Role of Rifaximin in the Prognosis of Critically Ill Patients with Liver Cirrhosis

Background/Objectives: Critically ill patients with liver cirrhosis impose a substantial health burden on the world. Rifaximin is a potential treatment option for such patients. Methods: We extracted critically ill patients with liver cirrhosis from the Medical Information Mart for Intensive Care (MIMIC) IV database. Based on study outcomes, the current study included prevention and treatment cohorts. A 1:1 propensity score matching (PSM) analysis was performed to match the characteristics of patients. The risk of ICU admission and intensive care unit (ICU), in-hospital, 90-day, and 180-day death were explored. Cox regression analyses were conducted, and hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated. Kaplan-Meier curves were further drawn to demonstrate the cumulative 90-day and 180-day survival rate. Results: Overall, 5381 critically ill patients with liver cirrhosis were included. In the prevention cohort, rifaximin could decrease the risk of ICU admission (HR = 0.427, 95%CI: 0.338-0.539, p < 0.001). In the treatment cohort, rifaximin could decrease the risk of ICU (HR = 0.530, 95%CI: 0.311-0.902, p = 0.019) and in-hospital death (HR = 0.119, 95%CI: 0.033-0.429, p = 0.001) in critically ill patients with liver cirrhosis. However, rifaximin could not decrease the risk of 90-day (HR = 0.905, 95%CI: 0.658-1.245, p = 0.541) and 180-day (HR = 1.043, 95%CI: 0.804-1.353, p = 0.751) death in critically ill patients with liver cirrhosis. Kaplan-Meier curve analyses also showed that rifaximin could not significantly decrease the 90-day (p = 0.570) and 180-day (p = 0.800) cumulative mortality. Conclusions: This study suggests that rifaximin can significantly decrease the risk of ICU admission and improve short-term survival but does not impact long-term survival in critically ill patients with liver cirrhosis.

The universal accumulation of p-aminophenol during the microbial degradation of analgesic and antipyretic acetaminophen in WWTPs: a novel metagenomic perspective

BACKGROUND

Acetaminophen, a widely used analgesic and antipyretic drug, has become a significant aquatic micro-pollutant due to its extensive global production and increased consumption, particularly during the COVID-19 pandemic. Its high-water solubility leads to its pervasive presence in wastewater treatment plants (WWTPs), posing substantial risks to the environment and human health. Biological treatment is one of the promising approaches to remove such pollutants. Although previous studies have isolated acetaminophen-degrading pure cultures and proposed catabolic pathways, the interactions between microbiotas and acetaminophen, the distribution feature of acetaminophen degradation genes, and the gene-driven fate of acetaminophen in the real-world environment remain largely unexplored.

RESULTS

Among the water samples from 20 WWTPs across China, acetaminophen was detected from 19 samples at concentrations ranging from 0.06 to 29.20 nM. However, p-aminophenol, a more toxic metabolite, was detected in all samples at significantly higher concentrations (23.93 to 108.68 nM), indicating the presence of a catabolic bottleneck in WWTPs. Metagenomic analysis from both the above 20 samples and global datasets revealed a consistently higher abundance of initial acetaminophen amidases compared to downstream enzymes, potentially having explained the reason for the bottleneck. Meanwhile, a close correlation between initial amidases and Actinomycetota revealed by genome-based taxonomy suggests a species-dependent degradation pattern. Additionally, a distinct amidase ApaA was characterized by newly isolated Rhodococcus sp. NyZ502 (Actinomycetota), represents a predominant category of amidase in WWTPs. Significant phylogenetic and structural diversity observed among putative amidases suggest versatile acetaminophen hydrolysis potential in WWTPs.

CONCLUSIONS

This study enhances our understanding of acetaminophen's environmental fate and highlights the possible occurrence of ecological risks driven by imbalanced genes in the process of acetaminophen degradation in global WWTPs. Video Abstract.

Dietary Gluten Intake and Cardiovascular Disease Mortality in Japanese Adults in the Takayama Study

BACKGROUND

There is growing attention toward the gluten-free diet in Japan, in spite of a low prevalence of celiac disease and high consumption of rice.

OBJECTIVES

The present study examined whether gluten intake is associated with an increased risk of cardiovascular disease (CVD) mortality in Japanese adults.

METHODS

In 1992, 13,355 men and 15,724 women, ≥35 y of age, in the Takayama study, completed a self-administered questionnaire. Gluten intake was estimated using a food frequency questionnaire as a baseline. Mortality was ascertained during 16 y of follow-up. Hazard ratios (HRs) and 95% confidence intervals (CIs) for CVD mortality were calculated according to gluten intake quartiles.

RESULTS

During 16.1 y of follow-up, 775 CVD deaths in men and 903 CVD deaths in women occurred. Compared with the lowest quartile of intake, the highest quartile of gluten intake was significantly associated with a decreased risk of CVD mortality after controlling for age, sex, and other covariates (HR = 0.73; 95% CI: 0.62, 0.86, P-trend = 0.0003).

CONCLUSIONS

Our data showed a significant inverse association between gluten intake and CVD mortality. The present study does not support the notion that gluten avoidance should have a beneficial effect on CVD mortality.

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.

Deep learning for hepatocellular carcinoma recurrence before and after liver transplantation: a multicenter cohort study

Hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) is a major contributor to mortality. We developed a recurrence prediction system for HCC patients before and after LT. Data from patients with HCC who underwent LT were retrospectively collected from three specialist centres in China. Pre- and post-operative variables were selected using support vector machine, random forest, and logistic regression (LR). Then, pre- and post-operative models were developed using three machine learning methods: LR, stacking, and two survival-based approaches. Models were evaluated using seven assessment indices, and patients were classified as either high- or low-risk based on recurrence risk. 466 patients were included and followed for a median of 51.0 months (95% CI 47.8-54.2). The pre-DeepSurv model (pre-DSM) had a C-index of 0.790 ± 0.003 during training, 0.775 ± 0.037 during testing, and 0.765 ± 0.001 and 0.819 ± 0.002 during external validation. After incorporating clinicopathologic variables, the post-DeepSurv model (post-DSM) had a 0.835 ± 0.008 C-index during training, 0.812 ± 0.082 during testing, and 0.839 ± 0.001 and 0.831 ± 0.002 during external validation. The post-DSM outperformed the Milan criteria by more accurately identifying patients at high risk of recurrence. Tumour recurrence predictions also improved significantly with DeepSurv. Both pre- and post-DSMs have the potential to guide personalised surveillance strategies for LT patients with HCC.

US Population Size and Outcomes of Adults on Liver Transplant Waiting Lists

Importance

Disparities in organ supply and demand led to geographic inequities in the score-based liver transplant (LT) allocation system, prompting a change to allocation based on acuity circles (AC) defined by fixed distances. However, fixed distances do not ensure equivalent population size, potentially creating new sources of disparity.

Objective

To estimate the association between population size around LT centers and waiting list outcomes for critically ill patients with chronic end-stage liver disease and high Model for End-stage Liver Disease (MELD) scores or acute liver failure (ALF).

Design, Setting, and Participants

This US nationwide retrospective cohort study included adult (aged ≥18 years) candidates for deceased donor LT wait-listed between June 18, 2013, and May 31, 2023. Follow-up was completed June 30, 2023. Participants were divided into pre-AC and post-AC groups.

Exposure

Population size within defined radii around each LT center (150 nautical miles [nm] for participants with high MELD scores and 500 nm for those with ALF) based on AC allocation policy.

Main Outcomes and Measures

LT candidate waiting list mortality and dropout rate were analyzed using generalized linear mixed-effect models with random intercepts for center and listing date before and after AC implementation. Fine-Gray competing risk regression, accounting for clustering, was used as a secondary model.

Results

The study analyzed 6142 LT candidates (1581 with ALF and 4561 with high MELD scores) during the pre-AC era and 4344 candidates (749 with ALF and 3595 with high- MELD scores) in the post-AC era, for a total of 10 486 participants (6331 male [60.5%]; mean [SD] age, 48.5 [7.1] years). In the high-MELD cohort, being listed at a center in the lowest tertile of population size was associated with increased waiting list mortality in the AC era (adjusted odds ratio [AOR], 1.68; 95% CI, 1.14-2.46). Doubling of the population size was associated with a 34% reduction in the odds of mortality or dropout (AOR, 0.66; 95% CI, 0.49-0.90). These results were consistent with those of the extended Fine-Gray models and were also corroborated by multiple sensitivity analyses. However, there were no significant population density-associated disparities in the ALF cohort.

Conclusions and Relevance

In this retrospective nationwide cohort study, being wait-listed in less populated regions was associated with greater mortality among critically ill LT candidates with high MELD scores, underscoring the limitations of allocation systems based purely on fixed distances.

