Characterization of NK Cells Using Single-Cell RNA Sequencing in Patients With Acute-On-Chronic Liver Failure

BACKGROUND AND AIM

Acute-on-chronic liver failure (ACLF) is characterized by fast progression and high mortality, with systemic inflammation and immune paralysis as its key events. While natural killer (NK) cells are key innate immune cells, their unique function and subpopulation heterogeneity in ACLF have not been fully elucidated. This study aimed to investigate the characteristics of NK cell subsets in the peripheral blood of patients with ACLF and determine their roles in the inflammatory responses.

METHODS

Circulating NK cells (14 751 cells) from patients with ACLF and healthy controls (HCs) were subjected to single-cell RNA sequencing (scRNA-seq). Clustering and annotation were used to identify the features of NK cell subsets and the characteristics of disease progression in ACLF.

RESULTS

Four NK cell subsets were obtained, including adaptive NK cells, mature NK cells, inflamed NK cells, and CD56bright NK cells. Compared with the HCs, the patients with ACLF had a significantly lower proportion of Mature NK cells and a higher proportion of Inflamed NK cells. Quasi-temporal analysis showed that Inflamed NK cells were highly enriched in the late quasi-temporal sequence, and genes related to pro-inflammatory were significantly up-regulated in Inflamed NK cells. In addition, scRNA-seq and flow cytometry confirmed that the expression level of cell migration inducing hyaluronidase 2 (CEMIP2) in NK cells progressively increased from the HC group to the ACLF survival group and then to the ACLF death group.

CONCLUSIONS

scRNA-seq reveals that Inflamed NK cell subsets are associated with ACLF progression and poor prognosis. CEMIP2 may be a molecular marker for ACLF progression.

Integrating prior decompensation into ACLF definition to enhance clinical management

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a complicated syndrome associated with high short-term mortality and reversibility. Whether the prior decompensation should be included in the definition of ACLF is controversial.

METHODS

A total of 532 patients with decompensation (prior or first) of chronic liver disease were retrospectively enrolled and analyzed from January 2018 to June 2023. Clinical data were used to identify the characteristics and determine prognosis.

RESULTS

Of the 532 patients, 99 patients did not meet APASL-ACLF criteria due to the existence of prior decompensation and 433 patients met the Asian Pacific Association for the Study of the Liver (APASL)-ACLF criteria. The two groups had similar characteristics including prognosis scores (Chinese Group on the Study of Severe Hepatitis B (COSSH)-ACLF II score: 7.59 vs. 7.67, p = 0.934; Chronic Liver Failure (CLIF) Consortium ACLF score: 42.90 vs. 44.81, p = 0.273), the distribution of patients with APASL ACLF research consortium score (AARC score) (5-7: 19.2%/12.0%; 8-10: 56.6%/55.0%; 11-15: 24.2%/33.0%, p > 0.05) and the 28-/90-day mortality rates (30.5%/43.2% vs. 36.3%/43.1%, p = 0.267/0.978). In all integrated ACLF patients, Receiver Operating Characteristic (ROC) curve analysis and decision curve analysis (DCA) showed that COSSH-ACLF IIs had higher prognostic efficiency and clinical net benefit than AARC score and CLIF-C ACLFs for 28-/90-day mortality.

CONCLUSION

Prior decompensated patients exhibited clinical characteristics and high short-term mortality similar to those of first decompensated patients. The COSSH-ACLF IIs demonstrated the highest prognostic efficiency for all integrated ACLF patients. Including prior decompensation in the ACLF definition can help to simplify and improve clinical management.

Timing and Indications for Liver Transplantation for Children with Chronic Liver Disease

Chronic liver disease (CLD) in children poses significant challenges, necessitating timely management to mitigate morbidity and mortality. Liver transplantation (LT) has emerged as a transformative intervention, offering improved long-term survival for paediatric patients with CLD. This review explores the evolving landscape of liver transplantation, focusing on indications and timing considerations. The aetiology of CLD is diverse, encompassing intrahepatic, extrahepatic cholestatic conditions, metabolic diseases, malignancy, and drug-induced liver injury. LT is indicated when children exhibit signs of hepatic decompensation, necessitating a comprehensive evaluation to assess transplant suitability. Indications for LT include biliary atresia, inborn errors of metabolism, hepatocellular carcinoma, and emerging indications such as mitochondrial hepatopathies and acute on chronic liver failure. The timing of transplantation is critical, emphasizing the need for early recognition of decompensation signs to optimise outcomes. Advancements in LT techniques and immunosuppressive therapies have enhanced patient and graft survival rates. Various transplant modalities, including reduced-size LT and living-related LT, offer tailored solutions to address the unique needs of paediatric patients. While LT represents a cornerstone in the management of paediatric CLD, careful patient selection, multidisciplinary collaboration, and ongoing refinements in transplant protocols are imperative for optimizing outcomes and addressing the evolving landscape of paediatric liver disease management.

Liver transplantation improves prognosis across all grades of acute-on-chronic liver failure patients: A systematic review and meta-analysis

BACKGROUND

Liver transplantation (LT) is recognized as an effective approach that offers survival benefits for patients with acute-on-chronic liver failure (ACLF). However, controversies remain regarding the LT selection criteria, and meta-analyses reporting overall survival outcomes across different ACLF severity grades are lacking.

AIM

To depict a comprehensive postoperative picture of patients with ACLF of varying severity and contribute to updating LT selection.

METHODS

Systematic searches in Web of Science, EMBASE, PubMed, and Cochrane databases were performed, from inception to December 26, 2023, for studies exploring post-transplant outcomes among ACLF patients, stratified by severity grades as identified by the European Association for the Study of the Liver-Chronic Liver Failure criteria. The primary outcome of interest was the survival rate within one year, with post-transplant complications as secondary outcomes. Additionally, the subgroup analysis examined region-specific one-year survival rates.

RESULTS

A total of 17 studies involving 28025 participants were included. Patients with ACLF-1 and ACLF-2 have favorable survival within one year, with survival rates reaching 87% [95% confidence interval (CI): 84%-91%] and 86% (95%CI: 81%-91%), respectively. Despite the relatively lower survival (73%, 95%CI: 66%-80%) and higher incidence of infection (48%, 95%CI: 29%-67%) observed in ACLF-3 patients, their survival exceeds that of those who do not undergo LT. Moreover, post-transplant survival was highest in North America across all ACLF grades.

CONCLUSION

LT can provide survival advantages for ACLF patients. To optimize the utilization of scarce donor organs and improve prognosis, comprehensive preoperative health evaluations are essential, especially for ACLF-3 patients.

Patients with AMA/anti-sp100/anti-gp210 Positivity and Cholestasis Can Manifest Conditions Beyond Primary Biliary Cholangitis

Background and Aims

The diagnostic value of primary biliary cholangitis (PBC)-specific antibodies in patients with elevated alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) levels, and other identifiable causes, was unclear. Our study aimed to determine whether etiological treatments in PBC-specific antibody-positive patients could improve liver biochemical tests, thereby distinguishing them from individuals with PBC.

Methods

We enrolled patients who were positive for PBC-specific antibodies and elevated ALP and/or GGT levels but with other identifiable etiologies. Changes in liver biochemistry following non-ursodeoxycholic acid etiological treatments were monitored.

Results

A total of 155 patients with positive PBC-specific antibodies and elevated ALP and/or GGT levels due to non-PBC diseases were enrolled. Among them, 100 patients were diagnosed with non-PBC liver diseases, mainly metabolic-associated fatty liver disease, drug-induced liver injury, and autoimmune hepatitis. Additionally, 55 patients had non-liver diseases, predominantly connective tissue diseases. The median follow-up duration was 15.9 (4.7-25.6) months. Among 141 patients who completed follow-up after receiving etiological treatments, 85.1% (120/141) showed improvement in ALP and/or GGT levels, with 51.8% (73/141) achieving normalization of both ALP and GGT. However, 68 patients continued to exhibit elevated ALP and/or GGT, with 55 patients displaying isolated GGT elevation and 11 patients showing liver histological changes not consistent with PBC.

Conclusions

PBC-specific antibodies, along with elevated ALP and GGT levels, may occur in various non-PBC diseases. Etiological treatments may improve or even resolve cholestatic biochemistry. For these patients, initiating etiological treatment rather than immediately starting ursodeoxycholic acid therapy would be justified.

Metabolic dysfunction-associated steatotic liver disease (MASLD): Exploring systemic impacts and innovative therapies

Metabolic dysfunction-associated steatotic liver disease (MASLD), which includes the inflammatory subtype metabolic dysfunction-associated steatohepatitis, is a prominent cause of chronic liver disease with systemic effects. Insulin resistance, obesity, and dyslipidaemia produce MASLD in over 30 % of adults. It is a global health issue. From MASLD to MASH, hepatic inflammation and fibrosis grow, leading to cirrhosis, hepatocellular cancer, and extrahepatic complications such CVD, CKD, and sarcopenia. Effects of MASLD to MASH are mediated through mechanisms that include inflammation, oxidative stress, dysbiosis, and predisposition through genetic makeup. Advances in diagnostic nomenclature in the past few years have moved the emphasis away from NAFLD to MASLD, focusing on the metabolic etiology and away from the stigma of an alcoholic-related condition. Epidemiological data show a large geographical variability and increasing prevalence in younger populations, particularly in regions with high carbohydrate-rich diets and central adiposity. Lifestyle modification is considered as the main management of MASLD currently. This may include dietary intervention, exercise, and weight loss management. Pharmaceutical management is primarily aimed at metabolic dysfunction with promising findings for GLP-1 receptor agonists, pioglitazone and SGLT-2 inhibitors, which can correct both hepatic and systemic outcome. However, it still depends on well-integrated multidisciplinary care models by considering complex relationships between MASLD and its effects on extrahepatic organs. Determining complications at an early stage; developing precision medicine strategies; exploring new therapeutic targets will represent crucial factors in improving their outcomes. This review discuss the systemic nature of MASLD and calls for multiple collaborations to reduce its far-reaching health impacts and our quest for understanding its pathological mechanisms. Thus, collective efforts that are required to address MASLD are under the public health, clinical care, and research angles toward effectively containing its rapidly increasing burden.

