Biochemical Evaluation of Patients of Alcoholic Liver Disease and Non-alcoholic Liver Disease

Hepatoprotective Effect of Antrodia camphorata Mycelium Powder on Alcohol-Induced Liver Damage

BACKGROUND/OBJECTIVES

Antrodia camphorata, also known as "Niuchangchih" in Taiwan, is a unique medicinal mushroom native to Taiwan. It is used in traditional medicine to treat various health conditions. In this study, we investigated the efficacy of A. camphorata mycelia on alcohol-induced liver damage, both in vitro and in vivo, in a Good Laboratory Practice (GLP) facility.

METHODS

The experimental groups consisted of a normal control group (G1), a negative control group (G2), an A. camphorata mycelium powder 50 mg/kg/day administration group (G3), a 100 mg/kg/day administration group (G4), a 200 mg/kg/day administration group (G5), and a positive control silymarin 200 mg/kg/day administration group (G6), with 10 Sprague Dawley rats assigned to each treatment group.

RESULTS

We found that treatment with A. camphorata mycelium powder significantly reduced alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, cholesterol, adiponectin, triglyceride, and malondialdehyde concentrations. Histopathological analysis also revealed that the inflammation score significantly decreased in the A. camphorata-treated groups.

CONCLUSION

Based on these results, we conclude that repeated oral administration of A. camphorata mycelium powder is effective in improving alcoholic liver disease.

Effects of prazosin treatment on liver enzymes are moderated by alcohol withdrawal symptoms in individuals with alcohol use disorder

BACKGROUND

Alcohol use disorder (AUD) is associated with significant liver pathology marked by elevated liver enzymes. Prazosin, an alpha1-noradrenergic antagonist significantly improves alcohol drinking outcomes in individuals with alcohol withdrawal symptoms (AW), but effects on liver enzymes are unknown. We assessed the effects of prazosin treatment on the liver enzymes alanine transaminase (ALT), aspartate transaminase (AST), and gamma-glutamyltransferase (GGT) in individuals with AUD.

METHODS

Participants (N=100) with AUD were enrolled in a 12-week randomized controlled trial and received either placebo or 16 mg/day of prazosin. Whole blood was drawn from 92 participants to measure liver enzyme levels every 4 weeks, and severity of AW was assessed weekly. Analysis predicting liver function outcomes used linear mixed effects models.

RESULTS

Controlling for alcohol consumption, a significant AW × treatment effect was seen for ALT (p < 0.05), AST (p < 0.05) and GGT (p < 0.01). Additionally, AST (b = 0.2, p < 0.01), ALT (b = 0.2, p < 0.05), and GGT (b = 0.3, p < 0.01) were elevated in individuals with higher AW in the placebo but not in the prazosin group (AST: p > 0.66; ALT: p > 0.65). Only in the prazosin group were lower GGT levels associated with higher withdrawal severity (b = -0.16, p < 0.05).

CONCLUSIONS

We found an interaction of alcohol withdrawal symptoms and prazosin treatment on liver enzyme levels, which were not influenced by week in the trial or the amount of alcohol consumed. Together, these findings suggest that prazosin treatment reduces liver enzymes over the course of AUD treatment among individuals with significant AW, though replication to establish clinical utility is needed.

Liver biopsy for assessment of suspected drug-induced liver injury in metabolic dysfunction-associated steatohepatitis clinical trials: Expert consensus from the Liver Forum

BACKGROUND

Causality assessment of suspected drug-induced liver injury (DILI) during metabolic dysfunction-associated steatohepatitis (MASH) clinical trials can be challenging, and liver biopsies are not routinely performed as part of this evaluation. While the field is moving away from liver biopsy as a diagnostic and prognostic tool, information not identified by non-invasive testing may be provided on histology.

AIM

To address the appropriate utilisation of liver biopsy as part of DILI causality assessment in this setting.

METHODS

From 2020 to 2022, the Liver Forum convened a series of webinars on issues pertaining to liver biopsy during MASH trials. The Histology Working Group was formed to generate a series of consensus documents addressing these challenges. This manuscript focuses on liver biopsy as part of DILI causality assessment.

