching to clinical responses.

Advances in the treatment of hepatocellular carcinoma: An overview of the current and evolving therapeutic landscape for clinicians

Hepatocellular carcinoma (HCC) is the sixth most common malignancy and the third leading cause of cancer-related death worldwide. Contemporary advances in systemic and locoregional therapies have led to changes in peer-reviewed guidelines regarding systemic therapy as well as the possibility of downstaging disease that may enable some patients with advanced disease to ultimately undergo partial hepatectomy or transplantation with curative intent. This review focuses on all modalities of therapy for HCC, guided by modern-day practice-changing randomized data where available. The surgical management of HCC, including resection and transplantation, both of which have evolving criteria for what is considered biologically resectable and transplantable, as well as locoregional therapy (i.e., therapeutic embolization, ablation, radiation, and hepatic arterial infusion), are discussed. Historical and modern-day practice-changing trials evaluating immunotherapy with targeted therapies for advanced disease, as well as adjuvant systemic therapy, are also summarized. In addition, this article examines the critical dimension of toxicities and patient-oriented considerations to ensure a comprehensive and balanced discourse on treatment implications.

HHLA2 activates c-Met and identifies patients for targeted therapy in hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is a highly aggressive malignancy with limited treatment options in advanced stages. While c-Met is a promising therapeutic target in HCC, identifying patients who will benefit from c-Met inhibitors remains a significant challenge. This study aimed to investigate the role of HHLA2, a B7 family member, in HCC and its potential as a liquid biopsy marker for c-Met inhibitor therapy.

METHODS

HHLA2 expression was analyzed in clinical HCC samples and public databases. In vitro studies using HCC cell lines assessed HHLA2's impact on proliferation, migration, invasion, and angiogenesis. In vivo studies using mouse models (orthotopic xenografts and hydrodynamic tail vein injection) evaluated HHLA2's role in tumor growth and metastasis. Mass spectrometry, co-immunoprecipitation, split-luciferase, and ELISA assays were used to investigate HHLA2-c-Met interactions. Patient-derived organoids (PDOs) were used to assess drug response. Statistical analyses included Student's t-tests, ANOVA, and Cox regression.

RESULTS

HHLA2 was found to be upregulated in HCC and associated with advanced disease, aggressive clinicopathological features, and poor prognosis. HHLA2 interacted with and constitutively activated c-Met, leading to increased expression of MMP9 and VEGFA, enhancing HCC cell proliferation, invasion, and angiogenesis. HHLA2 also suppressed hepatic natural killer cell infiltration in vivo. Inhibition of c-Met with PHA665752 effectively reversed HHLA2-mediated tumor-promoting effects in vitro and in vivo. HHLA2 expression in HCC tissues correlated with c-Met phosphorylation, and HHLA2 could be detected in the serum of patients with high tumor HHLA2 levels. PDOs with high HHLA2 expression exhibited increased sensitivity to c-Met inhibition.

CONCLUSIONS

HHLA2 acts as an oncogene in HCC by activating c-Met, promoting tumor progression and metastasis. HHLA2 expression correlates with c-Met activation and predicts poor prognosis in HCC patients. Importantly, HHLA2 can serve as a stratification marker for c-Met inhibitor therapy, potentially enabling a personalized approach to improve therapeutic outcomes in this challenging disease.

In Vitro Immune Response of Mononuclear Cells to Multidrug-Resistant Escherichia coli

Infections caused by multidrug-resistant organisms (MDRO) are linked to poor outcomes, particularly in patients with cirrhosis. The underlying mechanisms are not fully understood and may involve a different immune response against MDRO. This study aimed to compare the in vitro immune response between multidrug-resistant (MDR) Escherichia coli and antibiotic-susceptible E. coli strains. Surface protein extract and DNA extract were obtained from MDR E. coli (n = 6) and antibiotic-susceptible E. coli (n = 6) strains isolated from infected patients with cirrhosis. The extracts were used to stimulate in vitro peripheral blood mononuclear cells from healthy donors. After 48 h, cytokine levels (IFN-γ, IL-1β, IL-10, IL-12p70, MCP-1, IL-8, IL-6, MIP-1α, and MIP-1β) were measured. We observed no significant differences in cytokine production between MDR and susceptible strains. However, we identified notable interindividual variability in cytokine production for most of the cytokines studied. Only IFN-γ and IL-6 in surface extract and MCP-1 in DNA extract showed similar levels across all donors. We conclude that the cytokine profiles induced by MDR E. coli in vitro were similar to those in susceptible strains. These findings suggest that the poor prognosis associated with MDR E. coli infections is not due to a differential immune response but rather to other factors.