Effectiveness of body roundness index for the prediction of nonalcoholic fatty liver disease: a systematic review and meta-analysis

BACKGROUND

Several anthropometric indices, such as body mass index and waist circumference, have been used as clinical screening tools for the prediction of nonalcoholic fatty liver disease (NAFLD). To further refine these clinical tools for NAFLD, the body roundness index (BRI) has recently been evaluated. In this systematic review and meta-analysis, the objective was to evaluate the relationship and predictive capability of the BRI in identifying NAFLD.

METHODS

A comprehensive search was conducted in PubMed, Embase, Web of Science, and Scopus up to December 31, 2024. Eligibility criteria included observational studies on adults (≥ 18 years old) with measured BRI and its association with NAFLD. The Joanna Briggs Institute tool was used for risk of bias assessment. Meta-analyses used random-effects models to pool data on mean difference, odds ratio, sensitivity, specificity, and the area under the curve (AUC), with heterogeneity and publication bias assessed.

RESULTS

Ten studies involving 59,466 participants were included. The pooled mean difference in BRI between the NAFLD and non-NAFLD groups was 1.73 (95% confidence interval [CI]: 1.31-2.15). The pooled sensitivity and specificity of BRI for diagnosing NAFLD were 0.806 and 0.692, respectively. The pooled AUC for BRI was 0.803 (95% CI: 0.775-0.830), indicating good diagnostic accuracy. Unlike subgroup analysis by country, subgroup analysis by sex showed no significant differences. Higher BRI values were associated with increased odds of NAFLD (pooled OR = 2.87, 95% CI: 1.39; 5.96). Studies provided mixed results on the predictive ability of BRI compared to other indices like body mass index, mostly favoring BRI over conventional indices.

CONCLUSION

BRI demonstrates a good diagnostic performance for NAFLD, suggesting it may be a valuable clinical tool for NAFLD assessment. Further research is necessary to validate these findings and strengthen the evidence base.

Catastrophic health payments in Ghana post-National Health Insurance Scheme implementation: an analysis of service-specific health expenditures

BACKGROUND

Ghana implemented several health reforms in the 1970s and 1990s. Still, several access barriers persist, including high out-of-pocket (OOP) spending, which led to the implementation of the National Health Insurance Scheme (NHIS) in 2003 to achieve Universal Health Coverage and lower OOP spending. This study evaluates the incidence and intensity of catastrophic health expenditure (CHE) among Ghanaian households post-NHIS, considering OOP health spending on different health services.

METHODS

Data came from the Ghana Living Standards Surveys rounds 6 (2012/2013) and 7 (2016/2017) and the Annual Household Income and Expenditure Survey 2022/2023. Key variables were OOP spending on three health service categories (medical products, outpatient and inpatient) and total expenditure. The incidence and intensity of CHE for various health service categories were calculated using service-specific thresholds. A household incurs CHE for each service when OOP health spending as a share of total expenditure exceeds the service-specific threshold.

RESULTS

Overall, at the 10% threshold, CHE headcount for total OOP health spending increased from 1.26% (95% CI 1.11% to 1.44%) to 11.45% (95% CI 10.86% to 12.07%) between 2012 and 2023. CHE gaps were also substantial for overall and service-specific OOP health spending. Medical supplies account for a large share of total OOP health spending, with CHE headcount rising from 1.34% (95% CI 1.18% to 1.53%) to 12.24% (95% CI 11.64% to 12.89%) between 2012 and 2023 at the 10% original threshold. Although the results were mixed, rural, northern and low-income households experienced substantial financial burdens. At the 20% threshold, the CHE headcount for inpatient services increased from 0.84% (95% CI 0.64% to 1.10%) to 4.38% (95% CI 3.83% to 4.99%) for northern dwellers between 2012 and 2023.

DISCUSSION/CONCLUSIONS

Despite NHIS coverage, high-cost services like medical supplies, hospital stays and frequently used outpatient services substantially drive CHE in Ghana, particularly for underserved populations. Addressing them requires prioritised policy interventions to expand NHIS coverage for essential services and improve financial protection, especially for rural and low-income households.

Effectiveness and Safety of Remdesivir for the Treatment of COVID-19 Patients with Liver Cirrhosis: A Retrospective Cohort Study

BACKGROUND

Patients with liver cirrhosis are at an increased risk of mortality from coronavirus disease 2019 (COVID-19). Remdesivir, an adenosine analog, exhibits activity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is thus recommended for inpatients with COVID-19. This study evaluated the effectiveness and safety of remdesivir in patients with COVID-19 and liver cirrhosis.

METHODS

This retrospective study was conducted using data from Taiwan's largest healthcare system. The study cohort comprised adult patients with COVID-19 and liver cirrhosis who visited our emergency department between April 2021 and September 2022. Remdesivir's adverse effects, including bradycardia, anemia, unstable glucose levels, and abnormal liver function test results, were recorded. Treatment outcomes were assessed in terms of hospitalization duration, mortality, intubation, and intensive care unit admission.

RESULTS

This study included 1368 patients with COVID-19 and liver cirrhosis, of whom 46 received remdesivir. Remdesivir recipients were older (66.5 vs. 62 years; p = 0.042) and had a higher rate of oxygen therapy use (56.52% vs. 32.22%; p = 0.001) than nonrecipients. Common adverse effects of remdesivir included lower heart rates (83 vs. 96 bpm; p < 0.001) and decreased hemoglobin levels (9.5 vs. 10.2 g/dL; p = 0.003) without fatal consequences. No statistically significant difference between remdesivir recipients and nonrecipients in hospitalization duration, intubation rates, or mortality rates was found.

CONCLUSIONS

Remdesivir is safe for treating COVID-19 in patients with liver cirrhosis. Although remdesivir recipients exhibited trends toward improved outcomes in our study, large-scale studies are required to confirm its efficacy in this population.

Mitochondrial targeted therapies in MAFLD

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a clinical-pathological syndrome primarily characterized by excessive accumulation of fat in hepatocytes, independent of alcohol consumption and other well-established hepatotoxic agents. Mitochondrial dysfunction is widely acknowledged as a pivotal factor in the pathogenesis of various diseases, including cardiovascular diseases, cancer, neurodegenerative disorders, and metabolic diseases such as obesity and obesity-associated MAFLD. Mitochondria are dynamic cellular organelles capable of modifying their functions and structures to accommodate the metabolic demands of cells. In the context of MAFLD, the excess production of reactive oxygen species induces oxidative stress, leading to mitochondrial dysfunction, which subsequently promotes metabolic disorders, fat accumulation, and the infiltration of inflammatory cells in liver and adipose tissue. This review aims to systematically analyze the role of mitochondria-targeted therapies in MAFLD, evaluate current therapeutic strategies, and explore future directions in this rapidly evolving field. We specifically focus on the molecular mechanisms underlying mitochondrial dysfunction, emerging therapeutic approaches, and their clinical implications. This is of significant importance for the development of new therapeutic approaches for these metabolic disorders.

Acute-on-Chronic Liver Failure: Steps Towards Consensus

Acute-on-chronic liver failure (ACLF) is a clinical syndrome characterized by organ failure and high short-term mortality. Since its first definition in 2013, many international organizations have defined this syndrome and, till now, there has been no agreement regarding definitions and diagnostic criteria. Although the precise mechanism of ACLF is unknown, precipitant factors and the systemic inflammation response play a major role. Specific management of this high-mortality syndrome is still under development, but a general consensus in the diagnosis and management of ACLF is needed.

Insulin resistance and cancer: molecular links and clinical perspectives

The association between insulin resistance (IR), type 2 diabetes mellitus (T2DM), and cancer is increasingly recognized and poses an escalating global health challenge, as the incidence of these conditions continues to rise. Studies indicate that individuals with T2DM have a 10-20% increased risk of developing various solid tumors, including colorectal, breast, pancreatic, and liver cancers. The relative risk (RR) varies depending on cancer type, with pancreatic and liver cancers showing a particularly strong association (RR 2.0-2.5), while colorectal and breast cancers demonstrate a moderate increase (RR 1.2-1.5). Understanding these epidemiological trends is crucial for developing integrated management strategies. Given the global rise in T2DM and cancer cases, exploring the complex relationship between these conditions is critical. IR contributes to hyperglycemia, chronic inflammation, and altered lipid metabolism. Together, these factors create a pro-tumorigenic environment conducive to cancer development and progression. In individuals with IR, hyperinsulinemia triggers the insulin-insulin-like growth factor (IGF1R) signaling pathway, activating cancer-associated pathways such as mitogen-activated protein kinase (MAPK) and phosphatidylinositol 3-kinase (PIK3CA), which promote cell proliferation and survival, thereby supporting tumor growth. Both IR and T2DM are linked to increased morbidity and mortality in patients with cancer. By providing an in-depth analysis of the molecular links between insulin resistance and cancer, this review offers valuable insights into the role of metabolic dysfunction in tumor progression. Addressing insulin resistance as a co-morbidity may open new avenues for risk assessment, early intervention, and the development of integrated treatment strategies to improve patient outcomes.

Omega-3 Fatty Acids, Furan Fatty Acids, and Hydroxy Fatty Acid Esters: Dietary Bioactive Lipids with Potential Benefits for MAFLD and Liver Health

Metabolic dysfunction-associated fatty liver disease (MAFLD) is the most common form of chronic liver disease, for which only resmetirom has recently received FDA approval. Prevention is crucial, as it can help manage and potentially reverse the progression of MAFLD to more severe stages. Omega-3 fatty acids, which are a type of polyunsaturated fatty acid (PUFA), have numerous beneficial effects in health and disease, including liver disease. Other bioactive lipids, such as furanic fatty acids (FuFA) and hydroxy fatty acid esters (FAHFA), have also demonstrated several benefits on relevant markers of liver dysfunction in animal and cell models. However, the effects of FAHFAs on hepatic steatosis are inconsistent, and studies on the impact of FuFAs in MAFLD are scarce. Further and more extensive research is required to better understand their role in liver health. The aim of this narrative review is to provide a brief overview of the potential effects of omega-3 fatty acids and other bioactive lipids, such as FuFAs and FAHFAs, on liver disease, with a focus on MAFLD.