RESULTS

Expert opinion, guidance and recommendations on the role of liver biopsy as part of causality assessment of suspected DILI occurring during clinical trials for a drug(s) being developed for MASH are provided. Lessons learned from prior MASH programs are reviewed and gaps identified.

CONCLUSIONS

Although there are no pathognomonic features, histologic evaluation of suspected DILI during MASH clinical trials may alter patient management, define the pattern and severity of injury, detect findings that favour a diagnosis of DILI versus MASH progression, identify prognostic features, characterise the clinicopathological phenotype of DILI, and/or define lesions that influence decisions about trial discontinuation and further development of the drug.

Serum alkaline phosphatase can be elevated in patients with hypophosphatasia due to liver disease

BACKGROUND

Hypophosphatasia (HPP) is a rare inherited disorder caused by pathogenic loss-of-function variants in the ALPL gene, encoding the tissue-nonspecific isoenzym of alkaline phosphatase (ALP; TNSALP). Low serum ALP is the biochemical hallmark of HPP, but it is unknown whether ALP levels can increase due to concurring liver disease, which may lead to a missed diagnose of HPP. We present a patient with genetically confirmed HPP, who showed a transient increase of serum ALP levels due to alcohol-induced hepatitis.

CLINICAL REPORT

A 71-year old man was seen at our Bone Center for surveillance of HPP. Serum ALP was always low (23 U/L; reference value: <115 U/L). During follow-up, his serum ALP increased (156 U/L, further rising to 204 U/L), with concomitantly elevated serum gamma-glutamyl transferase and transaminases, and a rise in bone specific ALP (18.7 μg/L; reference value: 5.7-32.9 μg/L). This was attributed to alcohol-induced hepatitis. After refraining from alcohol intake, both serum ALP and bone specific ALP levels returned to initial low levels (30 U/L and 4.3 μg/L respectively).

CONCLUSIONS

We demonstrated the history of a 71-year old patient with HPP, presenting during routine follow-up with an elevated serum ALP level up to 204 U/L due to alcohol-induced hepatitis. This case illustrates that the diagnosis of HPP can potentially be missed when ALP levels are normal or elevated due to a concomitant liver disease.

Integrated metabolomics and network pharmacology revealing the mechanism of arsenic-induced hepatotoxicity in mice

Endemic arsenic (As) poisoning is a severe biogeochemical disease that endangers human health. Epidemiological investigations and animal experiments have confirmed the damaging effects of As on the liver, but there is an urgent need to investigate the underlying mechanisms. This study adopted a metabolomic approach using UHPLC-QE/MS to identify the different metabolites and metabolic mechanisms associated with As-induced hepatotoxicity in mice. A network pharmacology approach was applied to predict the potential target of As-induced hepatotoxicity. The predicted targets of differential metabolites were subjected to a deep matching for elucidating the integration mechanisms. The results demonstrate that the levels of ALT and AST in plasma significantly increased in mice after As exposure. In addition, the liver tissue showed disorganized liver lobules, lax cytoplasm and inflammatory cell infiltration. Metabolomic analysis revealed that As exposure caused disturbance to 40 and 75 potential differential metabolites in plasma and liver, respectively. Further investigation led to discovering five vital metabolic pathways, including phenylalanine, tyrosine, and tryptophan biosynthesis and nicotinate and nicotinamide metabolism pathways. These pathways may responded to As-induced hepatotoxicity primarily through lipid metabolism, apoptosis, and deoxyribonucleic acid damage. The network pharmacology suggested that As could induce hepatotoxicity in mice by acting on targets including Hsp90aa1, Akt2, Egfr, and Tnf, which regulate PI3K Akt, HIF-1, MAPK, and TNF signaling pathways. Finally, the integrated metabolomics and network pharmacology revealed eight key targets associated with As-induced hepatoxicity, namely DNMT1, MAOB, PARP1, MAOA, EPHX2, ANPEP, XDH, and ADA. The results also suggest that nicotinic acid and nicotinamide metabolisms may be involved in As-induced hepatotoxicity. This research identified the metabolites, targets, and mechanisms of As-induced hepatotoxicity, offering meaningful insights and establishing the groundwork for developing antidotes for widespread As poisoning.