Strategies to Reduce Hospital Length of Stay: Evidence and Challenges

Hospital length of stay (HLOS) is a critical healthcare metric influencing patient outcomes, resource utilization, and healthcare costs. While reducing HLOS can improve hospital efficiency and patient throughput, it also poses risks such as premature discharge, increased readmission rates, and potential compromise of patient safety. This literature review synthesizes current evidence on the determinants of HLOS, including patient-specific factors such as demographics, comorbidities, and socioeconomic status, as well as hospital-related factors like admission route, resource allocation, and institutional policies. We also examine the relationship between HLOS and key clinical outcomes, including mortality, readmission rates, and healthcare-associated infections. Additionally, we evaluate predictive modeling approaches, including artificial intelligence and machine learning, for forecasting HLOS and guiding early intervention strategies. While interventions such as enhanced recovery after surgery (ERAS) protocols, multidisciplinary care teams, and structured discharge planning have demonstrated efficacy in reducing HLOS, their success varies based on healthcare setting, patient complexity, and resource availability. Predictive analytics, incorporating clinical and non-clinical variables, offer promising avenues for improving hospital efficiency, yet may carry risks related to data quality and model bias. Given the impact of HLOS on clinical and economic outcomes, targeted interventions and predictive models should be applied cautiously, with future research focusing on refining personalized discharge strategies and addressing disparities across diverse patient populations.

Assessing health care disparities in US organ procurement organizations

There is extensive system-wide evidence of disparities in access to organ transplantation in the US based on race, ethnicity, and socioeconomic status. However, little information is available regarding care disparities among US organ procurement organizations (OPOs). Commissioned by the US Centers for Medicare and Medicaid Services (CMS), we studied racial/ethnic disparities in organ donation and transplantation across and within OPOs. Based on the 2020 CMS final rule, we calculated OPO donation and organ transplantation rates with 95% confidence intervals for racial (Black, White, and Asian American and Pacific Islander, AAPI) and ethnic (Hispanic and non-Hispanic) groups. OPOs were ranked with national rates as references and classified according to the CMS 3-tier system. Of the 58 OPOs, 8 and 4 had donation rates lower for Black and AAPI donors than for White donors; 21 and 18 had organ transplantation rates lower for Black and AAPI donors than for White donors; 1 and 1 had a donation rate or organ transplantation rate lower for Hispanic donors than for non-Hispanic donors. Significant racial/ethnic disparities in organ donation and transplantation exist among many OPOs, whereas the overall OPO performance is dominated by White and non-Hispanic donors. These disparities may be influenced by variations and structural barriers in resource access, donor identification, transplantation referral, and waitlisting processes-some of which lie partially outside the direct control of OPOs and disproportionately affect disadvantaged populations. Results support equitable organ donation and allocation through enhanced awareness of health care disparities, increased accountability of OPOs, and informed policies and interventions.

Machine Learning for Toxicity Prediction Using Chemical Structures: Pillars for Success in the Real World

Machine learning (ML) is increasingly valuable for predicting molecular properties and toxicity in drug discovery. However, toxicity-related end points have always been challenging to evaluate experimentally with respect to in vivo translation due to the required resources for human and animal studies; this has impacted data availability in the field. ML can augment or even potentially replace traditional experimental processes depending on the project phase and specific goals of the prediction. For instance, models can be used to select promising compounds for on-target effects or to deselect those with undesirable characteristics (e.g., off-target or ineffective due to unfavorable pharmacokinetics). However, reliance on ML is not without risks, due to biases stemming from nonrepresentative training data, incompatible choice of algorithm to represent the underlying data, or poor model building and validation approaches. This might lead to inaccurate predictions, misinterpretation of the confidence in ML predictions, and ultimately suboptimal decision-making. Hence, understanding the predictive validity of ML models is of utmost importance to enable faster drug development timelines while improving the quality of decisions. This perspective emphasizes the need to enhance the understanding and application of machine learning models in drug discovery, focusing on well-defined data sets for toxicity prediction based on small molecule structures. We focus on five crucial pillars for success with ML-driven molecular property and toxicity prediction: (1) data set selection, (2) structural representations, (3) model algorithm, (4) model validation, and (5) translation of predictions to decision-making. Understanding these key pillars will foster collaboration and coordination between ML researchers and toxicologists, which will help to advance drug discovery and development.

Immunological Mechanisms and Effects of Bacterial Infections in Acute-on-Chronic Liver Failure

Acute-on-chronic liver failure (ACLF) is a severe clinical syndrome characterized by high morbidity and mortality rates. Bacterial infection is a frequent precipitating factor and complication in ACLF patients, significantly worsening patient outcomes. Elucidating the mechanisms underlying bacterial infections and their impact on ACLF pathophysiology is crucial for developing effective therapies to reduce infection rates and mortality. Current research highlights that immune suppression in ACLF increases susceptibility to bacterial infections, which in turn exacerbate immune dysfunction. However, a comprehensive review summarizing the emerging mechanisms underlying this immunosuppression is currently lacking. This review aims to provide an overview of the latest research, focusing on alterations in the immune responses of innate immune cells-including monocytes, macrophages, and neutrophils-as well as adaptive immune cells such as T and B lymphocytes during the onset and progression of bacterial infections in ACLF. In addition, recent advances in immunomodulatory therapies, including stem cell-based interventions, will also be discussed.