MicroRNA-124a/Sirtuin 1 pathway inhibits autophagy to promote hepatocyte apoptosis in acute-on-chronic liver failure

BACKGROUND

The roles of microRNAs in the regulation of autophagy and apoptosis in hepatic cells suggest that they may serve as novel biomarkers or therapeutic targets for various liver injuries. In this study, we aim to analyze whether miR-124a regulates autophagy and apoptosis in hepatic cells, particularly in acute-on-chronic liver failure (ACLF).

MATERIALS AND METHODS

The plasma and liver tissues from the healthy control (HC) and ACLF patients were included. Moreover, LO2 cells were used to perform in vitro experiments. To measure hepatocyte apoptosis, a TUNEL kit was used. LPS, over-expression or knockdown, 3-methyladenine (3-MA) were used in vitro experiments. The expression levels of the autophagy related proteins (Beclin-1 and LC3), anti-apoptotic proteins (BAX and Bcl-2), Sirtuin 1 (SIRT1), and miR-124a were assessed using western blotting, ELISA, and qRT-PCR.

RESULTS

ACLF patients had significantly decreased expressions of SIRT1, Bcl-2, LC3, and Beclin-1 and significant upregulation of miR-124a and BAX in both plasma and liver tissues in comparison with the HC group. miR-124a was inversely correlated with autophagy markers and SIRT1, but positively correlated with apoptosis. Upon exposure to LPS, the levels of BAX and miR-124a were notably elevated, while Beclin-1, LC3, SIRT1, and Bcl-2 were notably downregulated in LO2 cells. These changes were further exaggerated in the presence of the miR-124a mimic and EX-527 compared to the miR-124a inhibitor and SRT1720 groups. Co-transfection of miR-124a inhibitor was able to partly counteract the pro-apoptotic effects of the autophagy inhibitor 3-MA.

CONCLUSION

miR-124a downregulates SIRT1, thereby suppressing hepatocyte autophagy and consequently inducing apoptosis.

Expression and clinical significance of serum lncRNA H19 in patients with metabolic dysfunction-associated fatty liver disease

Long non-coding RNA H19 (lncRNA H19) plays an important role in lipid metabolism, however, its relationship with metabolic dysfunction-associated fatty liver disease (MAFLD) remains unclear. The aim of this study is to investigate the expression and clinical significance of serum lncRNA H19 in patients with MAFLD. This study enrolled patients with MAFLD and a control group of healthy subjects from January 2023 to March 2024. The serum levels of lncRNA H19 were quantified using real-time quantitative polymerase chain reaction. The serum levels of lncRNA H19 in patients with MAFLD were significantly higher compared to the control group (P < .05). Moreover, there was a positive correlation between serum lncRNA H19 and body mass index, triglyceride, total cholesterol (TC), low-density lipoprotein cholesterol, fasting blood glucose and uric acid (all P < .05). Conversely, a negative correlation was observed between serum lncRNA H19 and high-density lipoprotein cholesterol (HDL-C; P = .009). Additionally, significant positive associations were found between serum lncRNA H19 and alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transpeptidase and liver stiffness measurement(all P < .05). The optimal cutoff value of serum lncRNA H19 for diagnosing MAFLD was 1.15, with an area under the curve of the receiver operating characteristic curve of 0.83, and the sensitivity and specificity were observed to be 87.7% and 72.5%, respectively. The lncRNA H19 exhibits associations with metabolic risk factors, liver function, and liver fibrosis, and can serve as a potential diagnostic biomarker for MAFLD.

Inter- and Intraobserver variability of attenuation coefficient measurement in innovative ultrasound diagnosis of metabolic dysfunction-associated steatotic liver disease: a cross-sectional study

Introduction

Evaluation of the ultrasound attenuation coefficient is widely used in the diagnosis of steatotic liver disease (SLD). US steatometry with real-time attenuation coefficient measurement (ACM) is an imaging tool that can replace and surpass the B-mode and improve the noninvasive diagnosis of SLD.

Aim

To evaluate the intra- and interobserver variability of ACM for the assessment of SLD.

Materials and methods

A single-center cross-sectional study was conducted at the Kyiv City Clinical Endocrinology Center. We examined 52 patients (25 men and 27 women) with a mean age of 53.2 ± 4.73 years. B-mode and ACM were performed on a Soneus P7 US system (Ultrasign, Ukraine). Examinations were performed by 2 radiologists with 28 (expert 1) and 17 (expert 2) years of experience and 4 general practitioners (GPs) without US experience (nonexperts 1-4). The training of 4 GPs on mastering the ACM was only 60 min due to US steatophantom. Each doctor performed 5 measurements of the ACM for each patient. The inter- and intraobserver variability of the results was determined by using an intraclass correlation coefficient (ICC) with a 95% confidence interval (95% CI).

Results

The overall intraobserver variability after 5 days of examination was as follows: for expert 1-0.958 (95% CI 0.938-0.974); for expert 2-0.936 (95% CI 0.905-0.980); nonexpert 1-0.891 (95% CI 0.843-0.929); nonexpert 2-0.915 (95% CI 0.876-0.945); nonexpert 3-0.927 (95% CI 0.893-0.953); nonexpert 4-0.880 (95% CI 0.827-0.927). Interobserver variability at the final timepoint (day 5) was as follows: between experts 1 and 2, 0.942 (95% CI 0.898-0.967); between nonexperts 1-4 overall, 0.871 (95% CI 0.800-0.921); and overall, 0.922 (95% CI 0.883-0.951).

Conclusion

Real-time US steatometry with ACM measurement is an informative, simple method with excellent intra- and interobserver variability and a reproducible method for population assessment for the early diagnosis and staging of SLD. The simplicity of ACM technology allows general practitioners to master the technique within 60 min. ACM measurements can be effectively employed by general practitioners (GPs) for population screening, enabling timely identification and management of MASLD.

Pathogenic Mechanisms of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)-Associated Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer and the third leading cause of cancer deaths worldwide. The etiology of HCC has now dramatically changed from viral hepatitis to metabolic dysfunction-associated steatotic liver disease (MASLD). The main pathogenesis of MASLD-related HCC is the hepatic lipid accumulation of hepatocytes, which causes chronic inflammation and the subsequent progression of hepatic fibrosis. Chronic hepatic inflammation generates oxidative stress and DNA damage in hepatocytes, which contribute to genomic instability, resulting in the development of HCC. Several metabolic and molecular pathways are also linked to chronic inflammation and HCC in MASLD. In particular, the MAPK and PI3K-Akt-mTOR pathways are upregulated in MASLD, promoting the survival and proliferation of HCC cells. In addition, MASLD has been reported to enhance the development of HCC in patients with chronic viral hepatitis infection. Although there is no approved medication for MASLD besides resmetirom in the USA, there are some preventive strategies for the onset and progression of HCC. Sodium-glucose cotransporter-2 (SGLT2) inhibitor, a class of medications, has been reported to exert anti-tumor effects on HCC by regulating metabolic reprogramming. Moreover, CD34-positive cell transplantation improves hepatic fibrosis by promoting intrahepatic angiogenesis and supplying various growth factors. Furthermore, exercise improves MASLD through an increase in energy consumption as well as changes in chemokines and myokines. In this review, we summarize the recent progress made in the pathogenic mechanisms of MASLD-associated HCC. Furthermore, we introduced new therapeutic strategies for preventing the development of HCC based on the pathogenesis of MASLD.

Early prediction of invasive fungal infection risk in acute-on-chronic liver failure: a prediction model based on admission indicators

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a severe clinical syndrome, and the incidence of invasive fungal infection (IFI) among hospitalized patients with ACLF is steadily increasing. The aim of this study is to develop a diagnostic nomogram to assist in the identification of IFI in these patients.

METHODS

A retrospective study included 705 patients from January 1, 2019, to October 31, 2023, randomly divided into training (n = 493) and validation (n = 212) cohorts. The diagnosis of IFI includes proven diagnosis and probable diagnosis. Kaplan analysis was performed to analyze the survival prognosis of ACLF patients with and without IFI. A nomogram was developed based on a logistic regression model derived through least absolute shrinkage and selection operator (LASSO) regression. The discrimination, accuracy, and clinical utility of the model were assessed using receiver operating characteristic curves, Hosmer-Lemeshow tests, calibration plots, and decision curve analysis.

RESULTS

Kaplan-Meier survival analysis confirmed that the median survival time of ACLF patients with IFI was significantly lower (by 68 days) than that of ACLF patients without IFI, and there were significant differences in the 90-day, 180-day, and 360-day survival rates between the two groups (P < 0.05). Based on LASSO regression, the following factors were identified as significant risk factors for predicting IFI: aminotransferase levels, prothrombin activity, hemoglobin, neutrophil-to-lymphocyte ratio, and serum total bilirubin. A nomogram was constructed incorporating these variables. The nomogram demonstrated good discriminative ability, with an area under the receiver operating characteristic curve (AUC) of 0.78 (95% confidence interval [CI]: 0.72-0.84) in the training cohort and 0.79 (95% CI: 0.70-0.87) in the validation cohort. Decision curve analysis further validated the clinical applicability of the nomogram.

CONCLUSION

ACLF patients with IFI have lower survival time than those without IFI. A nomogram was developed and validated to assist clinicians in the early prediction of IFI in hospitalized patients with ACLF.

CLINICAL TRIAL NUMBER

Not applicable.

Association between oxidative stress and liver fibrosis severity in non-alcoholic fatty liver disease: insights from the pro-oxidant antioxidant balance method in a population from Tehran and Mashhad, Iran

Background

The exact mechanisms of non-alcoholic fatty liver disease (NAFLD), recently redefined as metabolic dysfunction-associated steatotic liver disease (MASLD), remain unclear. However, oxidative stress is recognized as a factor across all stages of NAFLD. The Pro-oxidant Antioxidant Balance (PAB) method is an important clinical tool that provides an assessment of the balance between oxidants and antioxidant. We aimed to explore oxidative stress in NAFLD using the PAB method.

Methods

Individuals with NAFLD were recruited in 2021. Eligible participants underwent detailed assessments, including liver elastography for fibrosis evaluation. Blood samples (5 mL) were collected to measure serum PAB levels. The METAVIR score, derived from FibroScan measurements of liver stiffness, categorized fibrosis severity from F0 (no fibrosis) to F4 (advanced fibrosis or cirrhosis).