A High De Ritis Ratio is Associated with Mortality in Adult Trauma Patients

Introduction

The De Ritis ratio, which is the ratio of aspartate aminotransferase (AST) to alanine aminotransferase (ALT), has been suggested as a potential prognostic marker for various diseases. This study aimed to investigate the association between the De Ritis ratio and in-hospital mortality in adult trauma patients.

Methods

A total of 17,472 adult trauma patients hospitalized between January 1, 2009, and December 31, 2020, were allocated into groups according to the De Ritis ratio. The normal range of the De Ritis ratio was calculated from 3320 individuals in the National Taiwan Biobank. Statistical analyses were performed using SPSS software.

Results

Patients with a De Ritis ratio >1.6 had a significantly higher in-hospital mortality rate (7.3% vs 1.5%, odds ratio 5.29; Q1-Q3 2.72-10.30; p < 0.001) and a 2.71-fold higher in-hospital mortality rate (Q1-Q3 1.24-5.92; p = 0.012), after adjusting for sex, age, comorbidities, consciousness level, and injury severity, than those with a De Ritis ratio within the reference values.

Discussion

This study revealed that a De Ritis ratio >1.6 may serve as an early prognostic tool to identify adult trauma patients at high risk of in-hospital mortality.

Association between Elevated De Ritis Ratio and Mortality Outcome in Adult Patients with Thoracoabdominal Trauma

The De Ritis ratio is widely used to differentiate various causes of liver disease and serves as an independent prognostic predictor for different malignancies and non-malignant illnesses. This retrospective study aimed to identify the association between the De Ritis ratio on admission and mortality outcomes in adult thoracoabdominal trauma patients. A total of 2248 hospitalized adult trauma patients with thoracoabdominal injury, defined as an abbreviated injury scale (AIS) score ≥ 1 in the thoracic and abdominal regions, between 1 January 2009, and 31 December 2019, were included. They were categorized into three tertile groups according to the De Ritis ratio. A 1:1 propensity score-matched study group was established to attenuate the confounding effect of patient characteristics on the mortality outcome assessment. The AST levels of the tertile 1, 2, and 3 groups were 115.8 ± 174.9, 115.7 ± 262.0, and 140.5 ± 209.7 U/L, respectively. Patients in the tertile 3 group had a significantly higher level of AST than those in the tertile 1 group (p = 0.032). In addition, patients in the tertile 1 group had a significantly higher level of ALT than those in the tertile 2 and 3 groups (115.9 ± 158.1 U/L vs. 74.5 ± 107.0 U/L and 61.9 ± 86.0 U/L, p < 0.001). The increased De Ritis ratio in trauma patients with thoracoabdominal injuries was mainly attributed to elevated AST levels. The propensity score-matched patient cohorts revealed that the patients in the tertile 3 group presented a 3.89-fold higher risk of mortality than the patients in the tertile 2 group. In contrast, the patients in the tertile 1 group did not have a significantly different mortality rate than those in the tertile 2 group. This study suggests that a De Ritis ratio > 1.64 may be a useful biomarker to identify patients with a higher risk for mortality.

Evaluation of oxidative stress and biochemical biomarkers, and psychological parameters in cement plant workers

The cement industry is one of the main world industries with exposure to a wide range of hazardous chemical and physical occupational agents that may increase free radicals and lead to disease. The aim of this study was to evaluate oxidative stress, biochemical markers, and psychological parameters among cement plant workers. In this cross-sectional study, 40 workers exposed to cement and 40 office employees were selected as the exposed and non-exposed groups, respectively. Exposure to cement dust, silica, and noise were, respectively, assessed using the NIOSH 0600, NIOSH 7601, and noise dosimetry methods. Oxidative stress biomarkers including malondialdehyde (MDA), superoxide dismutase (SOD), catalase (CAT), total antioxidant capacity (TAC), and biochemical parameters were measured in the serum of all participants. Depression, anxiety, and stress were assessed by the Depression Anxiety Stress Scales (DASS-21) questionnaire. The results demonstrated that the level of MDA as a marker of oxidative stress was significantly higher in the exposed group. The level of antioxidant enzymes including SOD and CAT were also significantly higher in the exposed group. The level of TAC was lower in the exposed group, but the difference was not statistically significant. The levels of alkaline phosphatase (ALP), aspartate transaminase (AST), and the scores of depression and stress were also significantly higher in the exposed group. According to our results, noise, cement dust, and silica exposure were associated with oxidative stress, and this may be one of the mechanisms in which they adversely affect liver function and mental health.