Bile acids and their receptors in hepatic immunity

Similarly to conventional steroids, bile acids function as signaling molecules, acting on a family of membrane and nuclear receptors. The best-characterized bile acid-regulated receptors are the farnesoid X receptor, activated by primary bile acids, and the G-protein-coupled bile acid receptor 1 (also known as Takeda G protein-coupled receptor 5), which is activated by secondary bile acids, such as lithocholic acid (LCA) and deoxycholic acid. Both the farnesoid X receptor and G-protein-coupled bile acid receptor 1 are expressed in cells of innate immunity, monocytes/macrophages, and natural killer cells. Their activation in these cells provides counter-regulatory signals that are inhibitory in nature and attenuate inflammation. In recent years, however, it has been increasingly appreciated that bile acids biotransformations by intestinal microbiota result in the formation of chemically different secondary bile acids that potently regulate adaptive immunity. The 3-oxoLCA and isoalloLCA, two LCA derivatives, bind receptors such as the retinoic acid receptor-related orphan receptor gamma t (RORγt) and the vitamin D receptor (VDR) that are expressed only by lymphoid cells, extending the regulatory role of bile acids to T cells, including T-helper 17 cells and type 3 innate lymphoid cells (ILC3). In this novel conceptual framework, bile acids have emerged as one of the main components of the postbiota, the waste array of chemical mediators generated by the intestinal microbiota. Deciphering the interaction of these mediators with the immune system in the intestine and liver is a novel and fascinating area of bile acid renaissance.

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.

Acute and non-acute decompensation of liver cirrhosis (47/130)

In the traditional view, the occurrence of cirrhosis-related complications, such as hepatic encephalopathy, formation of ascites or variceal haemorrhage, marks the transition to the decompensated stage of cirrhosis. Although the dichotomous stratification into a compensated and decompensated state reflects a prognostic water-shed moment and remains to hold its prognostic validity, it represents an oversimplification of clinical realities. A broadening understanding of pathophysiological mechanisms underpinning decompensation have led to the identification of distinct prognostic subgroups, associated with different clinical courses following decompensation. Data provided by the PREDICT study uncovered three distinct sub-phenotypes of acute decompensation (AD). Moreover, acute-on-chronic liver failure (ACLF) has been established as a distinct clinical entity for many years, which is associated with a high short-term mortality. Recently, non-acute decompensation (NAD) has been proposed as a distinct pathway of decompensation, complementing current concepts of the spectrum of decompensation. In contrast to AD, NAD is characterized by a slow and progressive development of complications, which are often presented at first decompensation and/or in patients in an earlier stage of chronic liver disease. Successful treatment of AD or NAD may lead to a clinical stabilization or even the concept of recompensation. This review aims to provide an overview on current concepts of decompensation and to delineate recent advances in our clinical and pathophysiological understanding.

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.

Prognostic value of the modified Model for End-Stage Liver Disease score in patients treated with cardiac resynchronization therapy

Background

Hepatorenal dysfunction is prevalent among individuals with heart failure (HF).

OBJECTIVE

This study investigated prognostic value of the modified Model for End-Stage Liver Disease (Model for End-Stage Liver Disease excluding international normalized ratio [MELD-XI] scores and Model for End-Stage Liver Disease with albumin replacing international normalized ratio [MELD-Albumin]) score in patients undergoing cardiac resynchronization therapy (CRT).

Methods

We retrospectively evaluated 365 patients (mean age 58.7 ± 11.1 years; 64.9% men) undergoing CRT implantation between 2007 and 2019. Patients were divided into 4 groups based on the modified MELD score quartiles before CRT. The primary endpoint was the combination of all-cause mortality and HF hospitalization, whereas the secondary endpoint was CRT response at 6 months.

Results

During mean follow-up of 3.3 years (interquartile range 1.9-5.2 years), 168 patients reached the primary endpoint. Logistic regression revealed the MELD-Albumin score was independently associated with CRT response, even after adjusting for covariates (odds ratio 1.10; 95% confidence interval [CI] 1.02-1.19; P = .013). Kaplan-Meier analysis revealed that patients with a higher MELD-XI and MELD-Albumin score had a greater risk of adverse outcomes (log-rank test: P < .001). A Cox proportional hazards analysis showed that the modified MELD score remained significantly associated with adverse outcomes after adjusting for clinical and echocardiographic factors (MELD-XI: hazard ratio 1.06, 95% CI 1.02-1.11, P = .006; MELD-Albumin: hazard ratio 1.10, 95% CI 1.05-1.16, P < .001). Furthermore, receiver-operating characteristic analysis indicated that the MELD-Albumin score provided a stronger prognostic value for long-term adverse outcomes in patients undergoing CRT than the MELD-XI score (MELD-Albumin: area under the curve 0.692, 95% CI 0.644-0.742; MELD-XI: area under the curve 0.659, 95% CI 0.608-0.715; P = .008).

Conclusion

The MELD-Albumin score may be useful for stratifying patients at risk for CRT response and adverse outcomes in those undergoing CRT for HF.

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.

Gut Microbiome-Liver-Brain axis in Alcohol Use Disorder. The role of gut dysbiosis and stress in alcohol-related cognitive impairment progression: possible therapeutic approaches

The Gut Microbiome-Liver-Brain Axis is a relatively novel construct with promising potential to enhance our understanding of Alcohol Use Disorder (AUD), and its therapeutic approaches. Significant alterations in the gut microbiome occur in AUD even before any other systemic signs or symptoms manifest. Prolonged and inappropriate alcohol consumption, by affecting the gut microbiota and gut mucosa permeability, is thought to contribute to the development of behavioral and cognitive impairments, leading to Alcohol-Related Liver Disorders and potentially progressing into alcoholic cirrhosis, which is often associated with severe cognitive impairment related to neurodegeneration, such as hepatic encephalopathy and alcoholic dementia. The critical role of the gut microbiota is further supported by the efficacy of FDA-approved treatments for hepatic encephalopathy in alcoholic cirrhosis (i.e., lactulose and rifaximin). To stimulate new research, we hypothesize that interactions between a maladaptive stress response and a constitutional predisposition to neurodegeneration underlie the progression of AUD to conditions of Alcohol-Related Clinical Concerns with severe cognitive impairment, which represent a significant and costly burden to society. Early identification of AUD individuals at risk for developing these conditions could help to prioritize integrated therapeutic interventions targeting different substrates of the Gut Microbiome-Liver-Brain axis. Specifically, addiction medications, microbiome modulators, stress-reducing interventions, and, possibly soon, novel agents that reduce hepatic steatosis/fibrosis will be discussed in the context of digitally supported integrated therapeutic approaches. The explicit goal of this AUD treatment performed on the early stage of the disorder would be to reduce the transition from AUD to those conditions of Alcohol-Related Common Clinical Concerns associated with severe cognitive impairment, a strategy recommended for most neurological neurodegenerative disorders.

Acute alcohol-associated hepatitis: Latest findings in non-invasive biomarkers and treatment

Acute alcohol-associated hepatitis (AH) is a syndrome that occurs in heavy and long-term drinkers and results in severe jaundice and liver failure. The mortality rate in severe cases is 20%-50% at 28 days, and in cases that do not improve despite appropriately timed corticosteroid therapy, the mortality rate reaches 70% at 6 months. The only curative treatment is early liver transplantation, but less than 2% of patients with severe AH are eligible. In order to improve the prognosis, diagnostic tools are needed to detect appropriate cases at risk of severe conditions, and new therapies need to be developed that can replace corticosteroids. Recent research has revealed that the pathogenesis of AH involves a complex of factors, including changes in the gut microbiota, inflammatory and cytokine signalling, oxidative stress and mitochondrial dysfunction, and abnormalities in the hepatic regenerative capacity. Non-invasive diagnostic tools focusing on these specific pathologies have been reported in recent years. In addition, several novel agents targeting specific pathways are currently being developed and tested in clinical trials. This review will provide an overview of alcohol-associated hepatitis and focus on the latest diagnostic tools, particularly non-invasive biomarkers, and novel therapies.

Mechanisms and aetiology-dependent treatment of acute liver failure

This review compiles the mechanisms of acute liver failure (ALF) as well as the current and potential therapeutic approaches, including aetiology-specific treatment, and the issues encountered with such approaches. On a cellular level, ALF is characterized by massive hepatocyte death due to different types of cellular demise. Compensatory hyperplasia and functional recovery are possible when the regenerative capacity is sufficient to sustain hepatic function. ALF has a high mortality of about 30% and can lead to death in a very short time despite maximum therapeutic intervention. Besides aetiology-specific therapy and intensive care, the therapeutic option of emergency liver transplantation has significantly improved the prognosis of patients with ALF. However, due to limiting factors such as organ shortage, many patients die on the waiting list. In addition to graft assessment, machine perfusion may have the potential to recondition marginal organs and thus expand the organ donor pool.