Results

The study included 102 participants, with a mean age of 50.12 ± 10.03 years. Significant correlations were observed between FibroScan scores and variables such as age, body mass index (BMI), history of chronic diseases, and family history of NAFLD. PAB levels were notably higher in patients with advanced fibrosis (F2 and F3 groups: 86.32 ± 25.53) compared to those in early stages (F0 and F1 groups: 45.36 ± 21.29). Moreover, FibroScan scores showed a significant positive association with PAB values (odds ratio [OR]: 1.07; 95% confidence interval (CI): 1.04, 1.10), even after adjusting for confounding variables (OR: 1.13; 95% CI: 1.07, 1.18).

Conclusion

Elevated PAB levels were strongly associated with advanced stages of liver fibrosis in NAFLD patients, reflecting increased oxidative stress with disease progression. These results highlight the potential of PAB as a marker for monitoring oxidative stress and disease severity in NAFLD. Nevertheless, further large-scale studies are warranted.

Impact of blood lead and manganese levels on metabolic dysfunction-associated steatotic liver disease prevalence: insights from NHANES (2017-2020)

BACKGROUND

The metabolic dysfunction-associated steatotic liver disease (MASLD) paradigm represents a significant departure from the previous nonalcoholic fatty liver disease (NAFLD) framework, offering a non-stigmatizing approach that enhances awareness and accelerates patient understanding. Our primary aim was to investigate the potential relationship between blood lead and manganese exposure and the onset of MASLD.

METHODS

Using data from the National Health and Nutrition Examination Survey (NHANES) database spanning from 2017 to 2020, a cross-sectional study included 4,475 participants was performed to assess the relationship. The statistical analysis used throughout the study included multivariable linear regression and multiple logistic regression models, adjusted for potential confounders to ensure robust and reliable results. We applied a thorough multivariable analysis, examining various factors including age, sex, and ethnicity to enhance the robustness of our findings.

RESULTS

Employing linear regression models in our study, we observed a clear positive correlation between elevated levels of blood lead and manganese and Controlled attenuation parameter (CAP). Additionally, employing multiple logistic regression models for detailed analysis, we noted a significant increase in the likelihood of MASLD with higher levels of blood lead and manganese.

CONCLUSION

The findings of this study strongly suggest a notable correlation between increased levels of blood lead and manganese with both CAP and the presence of MASLD. This study represents a population-based approach, enhancing the generalizability of the findings to the broader U.S.

POPULATION

Safety and efficacy of PD-1 inhibitors plus tyrosine kinase inhibitors combination therapy in patients with advanced hepatocellular carcinoma combined with hyperbilirubinemia: a retrospective cohort study

Background

Programmed death-1 (PD-1) inhibitors plus tyrosine kinase inhibitors (TKIs) combination therapy are considered as a first-line treatment recommendation for advanced hepatocellular carcinoma (HCC). However, patients with hyperbilirubinemia are excluded from this therapeutic option due to limitations in indications. There is a notable absence of published studies evaluating the safety and efficacy of the PD-1 inhibitors plus TKIs combination therapy in patients with HCC combined with hyperbilirubinemia.

Methods

Patients with HCC complicated with hyperbilirubinemia who received combination therapy with PD-1 inhibitors and TKIs were retrospectively analyzed. Adverse events, tumor response, and laboratory parameters were recorded to assess the safety and efficacy of the treatment, as well as to identify potential risk factors influencing survival.

Results

A total of 108 participants were included in the study, with 56 patients (51.9%) reporting at least one adverse event, the majority of which were mild. The objective response rate (ORR) for the enrolled participants was 11.9%, and the disease control rate(DCR) reached 61.2%. The median overall survival (OS) for the entire cohort was 5.03 months, while the median progression-free survival (PFS) was 3.63 months. Multifactorial analysis showed that MELD score >18 and increased total bilirubin (TBIL) levels within one week were significant risk factors for OS. Patients with a decrease in TBIL levels within one week had significantly prolonged median OS (not reached vs 3.3months, P =0.013) and median PFS (7.03 months vs 2.77 months, P =0.010).

Conclusion

Combination therapy demonstrated favorable safety and tolerability among patients with HCC combined with hyperbilirubinemia. Patients who experienced a rapid decline in TBIL levels during the early phase of treatment with PD-1 inhibitors and TKIs were observed to derive clinical benefits. Early initiation of aggressive interventions aimed at reducing TBIL levels is recommended to optimize treatment outcomes.

High-Intensity Interval Training Enhances the Positive Effect of Pentoxifylline on Lipid Profile and Inflammatory Markers in an Endometriosis Animal Model

Background: The relationship between endometriosis and cardiovascular disease (CVD) is well established. However, the effects of various exercise training modalities and the anti-inflammatory effects of pentoxifylline (PTX) remain inadequately understood. This investigation is aimed at evaluating the effects of PTX, both independently and in conjunction with high-intensity interval training (HIIT) and moderate-intensity continuous training (MICT), on lipid and inflammatory markers including triglycerides (TGs), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and C-reactive protein (CRP) in a rat model of endometriosis. Materials and Methods: Sprague-Dawley's rats were divided into two primary groups: the healthy control group that received no intervention and the induced endometriosis group. Endometriosis was surgically induced in rats, and those with confirmed endometriotic lesions were further categorized into six groups: control, MICT, drug of PTX (D), MICT+D, HIIT, and HIIT+D. Two weeks after laparotomy, PTX consumption and exercise training were performed for 8 weeks. PTX was administered orally at 100 mg/kg/day. MICT and HIIT sessions were conducted 5 days per week, with MICT beginning at 55% of maximum capacity for 31 min in the first week and progressing to 70% of maximum capacity for 46 min by the eighth week. HIIT sessions consisted of 2 min of running followed by 1 min of passive rest at 85% of maximum capacity, starting with seven intervals in the first week and increasing to twelve by the end of the eighth week. The macroscopic size of endometriosis lesions was measured, and cardiovascular risk factors, including hs-CRP, TC, TG, HDL-C, and LDL-C, were assessed in serum samples. Results: The induction of endometriosis was associated with elevated cardiovascular risk factors, including hs-CRP, TC, and TG. HIIT+D significantly decreased lesion volume (p < 0.0001, 95%confidence interval (CI) = 57.239-94.718), hs-CRP (p = 0.049, CI = -54.083 to - 29.478), TC (p = 0.045, CI = -38.607 to - 25.392), and TG (p = 0.042, CI = 25.531-55.801). PTX significantly decreased lesion volume (p < 0.0001, CI =34.709-73.919) and TC (p = 0.016, CI = -45.153 to - 30.179). Conclusion: All interventions except MICT reduced lesion volume, whereas only HIIT+PTX and PTX, in the order of importance, improved some cardiovascular risk indices in the rat model of endometriosis.

Ramadan Fasting and Complications of Metabolic Dysfunction-Associated Steatotic Liver Disease: Impacts on Liver Cirrhosis and Heart Failure

BACKGROUND

Metabolic-dysfunction-associated steatotic liver disease (MASLD) and heart failure are two intersecting growing pandemics. Studies have demonstrated a strong association between MASLD and heart failure. Liver cirrhosis is a well-recognized complication of MASLD. This study aimed to summarize the potential effects of Ramadan fasting on MASLD, liver cirrhosis, and heart failure. The author searched the SCOPUS and PubMed databases using specific terms. The literature review focused on research articles published in English from 2000 to 2024. Twenty-two articles were selected for this narrative review. Ramadan fasting reduced serum cholesterol serum levels, improved symptoms of heart failure and reduced anthropometric measurements. However, it increased ascitic fluid production and plasma bilirubin levels and might increase the risk of hepatic encephalopathy and upper gastrointestinal haemorrhage in liver cirrhosis. Ramadan fasting might improve symptoms of heart failure and might decrease the risk of heart failure in patients with MASLD. Further research studies are needed to confirm the efficacy and evaluate the safety of Ramadan fasting in patients with heart failure and liver cirrhosis.

Metabolic dysfunction-associated steatotic liver disease in adults

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the umbrella term that comprises metabolic dysfunction-associated steatotic liver, or isolated hepatic steatosis, through to metabolic dysfunction-associated steatohepatitis, the progressive necroinflammatory disease form that can progress to fibrosis, cirrhosis and hepatocellular carcinoma. MASLD is estimated to affect more than one-third of adults worldwide. MASLD is closely associated with insulin resistance, obesity, gut microbial dysbiosis and genetic risk factors. The obesity epidemic and the growing prevalence of type 2 diabetes mellitus greatly contribute to the increasing burden of MASLD. The treatment and prevention of major metabolic comorbidities such as type 2 diabetes mellitus and obesity will probably slow the growth of MASLD. In 2023, the field decided on a new nomenclature and agreed on a set of research and action priorities, and in 2024, the US FDA approved the first drug, resmetirom, for the treatment of non-cirrhotic metabolic dysfunction-associated steatohepatitis with moderate to advanced fibrosis. Reliable, validated biomarkers that can replace histology for patient selection and primary end points in MASH trials will greatly accelerate the drug development process. Additionally, noninvasive tests that can reliably determine treatment response or predict response to therapy are warranted. Sustained efforts are required to combat the burden of MASLD by tackling metabolic risk factors, improving risk stratification and linkage to care, and increasing access to therapeutic agents and non-pharmaceutical interventions.

A short-term predictive model for disease progression in acute-on-chronic liver failure: integrating spectral CT extracellular liver volume and clinical characteristics

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a life-threatening hepatic syndrome. Therefore, this study aimed to develop a comprehensive model combining extracellular liver volume derived from spectral CT (ECVIC-liver) and sarcopenia, for the early prediction of short-term (90-day) disease progression in ACLF.

MATERIALS AND METHODS

A retrospective cohort of 126 ACLF patients who underwent hepatic spectral CT scans was included. According to the Asia-Pacific Association for the Study of the Liver (APASL) criteria, patients were divided into the progression group (n = 70) and the stable group (n = 56). ECVIC-liver was measured on the equilibrium period (EP) images of spectral CT, and L3-SMI was measured on unenhanced CT images, with sarcopenia assessed. A comprehensive model was developed by combining independent predictors. Model performance was evaluated using receiver operating characteristic (ROC) curve analysis, calibration curves, and decision curve analysis (DCA).