Statistical Machine Learning Approaches to Liver Disease Prediction

Medical diagnoses have important implications for improving patient care, research, and policy. For a medical diagnosis, health professionals use different kinds of pathological methods to make decisions on medical reports in terms of the patients’ medical conditions. Recently, clinicians have been actively engaged in improving medical diagnoses. The use of artificial intelligence and machine learning in combination with clinical findings has further improved disease detection. In the modern era, with the advantage of computers and technologies, one can collect data and visualize many hidden outcomes such as dealing with missing data in medical research. Statistical machine learning algorithms based on specific problems can assist one to make decisions. Machine learning (ML), data-driven algorithms can be utilized to validate existing methods and help researchers to make potential new decisions. The purpose of this study was to extract significant predictors for liver disease from the medical analysis of 615 humans using ML algorithms. Data visualizations were implemented to reveal significant findings such as missing values. Multiple imputations by chained equations (MICEs) were applied to generate missing data points, and principal component analysis (PCA) was used to reduce the dimensionality. Variable importance ranking using the Gini index was implemented to verify significant predictors obtained from the PCA. Training data (ntrain=399) for learning and testing data (ntest=216) in the ML methods were used for predicting classifications. The study compared binary classifier machine learning algorithms (i.e., artificial neural network, random forest (RF), and support vector machine), which were utilized on a published liver disease data set to classify individuals with liver diseases, which will allow health professionals to make a better diagnosis. The synthetic minority oversampling technique was applied to oversample the minority class to regulate overfitting problems. The RF significantly contributed (p<0.001) to a higher accuracy score of 98.14% compared to the other methods. Thus, this suggests that ML methods predict liver disease by incorporating the risk factors, which may improve the inference-based diagnosis of patients.

Resveratrol modulates Toxoplasma gondii infection induced liver injury by intervening in the HMGB1/TLR4/NF-κB signaling pathway

Toxoplasma gondii (T. gondii) is an obligate intracellular parasite that can cause liver diseases in the host, including hepatitis and hepatomegaly. High mobility group box 1 (HMGB1) is the main inflammatory mediator causing cell injury or necrosis. HMGB1 binds to toll like receptor 4 (TLR4), then activates the nuclear factor-κB (NF-κB) signaling pathway, which promotes the release of inflammatory factors. Our previous studies showed that HMGB1 mediated TLR4/NF-κB signaling pathway plays an important role in liver injury induced by T. gondii infection. Resveratrol (RSV) is a small polyphenol, which has anti-inflammatory, anti-cancer, anti-T. gondii effect. However, the effect of RSV on liver injury caused by T. gondii infection is unclear. This study used the RH strain tachyzoites of T. gondii to infect murine liver line, NCTC-1469 cells to establish an in vitro model and acute infection of mice for the in vivo model to explore the protective effect of RSV on liver injury induced by T. gondii infection. The results showed that RSV inhibited the proliferation of T. gondii in the liver, reduced the alanine aminotransferase/aspartate aminotransferase levels and pathological liver damage. Additionally, RSV inhibited the production of tumor necrosis factor-α, inducible nitric oxide synthase and HMGB1 by interfering with the TLR4/NF-κB signaling pathway. These results indicate that RSV can protect liver injury caused by T. gondii infection by intervening in the HMGB1/TLR4/NF-κB signaling pathway. This study will provide a theoretical basis for RSV treatment of T. gondii infection induced liver injury.

Efficacy and safety of apararenone (MT-3995) in patients with nonalcoholic steatohepatitis: A randomized controlled study

AIM

To evaluate the efficacy, safety, and tolerability of apararenone 10 mg/day in patients with nonalcoholic steatohepatitis (NASH).