Alcohol-Related Liver Disease, Followed by Metabolic Dysfunction-Associated Steatotic Liver Disease, Emerges as the Fastest-Growing Aetiologies for Primary Liver Cancer in the United States

OBJECTIVE

Primary liver cancer (PLC) is projected to be the third leading cause of cancer mortality in the United States in 2040. We examine the burden of PLC in the United States, stratified by sex, state and aetiological risk factors.

METHODS

Data on PLC prevalence, incidence, death and disability-adjusted life years (DALYs) were extracted from the Global Burden of Disease Study 2021. Changes in these parameters were calculated using the Joinpoint regression model.

RESULTS

There were 47,970 cases, 31,450 incident cases, 24,770 deaths and 576,920 DALYs from PLC in the United States. The highest prevalence (16,980), incidence (12,040), death (9840) and DALYs (213,410) from PLC were due to chronic hepatitis C virus infection. From 2000 to 2021, PLC incidences increased by 141%, and PLC deaths increased by 136%. Age-standardised incidence rates (ASIRs) and death rates (ASDRs) per 100,000 population for PLC increased, primarily driven by alcohol-related liver disease (ALD) (ASIR: annual percent change [APC]: +2.40%; ASDR: APC: +2.22%) and metabolic dysfunction-associated steatotic liver disease (MASLD) (ASIR: APC: +2.32%; ASDR: APC: +2.04%).

CONCLUSION

The burden of PLC in the United States has risen in the past two decades, driven mainly by ALD and followed by MASLD. These findings offer policymakers an accurate assessment of the PLC burden and emphasise the need for targeted risk factor mitigation, especially regarding alcohol related policy.

Pharmacological treatment for metabolic dysfunction-associated steatotic liver disease and related disorders: Current and emerging therapeutic options

Metabolic dysfunction-associated steatotic liver disease (MASLD; formerly known as nonalcoholic fatty liver disease) is a chronic liver disease affecting over a billion individuals worldwide. MASLD can gradually develop into more severe liver pathologies, including metabolic dysfunction-associated steatohepatitis (MASH), cirrhosis, and liver malignancy. Notably, although being a global health problem, there are very limited therapeutic options against MASLD and its related diseases. While a thyroid hormone receptor agonist (resmetirom) is recently approved for MASH treatment, other efforts to control these diseases remain unsatisfactory. Given the projected rise in MASLD and MASH incidence, it is urgent to develop novel and effective therapeutic strategies against these prevalent liver diseases. In this article, the pathogenic mechanisms of MASLD and MASH, including insulin resistance, dysregulated nuclear receptor signaling, and genetic risk factors (eg, patatin-like phospholipase domain-containing 3 and hydroxysteroid 17-β dehydrogenase-13), are introduced. Various therapeutic interventions against MASH are then explored, including approved medication (resmetirom), drugs that are currently in clinical trials (eg, glucagon-like peptide 1 receptor agonist, fibroblast growth factor 21 analog, and PPAR agonist), and those failed in previous trials (eg, obeticholic acid and stearoyl-CoA desaturase 1 antagonist). Moreover, given that the role of gut microbes in MASLD is increasingly acknowledged, alterations in the gut microbiota and microbial mechanisms in MASLD development are elucidated. Therapeutic approaches that target the gut microbiota (eg, dietary intervention and probiotics) against MASLD and related diseases are further explored. With better understanding of the multifaceted pathogenic mechanisms, the development of innovative therapeutics that target the root causes of MASLD and MASH is greatly facilitated. The possibility of alleviating MASH and achieving better patient outcomes is within reach. SIGNIFICANCE STATEMENT: Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common chronic liver disease worldwide, and it can progress to more severe pathologies, including steatohepatitis, cirrhosis, and liver cancer. Better understanding of the pathogenic mechanisms of these diseases has facilitated the development of innovative therapeutic strategies. Moreover, increasing evidence has illustrated the crucial role of gut microbiota in the pathogenesis of MASLD and related diseases. It may be clinically feasible to target gut microbes to alleviate MASLD in the future.

Targeting farnesoid X receptor as aging intervention therapy

Environmental toxicants have been linked to aging and age-related diseases. The emerging evidence has shown that the enhancement of detoxification gene expression is a common transcriptome marker of long-lived mice, Drosophila melanogaster, and Caenorhabditis elegans. Meanwhile, the resistance to toxicants was increased in long-lived animals. Here, we show that farnesoid X receptor (FXR) agonist obeticholic acid (OCA), a marketed drug for the treatment of cholestasis, may extend the lifespan and healthspan both in C. elegans and chemical-induced early senescent mice. Furthermore, OCA increased the resistance of worms to toxicants and activated the expression of detoxification genes in both mice and C. elegans. The longevity effects of OCA were attenuated in Fxr -/- mice and Fxr homologous nhr-8 and daf-12 mutant C. elegans. In addition, metabolome analysis revealed that OCA increased the endogenous agonist levels of the pregnane X receptor (PXR), a major nuclear receptor for detoxification regulation, in the liver of mice. Together, our findings suggest that OCA has the potential to lengthen lifespan and healthspan by activating nuclear receptor-mediated detoxification functions, thus, targeting FXR may offer to promote longevity.

Serial Procalcitonin Measurements for Determining Bacterial Infection and Mortality in Cirrhotic Patients With Systemic Inflammatory Response Syndrome

INTRODUCTION

The utility of serial procalcitonin (PCT) measurements in cirrhotic patients with systemic inflammatory response syndrome (SIRS) is not well understood. The aim of this study was to assess the effectiveness of serial PCT measurements for diagnosing bacterial infections and predicting 30-day mortality in this population.

METHODS

We prospectively studied 120 cirrhotic patients with SIRS, 64.2% of whom had bacterial infections. Serial PCT levels were measured within the first 72 hours of admission.

RESULTS

Patients with bacterial infections had significantly higher PCT levels at admission, 24 hours, and 72 hours compared with those without infections. PCT values >0.5 ng/mL within 72 hours demonstrated high sensitivity (81.8-87.5%) but moderate specificity (27.9-44.2%) for diagnosing bacterial infections. Serial PCT monitoring, including the 72-hr/baseline ratio and changes in PCT over 72 hours, provided insights into the evolution of bacterial infections and short-term mortality. Patients with a PCT 72-hour/baseline ratio >0.8 had higher 30-day mortality than those with a ratio <0.5 (50.0% vs 25.6%; odds ratio 3.91, 95% CI 1.40-10.97). Patients whose PCT levels decreased by >50% had lower 30-day mortality than those with increasing levels (23.3% vs 46.7%; odds ratio 0.25, 95% CI 0.08-0.74). Patients with Model for End-Stage Liver Disease scores >15 and bacterial infections who experienced a PCT decrease of <50% had higher 30-day mortality than those with greater reductions (57.7% vs 25.0%, P = 0.021).

DISCUSSION

Serial PCT measurements within 72 hours of admission are useful for determining bacterial infections and mortality in cirrhotic patients with SIRS. PCT monitoring may optimize antibiotic use and enhance early risk stratification, potentially improving patient outcomes.

A Case Report of a 61-Year-Old Woman With Jaundice and Cholelithiasis Presenting With Autoimmune Hepatitis

Autoimmune hepatitis (AIH) is a complex disease with a chronic cell-mediated immunologic process against healthy liver cells. The clinical presentation can vary since the exact cause of AIH is multifactorial. Here, we report a case of a 61-year-old woman with a past medical history of post-traumatic stress disorder and hypothyroidism who presented clinically with diffuse abdominal distention, nausea, vomiting, jaundice, rash on the torso and legs, and tea-burnt orange urine. The patient underwent an initial workup with a complete blood count (CBC), comprehensive metabolic panel (CMP), and gamma-glutamyl transpeptidase (GGT), with results leading towards a mixed intra- and extrahepatic process. This report will show various findings related to AIH to improve the detection and treatment of these patients early on.

A new human autologous hepatocyte/macrophage co-culture system that mimics drug-induced liver injury-like inflammation

The development of in vitro hepatocyte cell culture systems is crucial for investigating drug-induced liver injury (DILI). One prerequisite for monitoring DILI related immunologic reactions is the extension of primary human hepatocyte (PHH) cultures towards the inclusion of macrophages. Therefore, we developed and characterized an autologous co-culture system of PHH and primary human hepatic macrophages (hepM) (CoC1). We compared CoC1 with a co-culture of the same PHH batch + M0 macrophages derived from THP1 cells (CoC2) in order to represent a donor independent macrophage reaction. Then, we treated the mono- and co-cultures with drugs that cause DILI-menadione (MEN, 1 or 10 µM, 3 h), diclofenac (DIC, 0.5 or 5 mM, 6 h), or acetaminophen (APAP, 0.5 or 5 mM, 6 h)-and assessed culture stability, cell activity, macrophage differentiation, cytokine production and cell viability. Without drug treatment, CoC1 was the most stable over a culture time of up to 60 h. Cytokine array analysis revealed a proinflammatory profile of PHH mono-cultures due to isolation stress but showed different influences of hepM and M0 on the cytokine profile in the co-cultures. MEN, DIC and APAP treatment led to donor-dependent signs of cell stress and toxicity. HepM can either promote or reduce the DILI effects donor dependently in CoC1. CoC2 are slightly less sensitive than CoC1 in representing DILI. In summary, we present a new autologous co-culture system that can mimic DILI in a donor-dependent manner. This cellular system could be useful for new drug testing strategies and reducing animal testing.

