Treatment With Simvastatin and Rifaximin Restores the Plasma Metabolomic Profile in Patients With Decompensated Cirrhosis

Recent advances in the prevention and treatment of decompensated cirrhosis and acute-on-chronic liver failure (ACLF) and the role of biomarkers

The progression of cirrhosis with clinically significant portal hypertension towards decompensated cirrhosis remains clinically challenging and the evolution towards acute-on-chronic liver failure (ACLF), with one or more extrahepatic organ failures, is associated with very high mortality. In the last decade, significant progress has been made in the understanding of the mechanisms leading to decompensation and ACLF. As portal hypertension advances, bacterial translocation across an impaired gut barrier culminates in endotoxaemia, systemic inflammation and cirrhosis-associated immune dysfunction (CAID). Gut-derived systemic inflammation and CAID have become the logical targets for innovative therapies that prevent hepatic decompensation episodes and the progression to ACLF.Furthermore, classification of disease and biomarker discovery to personalise care have advanced in the field. This review discusses progress in biomarker discovery and personalisation of treatment in decompensated cirrhosis and ACLF.

Metabolomics in cirrhosis: Recent advances and opportunities

Liver cirrhosis (LC) represents a significant hepatic disorder that persistently commands the attention of the scientific community, especially concerning its pathogenesis and therapeutic approaches. Metabolomics, the comprehensive profiling of an organism's metabolome, has been increasingly applied in the research of cirrhosis over the past decade. This review summarizes the recent advancements and applications of metabolomics within the context of LC research, in recent five years. It highlights the role of metabolomics in the diagnosis of LC, the assessment of prognostic markers, and the evaluation of therapeutic outcomes. The discussion focuses on the potential and challenges of metabolomics in LC research, including the evolution of analytical technologies, advancements in bioinformatics, and the challenges impeding clinical implementation. Additionally, the review anticipates the forthcoming developments in metabolomics related to LC research, with the objective of facilitating innovative approaches for early detection and intervention in LC.

Serum aryl hydrocarbon receptor activity is associated with survival in patients with alcohol-associated hepatitis

BACKGROUND AND AIMS

Patients with alcohol-associated hepatitis (AH) have an altered fecal metabolome, including reduced microbiota-derived tryptophan metabolites, which function as ligands for aryl hydrocarbon receptor (AhR). The aim of this study was to assess serum AhR ligand activity in patients with AH.

APPROACH AND RESULTS

The study included 74 controls without AUD, 97 patients with AUD, and 330 patients with AH from 2 different multicenter cohorts (InTeam: 134, AlcHepNet: 196). Serum AhR activity was evaluated using an AhR reporter assay with HepG2-Lucia cells incubated with serum for 24 hours. Serum AhR activity was significantly higher in patients with AH compared with both controls (1.59 vs. 0.96-fold change, p < 0.001) and patients with AUD (1.59 vs. 0.93, p < 0.001). In both AH cohorts, patients with AhR activity ≥ 2.09 had significantly lower cumulative survival rates at 30, 60, 90, and 180 days compared to those with AhR activity < 2.09. When serum AhR activity was used to further stratify patients with severe AH, the cumulative 30, 60, 90, and 180-day survival rates for patients with severe AH and the AhR activity ≥ 2.09 group were all significantly lower than those with an AhR activity < 2.09 group.

CONCLUSIONS

Serum AhR activity was significantly higher in patients with AH compared with controls and individuals with AUD, and this increased activity was associated with higher mortality. Consequently, serum AhR activity holds potential as a prognostic marker.

Metabolomics profiles in acute-on-chronic liver failure: Unveiling pathogenesis and predicting progression

Acute-on-chronic liver failure (ACLF) usually develops based on acute decompensation (AD) of cirrhosis and is characterized by intense systemic inflammation, multiple organ failure, and high short-term mortality. Validated biomarkers for the diagnosis and prognosis of ACLF remain to be clarified. Metabolomics is an emerging method used to measure low-molecular-weight metabolites and is currently frequently implemented to understand pathophysiological processes involved in disease progression, as well as to search for new diagnostic or prognostic biomarkers of various disorders. The characterization of metabolites in ACLF has recently been described via metabolomics. The role of metabolites in the pathogenesis of ACLF deserves further investigation and improvement and could be the basis for the development of new diagnostic and therapeutic strategies. In this review, we focused on the contributions of metabolomics on uncovering metabolic profiles in patients with ACLF, the key metabolic pathways that are involved in the progression of ACLF, and the potential metabolite-associated therapeutic targets for ACLF.

Molecular characterization of chronic liver disease dynamics: from liver fibrosis to acute-on-chronic liver failure

Background & Aims

The molecular mechanisms driving the progression from early-chronic liver disease (CLD) to cirrhosis and, finally, acute-on-chronic liver failure (ACLF) are largely unknown. Our aim was to develop a protein network-based approach to investigate molecular pathways driving progression from early-CLD to ACLF.

Methods

Transcriptome analysis was performed on liver biopsies from patients at different liver disease stages, including fibrosis, compensated cirrhosis, decompensated cirrhosis and ACLF, and control healthy livers. We created 9 liver-specific disease-related protein-protein interaction networks capturing key pathophysiological processes potentially related to CLD. We used these networks as a framework and performed gene set-enrichment analysis (GSEA) to identify dynamic gene profiles of disease progression.

Results

Principal component analyses revealed that samples clustered according to the disease stage. GSEA of the defined processes showed an upregulation of inflammation, fibrosis and apoptosis networks throughout disease progression. Interestingly, we did not find significant gene expression differences between compensated and decompensated cirrhosis, while ACLF showed acute expression changes in all the defined liver disease-related networks. The analyses of disease progression patterns identified ascending and descending expression profiles associated with ACLF onset. Functional analyses showed that ascending profiles were associated with inflammation, fibrosis, apoptosis, senescence and carcinogenesis networks, while descending profiles were mainly related to oxidative stress and genetic factors. We confirmed by qPCR the upregulation of genes of the ascending profile and validated our findings in an independent patient cohort.

Conclusion

ACLF is characterized by a specific hepatic gene expression pattern related to inflammation, fibrosis, apoptosis, senescence and carcinogenesis. Moreover, the observed profile is significantly different from that of compensated and decompensated cirrhosis, supporting the hypothesis that ACLF should be considered a distinct entity.

Lay summary

By using transjugular biopsies obtained from patients at different stages of chronic liver disease, we unveil the molecular pathogenic mechanisms implicated in the progression of chronic liver disease to cirrhosis and acute-on-chronic liver failure. The most relevant finding in this study is that patients with acute-on-chronic liver failure present a specific hepatic gene expression pattern distinct from that of patients at earlier disease stages. This gene expression pattern is mostly related to inflammation, fibrosis, angiogenesis, and senescence and apoptosis pathways in the liver.

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We unveiled the molecular pathogenic mechanisms implicated in the progression of chronic liver disease to cirrhosis and ACLF.

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ACLF presents a specific hepatic gene expression pattern distinct from that of patients at earlier disease stages.

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Gene expression pattern of ACLF is mostly related to inflammation, fibrosis, angiogenesis, senescence and apoptosis pathways in the liver.