METHODS

In this multicenter, randomized, double-blind, placebo-controlled phase II study, patients received apararenone 10 mg or placebo once daily for 72 weeks. The primary efficacy end-point was percent change in serum alanine aminotransferase (ALT) from baseline to 24 weeks after randomization. Secondary efficacy end-points included changes in liver fibrosis markers. Adverse drug reactions (ADRs) and serum potassium levels were evaluated.

RESULTS

Forty-eight patients were randomly assigned to treatment (placebo, 23; apararenone, 25). The percent change in ALT at 24 weeks was -3.0% and -13.7% with placebo and apararenone, respectively (p = 0.308). The apararenone group showed greater reductions from baseline in fibrosis markers (type IV collagen 7S and procollagen-3 N-terminal peptide) and noninvasive tests of fibrosis (enhanced liver fibrosis score and Fibrosis-4 index) at all time points versus placebo. The percentage of patients with improvement of 1 point or more in fibrosis stage/without nonalcoholic fatty liver disease activity score worsening was 41.7% with apararenone and 26.1% with placebo (p = 0.203). Adverse drug reactions were reported in three (13.0%) and three (12.5%) patients in the placebo and apararenone groups, respectively. Serum potassium levels increased in the apararenone group during the study and decreased to near baseline after the end of treatment.

CONCLUSIONS

In patients with NASH, apararenone 10 mg/day for 72 weeks was effective in decreasing ALT levels, improved multiple potential fibrosis markers, and was safe and well tolerated. Pathological findings showed anti-inflammatory and antifibrotic effects of apararenone.

A review on molecular mechanism of alcoholic liver disease

Excessive alcohol consumption leads to damage to the organs of the body. More importantly, the liver is majorly affected organ upon alcohol consumption for most of the people; it causes inflammation and affects various pathways involved in metabolism. If the person is with high response of inflammatory in conduct with alcohol leads to the liver damage, which involves the creating effects with major cycle leads to homeostasis. In this review, we summarize the molecular mechanisms of alcoholic liver disease, such as the important role of genes, risk factors, pathogenicity, and role of micro RNA, the role of inflammation in the liver, and alcoholic fibrosis in the liver. There is increased oxidative stress, change in the biochemical alterations, and reduction in the antioxidant enzymes. These changes in the mechanism lead to liver injury. Hepatocyte nuclear factor-4 is the major transcriptional factor for the regulation of some genes involved in the lipid metabolism and oxidation process; with the help of the agonist, we can attenuate the level of the gene in the site of hepatic tissues, which will prevent the homeostatic condition. This review shows a clear view of the various pathways involved in alcohol consumption, which helps in the prevention of ALD using an agonist.

AST/ALT ratio as a predictor of mortality and exacerbations of PM/DM-ILD in 1 year-a retrospective cohort study with 522 cases

OBJECTIVE

To assess the associations between aspartate transaminase/alanine transaminase ratio (DRR) and mortality in patients with polymyositis/dermatomyositis-associated interstitial lung disease (PM/DM-ILD).

PATIENTS AND METHODS

This was a retrospective cohort study, which included 522 patients with PM/DM-ILD whose DRR on admission were tested at West China Hospital of Sichuan University during the period from January 1, 2008, to December 31, 2018. Cox regression models were used to estimate hazard ratios for mortality in four predefined DRR strata (≤ 0.91, 0.91-1.26, 1.26-1.73, and > 1.73), after adjusting for age, sex, DRR stratum, diagnosis, overlap syndrome, hemoglobin, platelet count, white blood cell count, the percentage of neutrophils, neutrophil/lymphocyte ratio, albumin, creatine kinase, uric acid/creatinine ratio, triglycerides, or low-density lipoprotein.

RESULTS

Higher DRR (> 1.73) was an independent predictor of 1-year mortality in multivariate Cox regression analysis (hazard ratio 3.423, 95% CI 1.481-7.911, p = .004). Patients with higher DRR more often required the use of mechanical ventilation and readmission for acute exacerbation of PM/DM-ILD at 1-year follow-up.

CONCLUSION

Higher DRR on admission for PM/DM-ILD patients are associated with increased mortality, risk of mechanical ventilation, and hospitalization in 1-year follow-up. This low-cost, easy-to-obtain, rapidly measured biomarker may be useful in the identification of high-risk PM/DM-ILD patients that could benefit from intensive management.