Diagnostic accuracy of hepatitis E virus antibody tests: A comprehensive meta-analysis

AIM

Hepatitis E virus (HEV) is a major global health issue, with an estimated 20 million infections annually. Although polymerase chain reaction (PCR) is the diagnostic gold standard due to its precision, it is expensive and technically demanding. Antibody tests offer a more practical and cost-effective alternative, although their accuracy can vary due to factors, such as test manufacturer, antigen composition, HEV genotype, and host immune status.

METHODS

A comprehensive search was conducted in PubMed, Cochrane, Scopus, and Web of Science databases. Studies included comparing the sensitivity and specificity of immunoglobulin M or immunoglobulin G antibody tests to PCR. Exclusion criteria were non-PCR comparisons, sample sizes under 10, IgA or antigen tests, non-human samples, or missing sensitivity and specificity data. Only English-language full-texts or abstracts were considered. Data analysis was performed using Meta-DTA v2.1.1 and Stata 16.0.

RESULTS

The meta-analysis evaluated 8054 blood samples from 21 studies. Immunoglobulin M antibody tests demonstrated an overall sensitivity of 83% (95% CI 76-88) and specificity of 98% (95% CI 97-99). Immunoglobulin G tests showed a sensitivity of 74% (95% CI 62-82) and specificity of 89% (95% CI 84-93). Among manufacturers, Wantai was the most accurate for immunoglobulin M detection, whereas MP led for immunoglobulin G. Notably, test sensitivity improved when the test protein genotype aligned with the HEV genotype.

CONCLUSION

This meta-analysis confirmed that antibody assays have a good sensitivity and high specificity to detect HEV infection in situations where PCR is not feasible, highlighting their potential as a practical diagnostic tool.

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.

Clinical and laboratory characteristics of Sjögren's syndrome-associated autoimmune liver disease: a real-world, 10-year retrospective study

OBJECTIVES

To investigate the clinical and laboratory features of Sjögren's syndrome-associated autoimmune liver disease (SS-ALD) patients and identify potential risk and prognostic factors.

METHODS

SS patients with or without ALD, who visited Tongji Hospital between the years 2011 and 2021 and met the 2012 American College of Rheumatology (ACR) classification criteria for Sjögren's syndrome, were retrospectively enrolled. The clinical and laboratory data of the enrolled patients, including autoimmune antibodies, were collected and analyzed with principal component analysis, correlation analysis, LASSO regression, and Cox regression.

RESULTS

A total of 117 SS-ALD patients were confirmed out of 568 SS patients. Compared to SS-non-ALD patients (n = 451), SS-ALD patients exhibited more severe involvement of the hepatic and hematologic systems, albeit with less pronounced typical SS symptoms. Disease activity was higher in SS-ALD patients, as indicated by elevated ESR, CRP, and IL-6 levels, particularly in the SS-overlap subgroup. Furthermore, SS-AIH patients without AIH-specific autoantibody testing or with negative testing results had higher AST and ALT levels than those who were autoantibody-positive. Our predictive model, incorporating IgG, IgM, AST, GGT, ALT, and C4, effectively identified ALD complications in SS patients, achieving an AUC of 0.924. Additionally, a grimmer prognosis was associated with higher baseline AST and ALT levels.

CONCLUSIONS

SS-ALD patients often manifest with an insidious onset and atypical SS symptoms, yet frequently exhibit severe systemic involvement, intense inflammatory and immune responses, and a poor prognosis. To improve the clinical outcomes in SS-ALD patients, regular monitoring, early identification, and active treatment should be applied. Key Points • The study provided a detailed profile of clinical and laboratory features of SS-ALD and SS-non-ALD patients, contributing to a predictive model of ALD complications in SS patients • SS-ALD patients manifested with an insidious onset but exhibited severe systemic involvement, robust inflammatory and immune responses, and poor prognosis • SS-AIH patients without available testing for AIH-specific autoantibodies or with negative results demonstrated worse liver function, thus routine screening for autoimmune liver antibodies is recommended in SS patients • More severe baseline liver function status was associated with poorer therapeutic responses to routine medications, so early detection and timely intervention are essential for SS patients.

Management of the acute on chronic liver failure in the intensive care unit

Acute on chronic liver failure (ACLF) reflects the development of organ failure(s) in a patient with cirrhosis and is associated with high short-term mortality. Given that ACLF has many different 'phenotypes', medical management needs to take into account the relationship between precipitating insult, organ systems involved and underlying physiology of chronic liver disease/cirrhosis. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (e.g. infection, severe alcoholic hepatitis and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo liver transplantation or recovery. Management of these patients is complex since they are prone to develop new organ failures and infectious or bleeding complications. ICU therapy parallels that applied in the general ICU population in some complications but differs in others. Given that liver transplantation in ACLF is an emerging and evolving field, multidisciplinary teams with expertise in critical care and transplant medicine best accomplish management of the critically ill ACLF patient. The focus of this review is to identify the common complications of ACLF and to describe the proper management in critically ill patients awaiting liver transplantation in our centres, including organ support, prognostic assessment and how to assess when recovery is unlikely.

Statin Therapy is Associated With Lower Risk of Mortality Among Liver Transplant Candidates With Metabolic Dysfunction-associated Steatohepatitis

Background

Statin therapy is historically underutilized in patients with chronic liver disease. There is increasing evidence to support the use of statins in patients with cirrhosis, though data in decompensated patients are limited. The primary aim of this study was to evaluate the association between statin use and mortality in patients with advanced liver disease, comparing MASH and non-MASH cirrhosis.

Methods

This single-center retrospective cohort study included patients undergoing liver transplant (LT) evaluation at a large quaternary care center. Patients were categorized by etiology as metabolic dysfunction-associated steatohepatitis (MASH) or non-MASH cirrhosis. Statin use was defined as having an active prescription at the time of LT evaluation. The association between statin use and mortality was evaluated using multivariable Cox proportional hazard regression.

Results

The study included 623 patients; 24% had MASH cirrhosis and 20% were prescribed a statin. Statin users were older, had a higher BMI, and were more likely to have coronary artery disease. At the end of the study, statin use was associated with lower mortality among MASH patients (16% vs. 35%, P = 0.010) and higher mortality among non-MASH patients (31% vs. 19%, P = 0.066). After controlling for age (HR 1.05, 95% CI: 1.00-1.10, P = 0.039), MELD-Na (HR: 1.07, 95% CI: 1.04-1.11, P < 0.001), BMI (HR: 1.09, 95% CI: 1.05-1.14, P < 0.001), and CAD (HR: 1.20, 95% CI: 0.54-2.69, P = 0.653), statin use conferred a 53% lower risk of death compared with no statin use in patients with MASH cirrhosis (HR: 0.47, 95% CI: 0.22-0.98, P = 0.043).

Conclusions

Statin use was associated with reduced mortality in patients with decompensated MASH cirrhosis undergoing LT evaluation, but increased mortality in those with non-MASH cirrhosis, particularly those with high-MELD-Na. These findings underscore the importance of reviewing individual patient characteristics and disease etiology when considering the benefits of statin therapy in patients with cirrhosis.

Cost Effectiveness of Tremelimumab Plus Durvalumab for Unresectable Hepatocellular Carcinoma in the USA

BACKGROUND

Treating unresectable hepatocellular carcinoma (uHCC) is challenging. Clinical trials have shown that Single Tremelimumab Regular Interval Durvalumab (STRIDE) offers clinical benefits as a first-line treatment for uHCC, but its cost effectiveness remains unknown in the USA.

OBJECTIVE

We aimed to assess the cost effectiveness of STRIDE (tremelimumab plus durvalumab) versus sorafenib and durvalumab monotherapy as the first-line treatment for uHCC in the USA.

METHODS

A partitioned survival model was constructed to assess the cost effectiveness of STRIDE compared to sorafenib and durvalumab monotherapy as the first-line treatment for uHCC from the US societal perspective. The time horizon was 48 months with 1-month cycles. Seven parametric survival functions replicated survival curves from clinical trials, with the best-fitting model used to calculate survival probabilities. Costs, health utilities, and adverse events were included, with quality-adjusted life-years (QALYs) as the primary effectiveness measure. Both costs and effectiveness were discounted at 3%. In the base-case analysis, the incremental cost-effectiveness ratio was compared to a willingness-to-pay threshold of $150,000 per QALY gained. Deterministic and probabilistic sensitivity analyses were conducted to examine the uncertainty of the model.