RESULTS

In the univariate analysis, BMI, WBC, PLT, PTA, L3-SMI, IC-EP, Z-EP, K140-EP, NIC-EP, ECVIC-liver, and Sarcopenia demonstrated associations with disease progression status at 90 days in ACLF patients. In multivariate logistic regression, white blood cell count (WBC) (OR = 1.19, 95% CI: 1.02-1.40; P = 0.026), ECVIC-liver (OR = 1.27, 95% CI: 1.15-1.40; P < 0.001), sarcopenia (OR = 4.15, 95% CI: 1.43-12.01; P = 0.009), MELD-Na score (OR = 1.06, 95%CI: 1.01-1.13;P = 0.042), and CLIF-SOFA score (OR = 1.37, 95%CI:1.15-1.64; P<0.001) emerged as independent risk factors for ACLF progression. The combined model exhibited superior predictive performance (AUCs = 0.910, sensitivity = 80.4%, specificity = 90.0%, PPV = 0.865, NPV = 0.851) compared to CLIF-SOFA, MELD-Na, MELD and CTP scores(both P < 0.001). Calibration curves and DCA confirmed the high clinical utility of the combined model.

CONCLUSIONS

Patients without sarcopenia and/or with a lower ECVIC-liver have a better prognosis, and the integration of WBC, ECVIC-liver, Sarcopenia, CLIF-SOFA and MELD-Na scores in a composite model offers a concise and effective tool for predicting disease progression in ACLF patients.

TRIAL REGISTRATION

Not Applicable.

A Comparison of Metabolic-Associated Fatty Liver Disease and Steatotic Liver Disease in a Cohort of Egyptian People Living with Human Immunodeficiency Virus

Background: The prevalence of fatty liver disease in people living with human immunodeficiency virus (PLHIV) is significantly higher than in general population. This study aims to compare the burden of fatty liver disease in Egyptian PLHIV using both metabolic dysfunction-associated fatty liver disease (MAFLD) and steatotic liver disease (SLD) criteria. Methods: A retrospective cross-sectional study was conducted on PLHIV attending the HIV reference center at Embaba Fever Hospital in Egypt between November 2019 and July 2021. Data collection included demographics, comorbidities, physical examination, laboratory tests, liver ultrasound, controlled attenuation parameter, and liver stiffness measurement using Fibroscan®. Results: The prevalence of SLD and MAFLD was 26.92% and 21.15%, respectively. The concordance between MAFLD and SLD definitions was low (kappa = 0.465). The presence of SLD was significantly associated with increased odds of significant fibrosis (P = 0.045). However, MAFLD was not significantly associated with fibrosis (P = 0.369). Conclusion: SLD demonstrates a stronger association with significant fibrosis than MAFLD in PLHIV. This highlights the potential of SLD as a more inclusive and representative classification for steatosis in PLHIV.

Role of noninvasive tests on the prediction of hepatocellular carcinoma in nonalcoholic fatty liver disease patients without cirrhosis: a systematic review and meta-analysis of aggregate and individual patient data

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) has been identified as an emerging risk factor for hepatocellular carcinoma (HCC). Identifying non-cirrhotic NAFLD patients at risk for HCC is crucial. We aimed to investigate the utility of noninvasive tests (NITs) as predictors for HCC and to determine optimal and cost-effective NIT cutoffs for HCC surveillance in non-cirrhotic NAFLD patients.

METHODS

Medline, EMBASE, and Scopus databases were searched for studies evaluating the relationship between NITs and HCC in this population. Random-effects models were used to estimate hazard ratios or risk ratios and 95% confidence interval (95% CI). Cutoffs of NITs for identifying high-risk patients for HCC were determined.

RESULTS

This systematic review comprised 20 studies. A meta-analysis of 379 194 patients was conducted using six studies with individual patient data and five studies with aggregate data. Among NITs studied, fibrosis-4 index (FIB-4), aspartate aminotransferase to platelet ratio index (APRI), and NAFLD fibrosis score (NFS) were significantly associated with HCC, with pooled risk ratio (95% CI) of 9.21 (5.79-14.64), pooled hazard ratio of 12.53 (6.57-23.90), and 13.32 (6.48-27.37), respectively. FIB-4, APRI, and NFS of more than 2.06, 0.65, and 0.51 resulted in the highest area under the receiver operating characteristics of 0.83, 0.80, and 0.85, respectively. Surveillance in patients with FIB-4 ≥ 5.91 and NFS ≥ 2.85 would be cost-effective with an annual HCC incidence of ≥15 per 1000 patient-years.

CONCLUSION

FIB-4, APRI, and NFS are associated with HCC development in non-cirrhotic NAFLD patients. Different NIT cutoffs may be used to enroll high-risk NAFLD patients for HCC surveillance, according to resource availability in different settings.

Therapeutic landscape of metabolic dysfunction-associated steatohepatitis (MASH)

Metabolic dysfunction-associated steatotic liver disease (MASLD) and its severe subgroup metabolic dysfunction-associated steatohepatitis (MASH) have become a global epidemic and are driven by chronic overnutrition and multiple genetic susceptibility factors. The physiological outcomes include hepatocyte death, liver inflammation and cirrhosis. The first therapeutic for MASLD and MASH, resmetirom, has recently been approved for clinical use and has energized this therapeutic space. However, there is still much to learn in clinical studies of MASH, such as the scale of placebo responses, optimal trial end points, the time required for fibrosis reversal and side effect profiles. This Review introduces aspects of disease pathogenesis related to drug development and discusses two main therapeutic approaches. Thyroid hormone receptor-β agonists, such as resmetirom, as well as fatty acid synthase inhibitors, target the liver and enable it to function within a toxic metabolic environment. In parallel, incretin analogues such as semaglutide improve metabolism, allowing the liver to self-regulate and reversing many aspects of MASH. We also discuss how combinations of therapeutics could potentially be used to treat patients.

Clinical outcomes and predictors in patients with acute on chronic liver failure in Southern Taiwan

BACKGROUND/AIMS

The study is to analyze the clinical characteristics and identify prognostic factors as well as evaluate predictive models in patients with acute-on-chronic liver failure (ACLF) from Southern Taiwan.

METHODS

The cohort study was conducted using the Chang Gung Research Database. We included patients with ACLF based on the definition provided by the Asian-Pacific Association for the Study of the Liver ACLF Research Consortium (AARC).

RESULTS

A total of 231 patients diagnosed with ACLF were included in this study, out of which 26 patients underwent liver transplantation (LT). The primary cause of ACLF was acute exacerbation of hepatitis B virus (HBV) in 68.4% of cases and followed by severe alcoholic hepatitis (20.8%). Among LT-free patients, the 28-day mortality rate was observed to be 31%. Older age, higher INR and ammonia levels, and the presence of severe hepatic encephalopathy on 3-6 days of treatment were independent predictors of 28-day mortality. The CLIF-C ACLF and COSSH-ACLF scores, evaluated on 3-6 days, demonstrated the highest predictive performance for 28-day mortality. The optimal cut-off values for the CLIF-C ACLF and COSSH-ACLF scores were determined to be 47 and 6.3, respectively. Patients with CLIF-C ACLF score >63 or COSSH-ACLF score >8.1 experienced 100% mortality by day 28.

CONCLUSION

The CLIF-C ACLF and COSSH-ACLF scores, evaluated within one week after treatment, exhibit strong predictive capabilities for short-term mortality in ACLF patients. These models are valuable tools for guiding timely decision-making, including the consideration of liver transplantation or withdrawal from treatment.

Organ dysfunction and failure in liver disease

Acute-on-chronic liver failure (ACLF) is a complex syndrome defined by the existence of different organ failures (OFs) in patients with chronic liver disease, mainly cirrhosis. Several definitions have been proposed to define the syndrome, varying in the grade of the subjacent liver disease, the type of precipitants and the organs considered in the definition. Liver, coagulation, brain, kidney, circulatory and pulmonary are the six types of OFs proposed in the different classifications, with different prevalence worldwide. Irrespective of the definition used, patients who develop ACLF present a hyperactive immune system, profound haemodynamic disturbances and several metabolic alterations that finally lead to organ dysfunction. These disturbances are triggered by different factors such as bacterial infections, alcoholic hepatitis, gastrointestinal bleeding or hepatitis B virus flare, among others. Because patients with ACLF present high short-term mortality, a prompt recognition is needed to start treatment of the trigger event and specific organ support. Liver transplantation is also feasible in carefully selected patients and should be evaluated.

Zhuyu pill attenuates metabolic-associated fatty liver disease by regulating macrophage polarization through TLR4 signaling pathway

BACKGROUND

Metabolic-associated fatty liver disease (MAFLD) is the leading chronic liver disease globally, impacting a large segment of the population. The Zhuyu Pill (ZYP), a traditional Chinese remedy, has been clinically used for treating MAFLD, with its effectiveness demonstrated in both human patients and animal models. However, the underlying mechanisms of how ZYP addresses MAFLD still require further investigation.

OBJECTIVE

This study investigated the molecular mechanism of ZYP in treating MAFLD through both in vivo and vitro methods.

METHODS

A murine MAFLD model was induced by a high-fat, high-fructose diet for 12 weeks. ZYP was administered for 4 weeks, with fenofibrate serving as a positive control. Indicators of lipid metabolism in serum and liver tissue were detected by automatic biochemical analyzer and ELISA, respectively. Histopathological evaluation of liver sections was performed using HE and oil red O staining. Transcriptomics was employed to further investigate the therapeutic mechanism of ZYP in MAFLD. Additionally, macrophages and their polarization in the liver were analyzed using ELISA, flow cytometry, immunohistochemistry, and immunofluorescence (IF). Candidate proteins and pathways were validated in vivo and in vitro by western blotting and IF. Validation of the pathway was performed in vitro using inhibitors and co-culture strategies.