Unraveling the Metabolic Pathways Between Metabolic-Associated Fatty Liver Disease (MAFLD) and Sarcopenia

Metabolic-Associated Fatty Liver Disease (MAFLD) is a public health concern that is constantly expanding, with a fast-growing prevalence, and it affects about a quarter of the world's population. This condition is a significant risk factor for cardiovascular, hepatic, and oncologic diseases, such as hypertension, hepatoma, and atherosclerosis. Sarcopenia was long considered to be an aging-related syndrome, but today, it is acknowledged to be secondarily related to chronic diseases such as metabolic syndrome, cardiovascular conditions, and liver diseases, among other comorbidities associated with insulin resistance and chronic inflammation, besides inactivity and poor nutrition. The physiopathology involving MAFLD and sarcopenia has still not been solved. Inflammation, oxidative stress, mitochondrial dysfunction, and insulin resistance seem to be some of the keys to this relationship since this hormone target is mainly the skeletal muscle. This review aimed to comprehensively discuss the main metabolic and physiological pathways involved in these conditions. MAFLD and sarcopenia are interconnected by a complex network of pathophysiological mechanisms, such as insulin resistance, skeletal muscle tissue production capacity, chronic inflammatory state, oxidative stress, and mitochondrial dysfunction, which are the main contributors to this relationship. In addition, in a clinical analysis, patients with sarcopenia and MAFLD manifest more severe hepatitis fibrosis when compared to patients with only MAFLD. These patients, with both disorders, also present clinical improvement in their MAFLD when treated for sarcopenia, reinforcing the association between them. Lifestyle changes accompanied by non-pharmacological interventions, such as dietary therapy and increased physical activity, undoubtedly improve this scenario.

Temporal trend in non-melanoma skin cancer mortality in China, 1992-2021: an analysis for the global burden of disease study 2021

Introduction

Non - melanoma skin cancer (NMSC) is a widespread malignant neoplasm affecting the skin globally. In China, over the past 30 years, the prevalence and incidence of NMSC have changed significantly, yet mortality rate (MR) data is scarce. The aim is to assess the MR data of NMSC patients worldwide from 1992 to 2021, analyze its temporal trends, and provide valuable epidemiological information for future prevention and management strategies of NMSC.

Methods

Using data from the Global Burden of Disease Study 2021 (GBD 2021), we analyzed crude mortality rate (CMR), age-standardized mortality rate (ASMR), and sex- and age-specific mortality trends, with temporal patterns assessed through longitudinal comparisons.

Results

The MR for NMSC has shown an upward trend globally. From 1992 to 2021, both the CMR and ASMR for NMSC have increased substantially. The global ASMR has risen by approximately 30% during this period. Males have a higher ASMR compared to females, and the elderly population exhibits an accelerated and elevated ASMR trend for NMSC. In China, the mortality of NMSC is on the rise, with the current male MR exceeding that of females. Although the ASMR is projected to decline by 2030, the number of mortality cases is expected to increase, especially among males. The MR for NMSC shows a significant bias towards the elderly demographic.

Discussion

The increasing mortality of NMSC, both globally and in China, highlights the importance of effective prevention and management strategies. In addition to implementing prevention and intervention measures in susceptible populations, it is crucial to establish a screening framework for NMSC to detect minor symptoms in a timely manner. This will help in early diagnosis and potentially reduce the mortality rate associated with NMSC. Thank you for your editorial support.

The functions of gut microbiota-mediated bile acid metabolism in intestinal immunity

BACKGROUND

Bile acids, derived from cholesterol in the liver, consist a steroidal core. Primary bile acids and secondary bile acids metabolized by the gut microbiota make up the bile acid pool, which modulate nuclear hormone receptors to regulate immunity. Disruptions in the crosstalk between bile acids and the gut flora are intimately associated with the development and course of gastrointestinal inflammation.

AIM OF REVIEW

This review provides an extensive summary of bile acid production, transport and metabolism. It also delves into the impact of bile acid metabolism on the body and explores the involvement of bile acid-microbiota interactions in various disease states. Furthermore, the potential of targeting bile acid signaling as a means to prevent and treat inflammatory bowel disease is proposed.

KEY SCIENTIFIC CONCEPTS OF REVIEW

In this review, we primarily address the functions of bile acid-microbiota crosstalk in diseases. Firstly, we summarize bile acid signalling and the factors influencing bile acid metabolism, with highlighting the immune function of microbially conjugated bile acids and the unique roles of different receptors. Subsequently, we emphasize the vital role of bile acids in maintaining a healthy gut microbiota and regulating the intestinal barrier function, energy metabolism and immunity. Finally, we explore differences of bile acid metabolism in different disease states, offering new perspectives on restoring the host's health and the gastrointestinal ecosystem by targeting the gut microbiota-bile acid-bile acid receptor axis.