RESULTS

In the base-case analysis, STRIDE was cost effective compared to sorafenib, with an incremental cost-effectiveness ratio of $97,995.51 per QALY gained, based on a willingness-to-pay threshold of $150,000 per QALY gained. However, STRIDE was not cost effective compared to durvalumab monotherapy at the same threshold, with an incremental cost-effectiveness ratio of $754,408.92 per QALY gained. Deterministic sensitivity analyses were consistent with the base-case analysis. A probabilistic sensitivity analysis indicated that STRIDE was more likely to be cost effective than sorafenib and durvalumab monotherapy when the willingness-to-pay exceeded $101,000 and $713,000, respectively.

CONCLUSIONS

The STRIDE regimen appears to be cost effective compared to sorafenib but not compared to durvalumab for first-line uHCC treatment in the USA. However, durvalumab has not yet been approved for uHCC in the USA. Future research should focus on long-term data and economic evaluations of other recommended biologics.

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.

Meta-Analysis of Placebo-Treated Patients: Dropout Rates From Treatment in MASH Randomised Controlled Trials

BACKGROUND

Dropout is common and affects the statistical power and randomization balance of randomised controlled trials (RCTs).

AIMS

To estimate the dropout rate in RCTs of metabolic dysfunction-associated steatohepatitis (MASH) and to examine factors associated with dropout in placebo-treated participants.

METHODS

PubMed and Cochrane databases were searched for phase 2-4 MASH RCTs with placebo arms through November 24, 2024. Dropout was defined as the attrition of patients included in the intention-to-treat analysis but did not complete treatment. RCTs were qualitatively reviewed to assess the expected and observed dropouts. Generalised linear mixed model was used to estimate pooled dropout rates.

RESULTS

Sixty RCTs with 3230 placebo-treated participants with MASH were analysed. Thirty-three RCTs reported the dropout rate used to estimate the effect size. Of these, 60.6%, 36.4%, and 3.0% had an expected dropout rate that was higher, lower, and similar, respectively, than the observed dropout rate in the placebo arm. Overall, the dropout rate was 11.06% (95% confidence interval [CI] 9.07 to 13.42), with a higher rate in phase 3-4 trials than in phase 2 trials. The corresponding rates due to adverse events, loss to follow-up and patient choice were 2.41% (95% CI 1.67 to 3.48), 1.79% (95% CI 1.06 to 2.99) and 4.06% (95% CI 2.97 to 5.53), respectively. Meta-regression determined that the dropout rate increased with longer treatment duration.

CONCLUSION

Placebo dropout in MASH RCTs is significant, mainly due to patient choice. Factors such as trial phase and treatment duration should be considered when calculating sample size in future clinical trials.

Clinical Assessment of Common Medications for Nonalcoholic Fatty Liver Disease: A Systematic Review and Bayesian Network Meta-Analysis

OBJECTIVE

With a steadily rising prevalence, nonalcoholic fatty liver disease (NAFLD) was a leading global cause of liver-related health problems. In the clinical management of NAFLD, various western pharmaceuticals were widely utilized. This network meta-analysis aimed to evaluate the effectiveness of common western medications for NAFLD patients.

METHODS

We systematically reviewed and screened articles based on predesigned criterion about western medications for NAFLD, which were from Embase, Cochrane Library, PubMed, CNKI, WanFang, and China Science and Technology Journal Database until August 1, 2024. Eligible studies included randomized controlled trials of patients aged 18 or older with NAFLD, comparing Western medicines to placebos or other Western medicine treatments. The risk of bias assessment tool 2.0 from the Cochrane system was used to assess the quality of the included articles. A Bayesian network meta-analysis was conducted using WinBUGS 1.4.3 with a random-effects model and Markov Chain Monte Carlo methods. Treatment rankings were based on Surface Under the Cumulative Ranking Curve (SUCRA) values, and heterogeneity was assessed with I2 and Q statistics. The outcomes were analyzed in WinBUGS and visualized using Stata 14.0, generating network plots and cumulative probability rankings to compare treatment effects. The systematic review was registered in PROSPERO (CRD42024509176).

RESULTS

Based on 37 included articles involving 7673 patients, pioglitazone demonstrated the most significant effects in resolving nonalcoholic steatohepatitis without worsening fibrosis, increasing high-density lipoprotein cholesterol levels, and achieving a ≥ 2-point reduction in NAFLD activity scores (odds ratio [OR] = 0.09, 95% confidence interval [CI]: 0.01 to 0.81), with a SUCRA probability of 91.4%. Aldafermin showed remarkable effects in improving liver function markers, including alanine aminotransferase (ALT), aspartate aminotransferase (AST), and γ-glutamyl transpeptidase, with cumulative probabilities of 90% for ALT and 69.8% for AST. Cluster analysis revealed that Resmetirom and Aldafermin were superior options for enhancing liver function, while pioglitazone emerged as the best treatment for the comprehensive improvement of NAFLD.

CONCLUSIONS

Pioglitazone outperformed other western medicines in terms of overall efficacy when treating NAFLD, but Aldafermin and Resmetirom showed superior improvement in liver function. This study provided a certain level of support for the use of specific clinical medications.

Enhancing the Therapeutic Efficacy of Berberine and Quercetin Through Salt Formulation for Liver Fibrosis Treatment

Liver fibrosis, caused by chronic hepatic injury, is a major threat to human health worldwide, as there are no specific drugs available for its treatment. Natural compounds, such as berberine (BBR) and quercetin (QR), have shown the ability to regulate energy metabolism and protect the liver without significant adverse effects. Additionally, combination therapy (the cocktail therapy approach), using multiple drugs, has shown promise in treating complicated conditions, including liver injury. In this study, we prepared a salt formulation of BBR and QR (BQS) to enhance their combined effect on liver fibrosis. The formation of BQS was confirmed using various analytical techniques, including nuclear magnetic resonance spectroscopy (NMR), differential scanning calorimetry (DSC), Fourier-transform infrared spectroscopy (FTIR), powder X-ray diffractometry (PXRD), and scanning electron microscopy (SEM). The results demonstrated that the dissolution efficiency and bioavailability of QR significantly increased in the BQS form, aligning with that of BBR, compared to the physically mixed (BQP) form. Moreover, BQS exhibited a superior inhibitory effect on fibrosis compared to BQP in the human hepatic stellate cell line LX-2 by modulating lipid accumulation, inflammation, apoptosis, and the cell cycle. Furthermore, in a mouse model of hepatic fibrosis induced by methionine and choline-deficient (MCD) diets, BQS demonstrated enhanced anti-fibrotic activities compared to BQP. These findings suggest that BQS holds promise as a potential alternative treatment for liver fibrosis. Importantly, this study provides novel insights into achieving a cocktail effect through the salt formation of two or more drugs. The results highlight the potential of salt formulations in enhancing the therapeutic efficacy and consistent biological processes of drug combinations.

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.

Biochar for mitigating pharmaceutical pollution in wastewater: A sustainable solution

Pharmaceutical contaminants (PCs), including antibiotics, analgesics, and other medications, pose a growing threat to aquatic ecosystems and human health due to their persistence and bioaccumulation potential. Biochar, a carbonaceous material derived from biomass pyrolysis, has emerged as a sustainable adsorbent for removing PCs from wastewater. Biochar is reported to remove PCs from water with an average range of 58 to 91 %, depending on the nature of feedstock, pyrolysis conditions, and characteristics of the pharmaceuticals. Biochar's effectiveness is attributed to its unique properties, including high porosity, large surface area and diverse functional groups, which enable the adsorption of various pharmaceutical compounds through physical and chemical interactions. Common PCs such as tetracycline, ciprofloxacin, ibuprofen, paracetamol, sulfamethoxazole, and cephalexin can be effectively removed using biochar. The adsorption process involves different mechanisms such as Van der Waals forces, electrostatic interactions, hydrogen bonding, and surface complexation. This review summarizes the current state of knowledge on biochar-based adsorption mechanisms, highlights successful applications in wastewater treatment, and identifies areas for future research. While promising, a deeper understanding of adsorption mechanisms, optimization of biochar production, and the development of effective regeneration methods are crucial for maximizing biochar's efficacy and ensuring its sustainable implementation in wastewater treatment systems.