RESULTS

ZYP significantly improved obesity and hepatic steatosis in MAFLD mice, reducing body/liver weight and regulating lipid metabolism indicators in serum and liver tissue. Bioinformatics analysis of transcriptomic data highlighted lipid metabolism regulation and inflammation control as key effects of ZYP in treating MAFLD. The in vivo experimental results showed that ZYP inhibited M1 polarization of macrophages (pro-inflammatory) and promoted M2 polarization of macrophages (anti-inflammatory) in MAFLD mice. Further in vivo and vitro experiments indicated that ZYP competes with LPS to bind to Toll-like receptor 4 (TLR4), suppressing M1 polarization in liver macrophages, and improving MAFLD. The in vitro co-culture system also confirmed that ZYP reduces liver lipid deposition by modulating M1 macrophage polarization.

CONCLUSIONS

ZYP alleviates MAFLD by inhibiting M1 polarization of liver macrophages, indicating that ZYP may be a promising treatment for MAFLD. Its mechanism of action is to inhibit the TLR4/MyD88/TRAF6 signaling pathway, modulate macrophage polarization, and improve inflammatory response.

Mechanisms and treatment approaches for ACLF

Acute-on-chronic liver failure (ACLF) is a life-threatening syndrome characterized by decompensation of cirrhosis, severe systemic inflammation and organ failures. ACLF is frequently triggered by intra- and/or extrahepatic insults, such as bacterial infections, alcohol-related hepatitis or flares of hepatic viruses. The imbalance between systemic inflammation and immune tolerance causes organ failures through the following mechanisms: (i) direct damage of immune cells/mediators; (ii) worsening of circulatory dysfunction resulting in organ hypoperfusion and (iii) metabolic alterations with prioritization of energetic substrates for inflammation and peripheral organ 'energetic crisis'. Currently, the management of ACLF includes the support of organ failures, the identification and treatment of precipitating factors and expedited assessment for liver transplantation (LT). Early LT should be considered in patients with ACLF grade 3, who are unlikely to recover with the available treatments and have a mortality rate > 70% at 28 days. However, the selection of transplant candidates and their prioritization on the LT waiting list need standardization. Future challenges in the ACLF field include a better understanding of pathophysiological mechanisms leading to inflammation and organ failures, the development of specific treatments for the disease and personalized treatment approaches. Herein, we reviewed the current knowledge and future perspectives on mechanisms and treatment of ACLF.

Novel treatment of acute and acute-on-chronic liver failure: Interleukin-22

Acute liver failure (ALF) is a life-threatening medical condition, characterized by rapidly progressive hepatic dysfunction, coagulopathy and hepatic encephalopathy in patients without chronic liver disease, while acute-on-chronic liver failure (ACLF) occurs in patients with existing chronic liver disease. ALF and ACLF are often associated with multiple organ failure and a high short-term mortality. In this review, we briefly discuss the causes and pathogenesis of ALF and ACLF, the current options available for the treatment of both deadly maladies and interleukin-22 (IL-22), a novel promising drug that may have great therapeutic potential for ALF and ACLF treatment. IL-22 is a cytokine produced by immune cells but mainly targets epithelial cells including hepatocytes. IL-22 has been shown to protect against organ damage and reduce bacterial infection in many preclinical models and several clinical trials including alcohol-associated hepatitis. The potential application of IL-22 for the treatment of ALF and ACLF is also elaborated.

Recompensation features and prognosis in hepatitis B virus-related acute-on-chronic liver failure patients

OBJECTIVE

This study aimed to investigate the characteristics and prognosis of recompensation in hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF).

METHODS

A total of 136 patients with HBV-related ACLF were followed up until the end of the study. Patients were categorized into recompensation and non-recompensation groups based on whether recompensation occurred in the first year. The survival rate and incidence of recompensation were calculated using the Kaplan-Meier method.

RESULTS

According to the BAVENO VII consensus criteria, 56 (41.18%) of these patients with ACLF regained recompensation in the 1-year follow-up. The recompensated group had less severe liver damage, higher alpha-fetoprotein, lower age, and lower model for end-stage liver disease score. Specifically, in terms of complications, the recompensated group showed a lower incidence compared with the non-recompensated group ( P  < 0.05). The 3-, 6-, 12-, 36-, and 60-month cumulative survival rates of ACLF were 44.9, 43.4, 43.4, 40.4, and 40.4% respectively. Among the patients who survived beyond 90 days, 57/61 (93.44%) patients showed recompensation of ACLF (with one patient recovering to recompensation after more than 1 year of follow-up), the 3-, 6-, 12-, and 24-month cumulative recompensation rates were 56.5, 90.9, 94.6, and 97.3%, respectively. Among the 57 patients with recompensation of ACLF, 87.7% maintained a stable condition, and 10.5% were diagnosed with hepatocellular carcinoma (HCC).

CONCLUSION

Milder necrosis, less inflammation, and more vigorous hepatic regeneration are conducive to recompensation and a better long-term prognosis in ACLF. However, the occurrence of HCC cannot be avoided and regular monitoring is necessary in the recompensation of ACLF.

Prognosis algorithms for acute decompensation of cirrhosis and ACLF

Accurate prediction of survival in patients with cirrhosis is crucial, as patients who are unlikely to survive in the short-term need to be oriented to liver transplantation and to novel therapeutic approaches. Patients with acute decompensation of cirrhosis without or with organ dysfunction/failure, the so-called acute-on-chronic liver failure (ACLF), have a particularly high short-term mortality. Recognizing the specificity of this clinical situation, dedicated classifications and scores have been developed over the last 15 years, including variables (e.g. organ failures and systemic inflammation) not part of the formerly available cirrhosis severity scores, namely Child-Pugh score or MELD. For patients with acute decompensation of cirrhosis, it led to the development of a dedicated score, the Clif-C-AD score, independently validated. For more severe patients, three different scoring systems have been proposed, by European, Asian and North American societies namely Clif-C-ACLF, AARC score and NASCELD-ACLF respectively. These scores have been validated, and are widely used across the world. The differences and similarities between these scores, as well as their validation and limitations are discussed here. Even if these scores and classifications have been a step forward in favouring homogeneity between studies, and in helping making decisions for individual patients, their predictive value for mortality can still be improved as their area under the ROC curve does not exceed .8. Novel scores including biomarkers reflecting the pathophysiology of acute decompensation of cirrhosis might help reach that goal.

Optimization of surgical evaluation algorithms for living donor liver transplantation

BACKGROUND

Living donor liver transplantation (LDLT) is an established and endorsed alternative for deceased donor liver transplantation with better recipient outcomes. Nevertheless, while extensive evaluation of potential donors is crucial, evaluation algorithms differ between transplant centres and guidelines.

METHODS

We included 317 individuals evaluated for LDLT between 07/2007-07/2022 in a retrospective analysis. The evaluation process was analysed to identify the key reasons for declining 77 potential donors. Additionally, 146 donors that underwent LDLT were analysed regarding risk factors for complications.

RESULTS

The main reasons for donor refusal were liver volumetry (40.3 %) and metabolic factors including obesity or steatotic liver disease (20.8 %). Contrast-enhanced computed tomography (CECT) identified 63.6 % of all declined donors; CECT combined with assessment of medical history, physical examination, blood testing and ultrasonography, identified 87.0 % of declined potential donors. Associated with this selection, complication rates in donors were low (≥II in 17.1 %; none with ≥IVb). Notably, higher age was a risk factor for developing a complication ≥II after hemi-hepatectomy (p = 0.0373).

CONCLUSIONS

We propose a progressive 4-step evaluation algorithm that begins with a very basic assessment combined with up-front CECT. This early phase of testing is expected to identify nearly 90 % of ineligible donors, thereby conserving critical resources, time and money, as well as minimising burden for potential donors.

FUNDING

J.M.W. received funding by grant We-4675/6-1 from the Deutsche Forschungsgemeinschaft (DFG) in Bonn, Germany.

Definition, diagnosis and epidemiology of acute-on-chronic liver failure

This narrative review addresses the definition of acute-on-chronic liver failure, a condition associated with high short-term mortality in patients with chronic liver disease and/or cirrhosis. We provide two major points of view: the East and the West perspective. Both definitions vary regarding the underlying patient population and organ failure(s) definition. Nevertheless, all the definitions have their clinical utility: from the core concept of having the "liver" as a conditio sine qua non, the syndrome cannot exist (Asian Pacific Association for the Study of the Liver); a data-driven, robust definition (European Association for the Study of the Liver); a bedside tool that can quickly identify patients at high risk of dying (North American Consortium for the Study of End-stage Liver Disease [NACSELD]). In each section, we provide the overall definitions, the criteria of organ failure(s), and some epidemiological data illustrating how these apply in each area of the world.

Drug-Induced Liver Injury in Patients With Chronic Liver Disease

OBJECTIVE

Drug-induced liver injury (DILI) is a global problem and can develop from exposure to prescription or over-the-counter medications as well as herbal and dietary supplements. The diagnosis of DILI is clinically challenging, and liver injury can be severe leading to liver failure, death, or liver transplantation. Patients with underlying chronic liver diseases (CLD) may be at increased risk for DILI, which is associated with factors related to drug or liver disease.

METHODS

This review summarises current knowledge on the risk and outcomes of DILI in patients with CLD.

RESULTS

Patients with CLD may be at an increased risk for DILI. Additionally patients with underlying CLD are at risk for more severe liver injury and worse outcomes after DILI.

DISCUSSION

The risk for and poor outcomes from DILI are accentuated in patients with CLD and potentially leading to the worst-case scenario of acute-on-chronic liver failure. We highlight the key observations on DILI with a broad range of underlying liver diseases and the high-DILI risk agents implicated in those populations.

The impact of incidental hepatocellular carcinoma in liver transplantation: A growing concern

Incidental hepatocellular carcinoma (iHCC) is a growing concern in liver transplantation, where tumors are unexpectedly discovered during histopathological examination of explanted livers. The prevalence of iHCC varies widely, with reported rates between 1.6 % and 40 %, influenced by differences in diagnostic practices and patient populations. Recent studies, including that by Kerstens et al., highlight the clinical significance of iHCC, revealing its association with alcohol-related liver disease and the limitations of current surveillance strategies. Conventional imaging techniques, such as ultrasound, often fail to detect small tumors, leading to delayed diagnosis. Advanced imaging modalities, including MRI, and emerging biomarkers, such as des-γ-carboxy prothrombin (DCP), are improving detection, but further research is needed to refine diagnostic protocols. The growing recognition of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) complicates the surveillance of iHCC, particularly as patients with MASLD often present with subtle or atypical clinical profiles. Personalized surveillance, incorporating advanced technologies like liquid biopsy and artificial intelligence, holds promise for improving early detection. Additionally, individualized post-transplant management strategies are crucial, given the lower survival rates observed in iHCC patients. As our understanding of iHCC evolves, a shift toward more tailored approaches in diagnosis, surveillance, and treatment is essential to improve outcomes and reduce the burden of incidental HCC in liver transplantation.