Expanding Indications in Transplant Oncology

Liver transplantation is aptly described as the only curative treatment for cirrhosis and cirrhosis with co-morbid hepatocellular carcinoma (HCC). Its utility in the management of various other primary and secondary liver cancers is gaining traction rapidly, with more thorough assessments on broader populations continuing to emerge. Most prominently, this includes colorectal cancer liver metastasis (CRLM), cholangiocarcinoma (CCA), neuroendocrine tumors (NETs), and more. Furthermore, despite being a well described treatment for HCC for many years, growing evidence supports a change in oncological strategy for HCC, with broadened selection criteria and more advanced systemic and locoregional therapies available. Our review aims to describe the evidence supporting the expansion of indications and selection criteria for liver transplantation in various oncologic indications of primary and secondary liver tumors.

Real-World Setting of Efficacy and Safety of 3 Years of Rifaximin Administration in Japanese Patients with Hepatic Encephalopathy: A Multicenter Retrospective Study

Background/Objectives: Rifaximin is a therapeutic agent for patients with hepatic encephalopathy (HE); however, there is little data on the effects of its long-term (>1 year) administration in Japanese patients with cirrhosis. The effects and safety of 3-year rifaximin treatment on HE was investigated in Japan. Methods: A total of 190 Japanese patients with cirrhosis who were continuously administered rifaximin for more than 1 year suffered overt or covert HE, which was diagnosed by a physician. Laboratory data were collected at baseline, 3, 6, 12, 18, 24, 30, and 36 months following rifaximin administration. We examined the cumulative overt HE incidences, overall survival rates, and hepatic functional reserves following rifaximin treatment. The occurrence of adverse events was also assessed. Results: The levels of ammonia improved significantly after 3 months of rifaximin administration, which continued for 3 years. Serum albumin and prothrombin activity also significantly improved 3 years after initiation of rifaximin treatment. Cumulative overt HE incidences were 12.1%, 19.7%, and 24.9% at 1, 2, and 3 years, respectively. The survival rates following rifaximin treatment were 100%, 88.9%, and 77.8% at 1, 2, and 3 years, respectively. In contrast, renal function and electrolytes did not change following rifaximin administration. Only three (1.6%) patients discontinued rifaximin therapy because of severe diarrhea after 1 year of rifaximin administration. No other serious adverse events were observed. Conclusions: Three years of continuous rifaximin (RFX) treatment was both effective and safe for patients with hepatic encephalopathy. Liver function improved and did not worsen during treatment.

Role of 11β-hydroxysteroid dehydrogenase type 1 inhibition in the antiobesity effect of J2H-1702 on adipocytes and a high-fat diet-induced NASH model

Obesity due to excessive body fat accumulation remains a global problem. Patients with obesity have high cortisol levels, and its dysregulation is caused by increased 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) levels. The effects and mechanism of J2H-1702, an 11β-HSD1 inhibitor, on nonalcoholic steatohepatitis (NASH) were explored. This study compared the antiadipogenic effects of J2H-1702, elafibranor (PPARα/δ agonist), and BVT14225 (selective 11β-HSD1 inhibitor) using mouse 3T3-L1 pre-adipocytes. J2H-1702, elafibranor, and BVT14225 inhibited adipocyte differentiation and intracellular lipid accumulation in 3T3-L1 cells by downregulating phospho-extracellular signal-regulated kinase, extracellular signal-regulated kinase, phospho-c-Jun-N-terminal Kinase, c-Jun-N-terminal Kinase, phospho-P38 (P-P38), P38, CCAAT/enhancer-binding proteins alpha and β, peroxisome proliferator-activated receptor γ, and glucocorticoid receptor. Additionally, J2H-1702, elafibranor, and BVT14225 treatments effectively inhibited 11β-HSD1 activity, as revealed by cortisol concentrations, and inhibited cortisone-induced adipocyte differentiation and intracellular lipid accumulation in 3T3-L1 cells. These effects were associated with 11β-HSD1 protein inhibition. Furthermore, J2H-1702 and BVT14225 increased the expression of Akt and phosphoinositide 3-kinase involved in insulin resistance in 3T3L-1 adipocytes. In the LX-2 human hepatic stellate cell line, the relative expression of N-cadherin, 11β-HSD1, collagen1α (COLA1), α-actin of smooth muscle (α-SMA) genes in LX-2 activated with TGF-β increased significantly, and after treatment with J2H-1702, it was significantly reduced. The expression of E-cadherin is decreased in TGF-β-treated LX-2 cells and increased after treatment with J2H-1702. We tested the potential of J2H-1702 as a therapeutic agent for NASH using a high-fat diet-induced NASH model, with obeticholic acid, an FXR agonist, and elafibranor as reference drugs. All drugs significantly decreased the elevated triglyceride levels in the livers of high-fat, high-carbohydrate (HFHC-fed mice. The results may add to the benefits of targeting 11β-HSD1 inhibitors with antiadipogenic activity in developing a therapeutic agent for obesity treatment.

Causal link between dietary antioxidant vitamins intake, oxidative stress injury biomarkers and colorectal cancer: A Mendelian randomization study

Oxidative stress and reactive oxygen species play a pivotal role in carcinogenesis. Recent studies have indicated a potential reduction in cancer incidence associated with antioxidant intake; however, these results remain controversial. We performed 2-sample Mendelian randomization (MR) analysis to explore the causal relationship between dietary antioxidant vitamins (retinol, carotene, vitamin C, and vitamin E), oxidative stress injury biomarkers (GST, CAT, SOD, and GPX), and the risk of colorectal cancer (CRC). The genetic instrumental variants (IVs) that had previously shown significant association with dietary antioxidant vitamins and oxidative stress injury biomarkers were screened from the UK Biobank and relevant published studies. The genome-wide association study (GWAS) data for total colorectal, colon, and rectal cancer were obtained from the FinnGen cohort. The primary MR analysis employed the inverse-variance-weighted (IVW) method. Furthermore, sensitivity analysis was performed to assess heterogeneity and horizontal pleiotropy. The results revealed no significant causal associations between dietary antioxidant vitamins, oxidative stress injury biomarkers, and the risk of CRC. The odds ratios (ORs) were as follows: 1.22 (95% confidence interval (CI): 0.65-2.28, P = .53) for retinol, 0.77 (95% CI: 0.50-1.18, P = .24) for carotene, 0.82 (95% CI: 0.42-1.63, P = .58) for vitamin C, and 1.20 (95% CI: 0.86-1.68, P = .28) for vitamin E. Regarding oxidative stress injury biomarkers, the ORs were 0.99 (95% CI: 0.93-1.06, P = .88) for GST, 0.99 (95% CI: 0.93-1.05, P = .65) for CAT, 1.02 (95% CI: 0.95-1.09, P = .57) for SOD, and 1.01 (95% CI: 0.95-1.07, P = .76) for GPX. Likewise, stratified analysis by tumor site revealed no beneficial effects in colon and rectal cancers. Our findings indicate that elevated levels of diet-related antioxidant vitamins, as well as biomarkers of oxidative stress injury, do not provide a protective effect against CRC risk.

Procalcitonin and presepsin for detecting bacterial infection and spontaneous bacterial peritonitis in cirrhosis: A systematic review and meta-analysis

BACKGROUND

Diagnosing bacterial infections (BI) in patients with cirrhosis can be challenging because of unclear symptoms, low diagnostic accuracy, and lengthy culture testing times. Various biomarkers have been studied, including serum procalcitonin (PCT) and presepsin. However, the diagnostic performance of these markers remains unclear, requiring further informative studies to ascertain their diagnostic value.

AIM

To evaluate the pooled diagnostic performance of PCT and presepsin in detecting BI among patients with cirrhosis.

METHODS

We performed a systematic search of the MEDLINE, EMBASE, and Scopus databases for studies that evaluated the diagnostic role of PCT and presepsin from inception to June 2024. Sensitivity and specificity values were pooled using a random effects model. BI was diagnosed based on clinical manifestations, physical examination, laboratory data, and radiological findings.

RESULTS

Of the 6639 articles retrieved, 28 met the inclusion criteria and included 4287 patients with 1789 cases of BI (41.7%). The bivariate pooled sensitivity and specificity estimates of PCT for BI diagnosis were 0.73 [95% confidence interval (CI): 0.64-0.81] and 0.83 (95%CI: 0.79-0.87), respectively. The diagnostic odds ratio (DOR) of PCT was 17.21 (95%CI: 9.57-30.95). Presepsin showed a pooled sensitivity of 0.75 (95%CI: 0.60-0.86), specificity of 0.80 (95%CI: 0.68-0.88), and DOR of 12.33 (95%CI: 5.10-29.83) for diagnosing BI. The pooled sensitivity and specificity of PCT for diagnosing spontaneous bacterial peritonitis (SBP) were 0.76 (95%CI: 0.67-0.84) and 0.87 (95%CI: 0.78-0.92), respectively. The positive likelihood ratio of PCT was 5.57 (95%CI: 3.34-9.29), which was sufficiently indicative of SBP. The DOR of PCT was 29.50 (95%CI: 12.30-70.80).

CONCLUSION

PCT and presepsin have high sensitivity and specificity for detecting BI in patients with cirrhosis. Furthermore, PCT has good diagnostic value as a rule-in test for SBP diagnosis.