Omics in acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is a critical syndrome that develops in patients with chronic liver disease and is characterized by acute decompensation, single- or multiple-organ failure and high short-term mortality. Over the past few decades, ACLF has been progressively recognized as an independent clinical entity, and several criteria and prognostic scores have been proposed and validated by different scientific societies. However, controversies still exist in some aspects across regions, which mainly involve whether the definition of underlying liver diseases should include cirrhosis and non-cirrhosis. The pathophysiology of ACLF is complicated and remains unclear, although accumulating evidence based on different aetiologies of ACLF shows that it is closely associated with intense systemic inflammation and immune-metabolism disorder, which result in mitochondrial dysfunction and microenvironment imbalance, leading to disease development and organ failure. In-depth insight into the biological pathways involved in the mechanisms of ACLF and potential mechanistic targets that improve patient survival still needs to be investigated. Omics-based analytical techniques, including genomics, transcriptomics, proteomics, metabolomics and microbiomes, have developed rapidly and can offer novel insights into the essential pathophysiologic process of ACLF. In this paper, we briefly reviewed and summarized the current knowledge and recent advances in the definitions, criteria and prognostic assessments of ACLF; we also described the omics techniques and how omics-based analyses have been applied to investigate and characterize the biological mechanisms of ACLF and identify potential predictive biomarkers and therapeutic targets for ACLF. We also outline the challenges, future directions and limitations presented by omics-based analyses in clinical ACLF research.

Global burden and risk factors of MASLD: trends from 1990 to 2021 and predictions to 2030

The prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) is increasing globally, posing a major public health issue. This study analyzes the global, regional, and national burden of MASLD and its risk factors from 1990 to 2021, with projections to 2030. We obtained data on MASLD prevalence, deaths, and disability-adjusted life years (DALYs) from the Global Burden of Disease 2021 for 204 countries. Counts and rates per 100,000 population were calculated, and trends to 2030 were predicted using the Bayesian Age-Period-Cohort model. In 2021, there were 1,267.9 million MASLD cases globally, with 138.3 thousand deaths and 3667.3 thousand DALYs. The global age-standardized prevalence, death, and DALY rates were 15,018.1, 1.6, and 42.4 per 100,000 population, increasing by 24.3%, 5.5%, and 5.5% since 1990. North Africa and the Middle East had the highest prevalence, while Andean and Central Latin America had the highest death and DALY rates. Men aged 15-69 and 90-94 had higher DALY rates, while women aged 70-89 and 95+ had higher rates. A reversed V-shaped association was found between the sociodemographic index and DALY rate. High fasting plasma glucose (5.9%) and smoking (2.4%) were major risk factors. Public health efforts should prioritize early detection and management of MASLD in younger populations and develop targeted strategies for older adults, especially women, to reduce the disease burden. Effective policies to address high fasting plasma glucose and smoking can mitigate MASLD's impact.

Dynamic skeletal muscle loss and its predictive role on 90-day mortality in patients with acute-on-chronic liver failure

Background

Low skeletal muscle mass is an independent risk factor for increased mortality in patients with acute-on-chronic liver failure (ACLF). However, no study has evaluated the temporal changes in muscle mass during the course of ACLF. Therefore, this study aimed to investigate the dynamic changes in muscle mass and their prognostic role in patients with ACLF.

Methods

A retrospective analysis was conducted on consecutive patients with ACLF who underwent two or more abdominal computed tomography examinations within 90 days of admission. The percentage change rates of the skeletal muscle index at the third lumbar vertebra (L3-SMI) were calculated as (L3-SMIfinal - L3-SMIinitial)/(L3-SMIinitial) × 100%.

Results

A total of 154 patients with ACLF were included. During the course of ACLF, the percentage change rates of L3-SMI at 2-7, 8-14, 15-30, 31-60, and 61-90 days were - 0.83 ± 4.43, -3.76 ± 4.40, -7.30 ± 5.89, -10.10 ± 7.45, and - 5.53 ± 9.26, respectively. Significant reductions in L3-SMI were noted in patients with severe conditions compared to other patients at 2-7 days and 15-30 days. Moreover, the rate of decrease in L3-SMI in patients with a lower respiratory quotient (RQ) was significantly greater than that in patients with a normal RQ at 2-7 days and 15-30 days. Additionally, high muscle loss (HR 2.059; 95% CI 1.122-3.780, p = 0.020), rather than pre-existing sarcopenia (HR 1.430; 95% CI 0.724-2.826, p = 0.303) at baseline, was independently associated with 90-day mortality.

Conclusion

Deterioration in muscle mass is associated with disease severity and poor nutritional status and serves as a more effective predictor of adverse short-term outcomes in patients with ACLF. These findings underscore the importance of dynamic evaluation of muscle loss and emphasize the necessity of reversing muscle loss in patients with ACLF.

Prognostic factors for mortality in patients with acute-on-chronic liver failure

OBJECTIVE

The aim is to explore significant prognostic factors for 90-day mortality in patients with acute-on-chronic liver failure (ACLF) and assist clinicians in the early identification of critically ill ACLF patients.

METHODS

A retrospective analysis was conducted on 288 ACLF patients, who were classified into survivors (n = 187) and nonsurvivors (n = 101) based on 90-day outcomes. Multivariate stepwise logistic regression analyses were employed to identify significant prognostic factors and construct a novel prognostic model, the AHUCTPI. The model's performance was assessed and the internal validation was performed. Additionally, the influence of dynamic changes in laboratory markers on 90-day mortality was examined.

RESULTS

Independent risk factors for 90-day mortality included age ≥45 years, presence of hepatic encephalopathy (HE), and upper gastrointestinal bleeding (UGB) during hospitalization, imaging-confirmed cirrhosis at admission, elevated baseline total bilirubin (TBIL), reduced baseline platelet-to-neutrophil ratio (PNR), and elevated baseline international normalized ratio (INR) (P < 0.05 for all). The AHUCTPI model's formula is as follows: Logit (p) = -10.019 + 1.808 × age (1 if ≥45 years, 0 if <45 years) + 1.048 × HE (1 if present, 0 if absent) + 1.721 × UGB (1 if present, 0 if absent) + 1.362 × cirrhosis (1 if present, 0 if absent) + 0.008 × TBIL (μmol/L) - 0.039 × PNR + 1.963 × INR. The AUHCTPI model demonstrated superior predictive accuracy compared with the MELD (Model for End-Stage Liver Disease) score, with the area under the receiver operating characteristic curve values of 0.914 and 0.739, respectively, and calibration curves closely approximating the ideal curve.

CONCLUSION

ACLF is a complex, dynamic syndrome. Age, HE, and UGB during hospitalization, imaging-diagnosed cirrhosis at admission, baseline TBIL, PNR, and INR were significant predictors for 90-day mortality in ACLF patients, and the AHUCTPI model provides excellent calibration and discrimination. Dynamic monitoring of laboratory trends enhances prognostic accuracy and supports timely clinical decision-making.

Risk factor analysis and predictive model construction of lean MAFLD: a cross-sectional study of a health check-up population in China

AIM

Cardiovascular disease morbidity and mortality rates are high in patients with metabolic dysfunction-associated fatty liver disease (MAFLD). The objective of this study was to analyze the risk factors and differences between lean MAFLD and overweight MAFLD, and establish and validate a nomogram model for predicting lean MAFLD.

METHODS

This retrospective cross-sectional study included 4363 participants who underwent annual health checkup at Yuyao from 2019 to 2022. The study population was stratified into three groups: non-MAFLD, lean MAFLD (defined as the presence of fatty liver changes as determined by ultrasound in individuals with a BMI < 25 kg/m2), and overweight MAFLD (BMI ≥ 25.0 kg/m2). Subsequent modeling analysis was conducted in a population that included healthy subjects with < 25 kg/m2 (n = 2104) and subjects with lean MAFLD (n = 849). The study population was randomly split (7:3 ratio) to a training vs. a validation cohort. Risk factors for lean MAFLD was identify by multivariate regression of the training cohort, and used to construct a nomogram to estimate the probability of lean MAFLD. Model performance was examined using the receiver operating characteristic (ROC) curve analysis and k-fold cross-validation (k = 5). Decision curve analysis (DCA) was applied to evaluate the clinical usefulness of the prediction model.

RESULTS

The multivariate regression analysis indicated that the triglycerides and glucose index (TyG) was the most significant risk factor for lean MAFLD (OR: 4.03, 95% CI 2.806-5.786). The restricted cubic spline curves (RCS) regression model demonstrated that the relationships between systolic pressure (SBP), alanine aminotransferase (ALT), serum urate (UA), total cholesterol (TCHO), triglyceride (TG), triglyceride glucose (TyG) index, high density lipoprotein cholesterol (HDLC), and MAFLD were nonlinear and the cutoff values for lean MAFLD and overweight MAFLD were different. The nomogram was constructed based on seven predictors: glycosylated hemoglobin A1c (HbA1c), serum ferritin (SF), ALT, UA, BMI, TyG index, and age. In the validation cohort, the area under the ROC curve was 0.866 (95% CI 0.842-0.891), with 83.8% sensitivity and 76.6% specificity at the optimal cutoff. The PPV and NPV was 63.3% and 90.8%, respectively. Furthermore, we used fivefold cross-validation and the average area under the ROC curve was 0.866 (Figure S3). The calibration curves for the model's predictions and the actual outcomes were in good agreement. The DCA findings demonstrated that the nomogram model was clinically useful throughout a broad threshold probability range.

CONCLUSIONS

Lean and overweight MAFLD exhibit distinct metabolic profiles. The nomogram model developed in this study is designed to assist clinicians in the early identification of high-risk individuals with lean MAFLD, including those with a normal BMI but at metabolic risk, as well as those with abnormal blood lipid, glucose, uric acid or transaminase levels. In addition, this model enhances screening efforts in communities and medical screening centers, ultimately ensuring more timely and effective medical services for patients.

Integrative anticoagulation of nafamostat mesylate in double plasma molecular adsorption system plus sequential half-dose plasmapheresis for patients with liver failure: a randomised controlled trial protocol

INTRODUCTION

Nafamostat mesylate (NM) is widely recognised as a premier anticoagulant, especially in Japan and Korea. However, it has not yet been used as an anticoagulant in double plasma molecular adsorption system (DPMAS) plus sequential half-dose plasmapheresis (PE) therapy. This study aims to comprehensively evaluate the safety and efficacy of NM-integrated anticoagulation during DPMAS plus sequential half-dose PE therapy for patients with liver failure.

METHODS AND ANALYSIS

A two-arm, open-label, parallel, randomised controlled trial involving 132 patients with liver failure will be conducted in China. Eligible participants will be randomly allocated to either the nafamostat mesylate integrative anticoagulation group or the heparin integrative anticoagulation group, employing a central randomisation system at a 1:1 ratio throughout the course of DPMAS plus sequential half-dose PE therapy. The primary outcome includes the number of successfully completed DPMAS plus sequential half-dose PE therapy. The secondary outcomes include liver function indicators, extracorporeal circulation pressures, coagulation function parameters, all-cause mortality rates and survival rates. Clinical safety will be assessed by analysis of the number of bleeding events, the number of clotting events and adverse events. Outcome analyses will be performed on both the intention-to-treat population, which includes all patients randomised, and the per-protocol population, which includes eligible patients who adhere to the planned treatment and follow-ups.

ETHICS AND DISSEMINATION

The trial protocol was approved by the Biomedical Research Ethics Committee of West China Hospital of Sichuan University (approval number (2022)860). During the protocol revision process, all changes were reexamined and reapproved by the Biomedical Research Ethics Committee of West China Hospital of Sichuan University. The results will be presented at national and international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2200064725.

The Management of Cardiometabolic Risk in MAFLD: Therapeutic Strategies to Modulate Deranged Metabolism and Cholesterol Levels

Background and Objectives: Fatty Liver Disease is a major health problem worldwide. We can distinguish liver steatosis as non-associated or associated with chronic/acute alcohol consumption. These two entities share similar stages ranging from hepatic fat storage (namely, steatosis) to inflammation, necrosis, and fibrosis until hepatocellular carcinoma (HCC). Over time, "Metabolic Associated Fatty Liver Disease" (MAFLD) has replaced nonalcoholic fatty liver disease (NAFLD) nomenclature and has included cardiometabolic criteria in these patients definition. Thus, obesity, type 2 diabetes mellitus (T2DM), hypertension, and dyslipidemia are MAFLD features and are of the metabolic syndrome. Importantly, there is not a specific treatment for MAFLD, but there are therapeutic strategies that act on metabolic dysfunction related to MAFLD. They can reduce the progression of liver fibrosis and its complications. Materials and Methods: For all these reasons, we conducted a narrative review of the literature, and we focused on metabolic dysfunction related to MAFLD, with a special regard for cholesterol metabolism. Results: MAFLD is a recently redefined condition that better describes the metabolism derangement responsible for fatty liver disease. This distinguishes MAFLD from NAFLD. In fact, the diagnostic criteria for MAFLD require the presence of liver steatosis together with at least one of the following: obesity, T2DM, or evidence of metabolic disorder such as hypertriglyceridemia, low high-density lipoprotein cholesterol, or hypertension. As a result, MAFLD is closely linked to an increased cardiometabolic risk. Current therapeutic approaches can be used to reduce this risk, focusing on lifestyle interventions and pharmacological strategies. Several treatments in patients diagnosed with MAFLD are mainly cholesterol-lowering remedies. Among these, Pro-protein Convertase Subtilisin/Kexin type 9 inhibitors (PCSK9i) show the most promising efficacy profile but data on liver fibrosis are lacking. Agonists of GLP-1 receptor, Sodium-glucose cotransporter-2 inhibitors (SGLT2i) and Dipeptidyl Peptidase-4 inhibitors (DPP-4i) have a " multi-hit " action allowing their use also in diabetic patients with MAFLD. Conclusions: Lifestyle modifications, some nutraceuticals, statins, incretins, and PCSK9i have changed the natural course and significantly improved the cardiometabolic outcomes of MAFLD. Emerging cholesterol-lowering drugs, such as Bempedoic acid, can overcome low compliance to statins' use and their controversial effect on liver fibrosis. Finally, medications targeting insulin resistance allow for strategic interventions of the convoluted pathophysiology of MAFLD in multiple steps, with the potential to reduce liver steatosis, inflammation, and necrosis and, sometimes even to reverse liver fibrosis.

Linking Cardiovascular Disease and Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD): The Role of Cardiometabolic Drugs in MASLD Treatment

The link between cardiovascular disease (CVD) and metabolic dysfunction-associated steatotic liver disease (MASLD) is well-established at both the epidemiological and pathophysiological levels. Among the common pathophysiological mechanisms involved in the development and progression of both diseases, oxidative stress and inflammation, insulin resistance, lipid metabolism deterioration, hepatokines, and gut dysbiosis along with genetic factors have been recognized to play a pivotal role. Pharmacologic interventions with drugs targeting common modifiable cardiometabolic risk factors, such as T2DM, dyslipidemia, and hypertension, are a reasonable strategy to prevent CVD development and progression of MASLD. Recently, a novel drug for metabolic dysfunction-associated steatohepatitis (MASH), resmetirom, has shown positive effects regarding CVD risk, opening new opportunities for the therapeutic approach of MASLD and CVD. This review provides current knowledge on the epidemiologic association of MASLD to CVD morbidity and mortality and enlightens the possible underlying pathophysiologic mechanisms linking MASLD with CVD. The role of cardiometabolic drugs such as anti-hypertensive drugs, hypolipidemic agents, glucose-lowering medications, acetylsalicylic acid, and the thyroid hormone receptor-beta agonist in the progression of MASLD is also discussed. Metformin failed to prove beneficial effects in MASLD progression. Studies on the administration of thiazolinediones in MASLD suggest effectiveness in improving steatosis, steatohepatitis, and fibrosis, while newer categories of glucose-lowering agents such as GLP-1Ra and SGLT-2i are currently being tested for their efficacy across the whole spectrum of MASLD. Statins alone or in combination with ezetimibe have yielded promising results. The conduction of long-duration, large, high-quality, randomized-controlled trials aiming to assess by biopsy the efficacy of cardiometabolic drugs to reverse MASLD progression is of great importance.

Adherence to the planetary health diet index and metabolic dysfunction-associated steatotic liver disease: a cross-sectional study

Backgrounds

Adherence to the Planetary Health Diet Index (PHDI) has been shown to benefit both individual health and the planet. However, its impact on Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) remains unclear. This study aimed to investigate the relationship between PHDI adherence and the MASLD risk.

Methods

We analyzed a cohort of 15,865 adults (aged ≥18 years) using data from the National Health and Nutrition Examination Survey (NHANES, 2005-2018). The PHDI was derived from 24-h dietary assessments and comprised the scores of 15 food groups. Multivariate logistic regression was used to investigate the association between PHDI and MASLD, while restricted cubic spline (RCS) regression and threshold analysis were employed to explore potential non-linear relationship. Subgroup analyses were conducted to assess the influence of various demographic and clinical characteristics on the observed associations. Mediation analysis was performed to evaluate the indirect effect of PHDI on MASLD, and weighted quantile sum (WQS) regression was used to assess the influence of individual PHDI nutrients on MASLD.

Results

Among the cohort, 6,125 individuals were diagnosed with MASLD. Multivariate logistic regression revealed that a higher quintile of PHDI was significantly associated with reduced MASLD risk in the fully adjusted model (OR = 0.610, 95%CI 0.508-0.733, p < 0.001). Notably, nonlinear relationships between PHDI and MASLD risk were observed through RCS analysis (p = 0.002). Subgroup analyses indicated that PHDI was particularly effective in reducing MASLD risk among females, those with higher education attainment, and those living with a partner. WQS regression identified saturated fatty acids as the most significant factor contributing to MASLD risk (weight = 0.313). Additionally, BMI and waist circumference (81.47 and 87.66%, respectively) partially mediated the association between PHDI and MASLD risk, suggesting that the effect of PHDI on MASLD operates, in part, through its impact on BMI and waist circumference. The association between PHDI and MASLD remained robust across multiple sensitivity analyses.

Conclusion

Our findings indicate that adherence to PHDI is linked to a lower risk of MASLD, providing crucial insights for strategies aimed at mitigating the MASLD epidemic while simultaneously fostering environmental sustainability.

Application and assessment of NNN linkages in liver transplant postoperative care: a prospective study

BACKGROUND

Standardized nursing frameworks are widely used to unify nursing practices and enhance patient outcomes, but their application in liver transplantation is still limited. This study evaluates the use of NANDA-I, NOC, and NIC linkages in the perioperative care of liver transplant recipients, aiming to inform future nursing practice improvements.

METHODS

This prospective observational cohort study (December 2022-August 2023) included 44 liver transplant recipients using consecutive sampling. The Delphi method refined the NANDA-I, NOC, and NIC (NNN) linkage framework to 15 nursing diagnoses, 42 outcomes, and 106 interventions. Postoperative NOC indicators were assessed on surgery day and postoperative days 3, 7, 14, and at discharge. One-way repeated measures ANOVA, with Greenhouse-Geisser correction for sphericity violations, analyzed the indicators.

RESULTS

Twelve nursing diagnoses had a 100% usage rate, with an average intervention usage rate of 96.59%. Nine diagnoses showed consistent improvement in NOC scores across four time points, with significant differences (P < 0.008). In contrast, five diagnoses displayed fluctuating scores, highlighting the need for targeted interventions.

CONCLUSIONS

The NNN linkages effectively tracked postoperative changes and guided care for liver transplant patients. The findings support refining nursing care protocols to address fluctuating outcomes and improve patient recovery.