Does a changing donor pool explain the recent rise in the United States kidney nonuse rate?

The proportion of deceased donor kidneys recovered for transplantation that are not transplanted reached 28% in 2023. Past research demonstrated that >90% of the nonuse rate (NUR) increase in the 2000s could be explained by the broadening donor pool. We used the Organ Procurement and Transplantation Network data to study kidneys recovered from 2010-2023, applying causal inference methods to assess the degree to which the recent, sharp rise in the NUR could be explained by changes in donor clinical characteristics. Unadjusted odds of kidney nonuse were 63% higher (95% CI: 56%, 70%) in 2023 vs 2018. After adjusting for donor factors, the odds of nonuse were only 12% (9%, 15%) higher in 2023. Both regression and propensity weighting demonstrated that 75% to 80% of the recent NUR increase can be explained by a rapidly expanding donor pool. Encouragingly, the NUR has not increased and remains low for above-average quality kidneys. However, the unexplained risk of nonuse for kidneys in the highest kidney donor risk index quartile increased by ∼ 30%, potentially due to residual confounding and/or system-level, exogenous factors such as allocation policy changes. To improve placement efficiency, allocation policy should adapt to the increasingly heterogeneous donor pool by allocating kidneys differently along the donor quality spectrum.

Cepharanthine relieves nonalcoholic steatohepatitis through inhibiting STAT1/CXCL10 axis-mediated lipogenesis and inflammatory responses

ETHNOPHARMACOLOGICAL RELEVANCE

Stephania rotunda Lour., a medicinal herb, has been utilized in both Traditional Chinese Medicine (TCM) and Traditional Indian Medicine to treat conditions such as fever, dysentery, and inflammation. Cepharanthine (CEP), a primary active ingredient of Stephania rotunda Lour., has demonstrated a range of pharmacological activities, including anti-oxidative, anti-inflammatory, anti-cancer, anti-viral and anti-parasitic properties. However, the effects and underlying mechanisms of CEP on improving nonalcoholic steatohepatitis (NASH) remain unclear.

AIM OF THE STUDY

This study aimed to investigate the effects of CEP on mitigating diet-induced NASH and explore its underlying mechanisms.

MATERIALS AND METHODS

A High-Fat Diet (HFD) and the high levels of free fatty acids (FFA) were used to establish in vivo and in vitro NASH models to evaluate the intervention effect of CEP. Subsequently, RNA-sequencing, western blotting, quantitative real-time PCR (qRT-PCR) and siRNA transfection were employed to investigate its underlying mechanisms.

RESULTS

Our findings indicated that CEP significantly reduced lipogenesis and inflammatory responses in both HFD-fed rats and FFA-induced hepatic cells (including HepG2, L02 and AML12 cell lines), as is evidenced by the reduction of triglyceride (TG), lipid accumulation, and the release of inflammatory cytokines such as TNF-α, IL-6 and IL-1β. Mechanistically, CEP significantly inhibits CXC motif chemokine ligand 10 (CXCL10) expression both in vivo and in vitro. It also regulates sterol regulatory element binding protein-1c (SREBP1c)-induced lipogenic gene expression and CXCL10-mediated nuclear factor kappa B (NFκB) activation. Notably, knockdown of CXCL10 mimics the ability of CEP to reduce lipid accumulation and inflammatory responses, which is also observed following the blockade of signal transducer and activator of transcription 1 (STAT1) in HepG2 cells.

CONCLUSION

CEP alleviates NASH by inhibiting lipogenesis and inflammatory responses in a STAT1/CXCL10 axis-dependent manner.

Artemisia capillaris Thunb. Water extract alleviates metabolic dysfunction-associated Steatotic liver disease Disease by inhibiting miR-34a-5p to activate Sirt1-mediated hepatic lipid metabolism

ETHNOPHARMACOLOGICAL RELEVANCE

Artemisia capillaris Thunb. (ACT) is a plant in the Asteraceae family. Its traditional effects are to clear away dampness and heat, promote gallbladder and reduce jaundice. Traditional Chinese medicine believes that MASLD is a damp-heat syndrome. The group's previous study showed that Artemisia capillaris Thunb. Water Extract (ACTE) has an improved effect on MASLD.

AIM OF THE STUDY AND METHODS

In order to further understand its mechanism of action, this study established a mouse MASLD model and a HepG2 cell lipid droplet model, combined small RNA sequencing and miRNA transfection experiments, to explore the mechanism of ACTE to improve MASLD by modulating miRNA-targeted mRNA. Non-targeted metabolomics method was used to detect and analyze ACTE.

RESULTS

This study screened miR-34a-5p and confirmed its target mRNA-Sirtuin 1 (Sirt1). MASLD induced high expression of miR-34a-5p and low expression of Sirt1, and ACE reversed these changes. When overexpressing miR-34a-5p or knocking down Sirt1, the effect of ACE in reducing PO (palmitic acid and oleic acid complex)-induced lipid accumulation in HepG2 cells was attenuated. ACTE reduces the expression of FASN, SCD1, ACC, and SREBP-1c, promotes the expression of CPT-1 and HSL, thereby reducing lipid accumulation.

CONCLUSIONS

ACTE activates Sirt1 by inhibiting the expression of miR-34a-5p, thereby reducing liver lipid accumulation and improving HFD-induced MASLD. These findings highlight the potential of ACTE in reducing weight, controlling obesity, and improving lipid metabolism disorders.

Ferulic acid from Angelica sinensis (Oliv.) Diels ameliorates lipid metabolism in alcoholic liver disease via AMPK/ACC and PI3K/AKT pathways

ETHNOPHARMACOLOGICAL RELEVANCE

Angelica sinensis (Oliv.) Diels is a well-known traditional medicinal plant. In China, it is a common blood tonic drug that has been inherited for thousands of years. There is a consensus that Angelica sinensis (Oliv.) Diels has a protective effect against various liver diseases. However, the effects and mechanisms of Angelica sinensis (Oliv.) Diels and its active components on alcoholic liver disease (ALD) have not been clearly defined yet.

AIM OF THE STUDY

The aim of this study is to evaluate the effect and explore the mechanism of ferulic acid (FA) from Angelica sinensis (Oliv.) Diels ameliorates lipid metabolism in ALD.

METHODS

C57BL/6 mice were fed ethanol-containing liquid feeds to establish ALD model in vivo. The lipid metabolism-related indexes were detected by kits, H&E staining and oil red O staining were used to analyze liver histopathological changes and fat deposition, to evaluate the protective effect of water extraction and ethanol precipitation of Angelica sinensis radix (WEEPAS) on ethanol-induced liver injury. The active components and potential targets of Angelica sinensis (Oliv.) Diels for ALD were screened by network pharmacology and molecular docking. Ethanol was co-incubated with HepG2 cells to construct the ALD model in vitro, then the same approaches were used to explore the effect of FA for ALD in vivo and in vitro. The levels of proteins and mRNA related to AMPK/ACC and PI3K/AKT pathways were detected by Western Blotting and RT-qPCR.

RESULTS

WEEPAS could protect mice from ethanol-induced liver tissues injury by ameliorating fat deposition and inhibiting oxidative stress response. Network pharmacology and molecular docking results suggested that FA might be the main bioactive component in Angelica sinensis (Oliv.) Diels for ALD, and its mechanism might be related to the regulation of AMPK and PI3K/AKT signaling pathways. In vitro and in vivo experiments further demonstrated that FA regulated lipid metabolism via AMPK/ACC and PI3K/AKT pathways, thereby ameliorating ethanol-induced liver tissues injury and lipid metabolism disorders in HepG2 cells and mice, which were consistent with the network pharmacology results.

CONCLUSION

In summary, the results indicated that FA from Angelica sinensis (Oliv.) Diels was able to ameliorate ethanol-induced ALD. The mechanism may be related to the regulation of lipid metabolism via AMPK/ACC and PI3K/AKT pathways.

NANOTECHNOLOGY-DRIVEN THERAPEUTICS FOR LIVER CANCER: CLINICAL APPLICATIONS AND PHARMACEUTICAL INSIGHTS

Hepatocellular carcinoma (HCC) represents a significant threat to global health and is responsible for significant mortality rates worldwide. Conventional treatment options such as surgery and chemotherapy have inherent limitations. In order to remedy these deficits, the development of novel therapeutic strategies is essential. Nanomedicines have shown promise in HCC treatment as they offer improved stability, controlled release, and increased drug loading capacity. This review explores the application of nanoconstructs in HCC treatment, including active and passive targeting strategies. In addition, liver cell targeting approaches, targeting moieties, and conjugation chemistry for surface functionalization are investigated. A compact overview of various therapeutic approaches to HCC treatment is also given.

Proteomics-guided Biomarker Discovery, Validation, and Pathway Perturbation in Infection-related Acute Decompensation of Cirrhosis

BACKGROUND & AIMS

Inappropriate treatment of infections fuels drug resistance, organ failures, and costs in cirrhosis. We explored proteomics to improve infection diagnosis and management in acutely decompensated (AD) cirrhosis.

METHODS

We enrolled 391 patients with AD cirrhosis (92% males, median-age: 41 years), 84 in the discovery cohort (54 infected, 30 non-infected), 147 in the validation cohort I (106 infected, 41 non-infected), and 160 in the validation cohort II (108 infected, 52 non-infected). High-throughput proteomics identified biomarkers in the discovery cohort, validated through enzyme-linked immunoassay in subsequent cohorts. A model for infection was evaluated through discrimination, calibration, and decision curves and was externally validated.

RESULTS

Infected patients exhibited higher leucocyte counts, procalcitonin, organ failures, Model for End-stage Liver Disease scores, and 30-day mortality (P < .001 each). Proteomics identified 516 proteins, 27 upregulated and 38 downregulated, in infections. LGALS3BP, PLTP, CFP, and GPX3 were independently linked to infections (adjusting for severity and systemic inflammatory response syndrome), with composite area under the receiver operating characteristic curve (AUC) of 0.854 (95% confidence interval [CI], 0.787-0.922) in validation cohort I. A PACIFY model (LGALS3BP + procalcitonin + CLIF-COF + lactate) predicted infections with AUC of 0.965 (95% CI, 0.933-0.997) and 0.906 (95% CI, 0.860-0.952) in validation cohorts I and II, outperforming procalcitonin, systemic inflammatory response syndrome, white blood cell, neutrophil-to-lymphocyte ratio, neutrophil %, and composite models (P < .001). The model demonstrated fair calibration, with decision curves indicating a net benefit of the model in treating infections and reducing unnecessary antimicrobial use. Consistent findings were observed on external validation (AUC, 0.949; 95% CI, 0.916-0.982), re-enforcing the accuracy and clinical utility of the model. A deployable app was developed for infection risk estimation, enhancing practical applicability. Impaired phagocytosis, complement functions, hypocoagulation, hypofibrinolysis, dysregulated carbohydrate metabolism, autophagy, heightened cell death, and proteolysis were key perturbed pathways in infections.

CONCLUSION

The study identifies novel protein signatures and pathways linked with infections in AD cirrhosis. A biomarker-guided treatment of infections can limit unnecessary antimicrobial use and the burden of drug resistance in cirrhosis.

Immunosuppressive treatment in autoimmune decompensated cirrhosis, when to say enough: A retrospective analysis

Immunosuppressive therapy in decompensated cirrhotic patients with an indication for liver transplantation (LT) is controversial. This study aims to evaluate transplant-free survival rates in patients diagnosed with decompensated autoimmune hepatitis (AIH) with and without immunosuppressants (IS) treatment, and to identify predictors of mortality or LT. We retrospectively analyzed LT-evaluated consecutive patients with decompensated AIH at a single center, between 2013 and 2021. Patients were categorized into IS (IS Group) and non-IS (No IS Group). Survival curves for the 2 groups were evaluated using the Kaplan-Meier method, and differences were compared using the Log-rank test. Multiple regression analysis was conducted using Cox test. A total of 125 consecutive patients (mean age: 36.4 years; 81.6% female) were evaluated. The median transplant-free survival in the IS Group (72/125) were 22.6 months vs 6.57 months in the No IS Group (53/125) (P = .002). Cox-regression analysis revealed associations between moderate/severe ascites (hazard ratio [HR] = 2.37, 95% CI = 1.48-3.80, P = <.001) and MELD-Na (HR = 1.12, 95% CI = 1.08-1.16, P = <.001) with transplantation or death, while immunosuppression treatment acted protectively (HR = 0.55, 95% CI = 0.86-0.85, P = .008). Analyzing patients with MELD >22 (27/125) showed a loss of IS protective effect (OR = 0.45, 95% CI = 0.17-1.20, P = .11), and the presence of moderate/severe ascites increased the risk of death/LT (HR = 5.86, 95% CI = 1.26-27.2, P = .02). Autoimmune decompensated cirrhosis is associated with high overall mortality, and IS improves the transplant-free survival rate. In patients with MELD-Na >22, treatment ceases to be beneficial, especially if they have moderate/severe ascites. These patients, if receiving immunosuppression, may be disadvantaged in the possibility of accessing LT.

Therapeutic Targets and Approaches to Manage Inflammation of NAFLD

Non-alcoholic fatty liver disease (NAFLD) and its advanced form, non-alcoholic steatohepatitis (NASH), are the leading causes of chronic liver disease globally. They are driven by complex mechanisms where inflammation plays a pivotal role in disease progression. Current therapies, including lifestyle changes and pharmacological agents, are limited in efficacy, particularly in addressing the advanced stages of the disease. Emerging approaches targeting inflammation, metabolic dysfunction, and fibrosis offer promising new directions, though challenges such as treatment complexity and heterogeneity persist. This review concludes the main therapeutic targets and approaches to manage inflammation currently and emphasizes the critical need for future drug development and combination therapy for NAFLD/NASH management.

SFAs facilitates ceramide's de novo synthesis via TLR4 and intensifies hepatocyte lipotoxicity

BACKGROUND

Non-alcoholic steatohepatitis (NASH), an advanced manifestation of non-alcoholic fatty liver disease (NAFLD), is characterized by hepatocyte injury, inflammation, and fibrosis. Saturated fatty acids (SFAs) have emerged as key contributors to hepatocyte lipotoxicity and disease progression. Toll-like receptor 4 (TLR4) acts as a sentinel for diverse ligands, including lipopolysaccharide (LPS) and endogenous molecules like palmitic acid (PA)-induced ceramide (CER) accumulation, promoting hepatocyte demise. However, the intricate mechanisms underlying TLR4's modulation of ceramide metabolism and their concerted effect on SFA-mediated hepatotoxicity remain elusive.

METHODS

A NASH mouse model with liver-specific TLR4 knockdown was established through palm oil feeding and AAV2/8 tail vein injection. Histological and biochemical assessments were conducted to evaluate the mice's condition and liver damage extent. Liquid chromatography-mass spectrometry (LC-MS) was employed to quantify ceramide levels in liver tissues, offering insights into NASH mechanisms.

RESULTS

The PO-fed model exhibited elevated serum ALT, AST, and liver TG levels, enhancing lipid accumulation and hepatocellular damage. TLR4 knock-down reduced liver mass and the liver-to-body weight ratio, signifying a decreased hepatic burden. Histopathological evaluations revealed substantial improvement in hepatic steatosis in TLR4-silenced PO-fed mice, with diminished lipid droplets and inflammatory infiltrates. LC-MS analysis showed a marked decrease in long-chain ceramides (C14, C16, C20) in TLR4-knockdown PO-fed mice. Furthermore, expression of MyD88, SPTLC1, SPTLC2, and inflammatory markers IL-1β, IL-6, TNF-α were significantly attenuated.

CONCLUSION

SFAs activate the TLR4 signaling pathway via MyD88, fostering ceramide de novo synthesis, which exacerbates hepatocyte lipotoxicity and accelerates NASH progression.

Pan-caspase inhibitors induce secretion of HIV-1 latency reversal agent lymphotoxin-alpha from cytokine-primed NK cells

The persistence of HIV-1 latency reservoirs in CD4+ T cells is a significant obstacle for curing HIV-1. Shock-and-kill strategies, which aim to reactivate latent HIV-1 followed by cytotoxic clearance, have shown limited success in vivo due to insufficient efficacy of latency reversal agents (LRAs) and off-target effects. Natural killer (NK) cells, with their ability to mediate cytotoxicity independent of antigen specificity, offer a promising avenue for enhancing the shock-and-kill approach. Previously, we observed that pan-caspase inhibitors induce NK cells to secrete an LRA in vitro. Here, we aimed to identify this LRA using a targeted proteomic approach. We identified lymphotoxin-α (LTα) as the key LRA secreted by NK cells following pan-caspase inhibitor treatment. LTα was shown to significantly induce HIV-1 LTR promoter activity, a hallmark of viral reactivation. Neutralization of LTα effectively abolished the observed LRA activity, confirming its central role. Moreover, cytokine-primed but not resting human primary NK cells exhibited LRA activity that could be neutralized with LTα neutralizing antibodies. Finally, pan-caspase inhibitor treatment did not decrease the ability of the cytokine-primed NK cells to kill target cells. These findings demonstrate that cytokine-primed NK cells, through LTα secretion, can effectively reactivate latent HIV-1 following pan-caspase inhibitor treatment, without compromising NK cell cytotoxicity. This highlights a potential enhancement strategy utilizing NK cells for shock-and-kill approaches in HIV-1 cure research.