Mulakal J, Maliakel BP, Krishnakumar IM. A Novel Curcumin-Galactomannoside Complex Delivery System Improves Hepatic Function Markers in Chronic Alcoholics: A Double-Blinded, randomized, Placebo-Controlled Study

Considering the recent interest in free (unconjugated) curcuminoids delivery, the present study investigated the efficacy of a novel food-grade free-curcuminoids delivery system (curcumin-galactomannoside complex; CGM) in improving the hepatic function markers (inflammation and oxidative stress) in chronic alcoholics. The double-blinded, placebo-controlled study randomized 48 subjects with elevated serum transaminases and gamma-glutamyl transferase (GGT) levels, who were allocated to two groups (n=24) and to receive either placebo or CGM at (250 mg × 2)/day for 8 weeks. While liver function markers (transaminases and GGT) in the placebo group showed an increase (~ 9.5%), CGM group indicated a significant decrease in transaminases (31%) and GGT (29%) from the baseline levels. The beneficial effect of CGM was also clear from the significant increase (p <0.001) in endogenous antioxidants (GSH, SOD, and GPx) and decrease in inflammatory markers (IL-6 and CRP) levels (p <0.001) as compared to both the baseline and placebo group. To summarize, the nutritional intervention of CGM-curcumin was found to offer a significant hepatoprotective effect to attenuate the alcohol induced alterations to hepatic function markers. The Indian Medical Council and Drug Controller General of India approved Clinical Trial Registry No. CTRI/2018/03/012385.

Biochemical and morphological biomarkers of the liver damage in the Neotropical fish, Piaractus mesopotamicus, injected with crude extract of cyanobacterium Radiocystis fernandoi

Cyanobacterial proliferation in river and lakes is the result of eutrophication. The cyanobacterium Radiocystis fernandoi strain R28 produces mostly two MC variants MC-RR and MC-YR and small amounts of other oligopeptides, but does not produce MC-LR. The present study investigated the hepatotoxic potential of the crude extract of the R. fernandoi strain R28 on the Neotropical fish, Piaractus mesopotamicus, at 3, 6, and 24 h after intraperitoneal injection (100 μg MC-LR equivalent per kg^-1 body mass) using biochemical and morphological biomarkers of liver damage. Although the protein phosphatases PP1 and PP2A were not inhibited during the 24-h treatment, liver parenchyma and hepatocyte structure were disrupted. Alkaline phosphatase increased at 3 h post-injection and decreased after 24 h; alanine aminotransferase and aspartate aminotransferase increased in a time-dependent manner up to 24 h indicating impaired liver function. Progressive histopathological changes were consistent with biochemical results demonstrating alterations in liver structure and function. In conclusion, the crude extract of R. fernandoi strain R28 has high hepatotoxic potential and can severely compromise fish health.

Influence of non-pathological factors on ALT measurements

Alanine transaminase (ALT) is still the most sensitive marker for evaluating the damage of liver cells. ALT measurements may be affected by common non-pathological factors such as gender, age, pregnancy, different physiological conditions, circadian rhythm, diet, drinking, smoking, strenuous exercise, metabolic factors, drugs, blood collection methods, and specimen collection, transmission, and preservation. It is important to emphasize the definition of limits of normal ALT and the influence of the above-mentioned non-pathological factors on its test results.

Constitutive androstane receptor activation promotes bilirubin clearance in a murine model of alcoholic liver disease

Increased plasma levels of bilirubin have been reported in rat models and patients with alcoholic liver disease (ALD). The constitutive androstane receptor (CAR) is a known xenobiotic receptor, which induces the detoxification and transport of bilirubin. In the present study, the bilirubin transport regulatory mechanisms, and the role of CAR activation in hepatic and extrahepatic bilirubin clearance were investigated in a murine model of ALD. The mice were fed a Lieber-DeCarli ethanol diet or an isocaloric control diet for 4 weeks, followed by the administration of CAR agonists, 1,4-bis-[2-(3,5-dichlorpyridyloxy)]benzene (TCPOBOP) and phenobarbital (PB), and their vehicles to examine the effect of the pharmacological activation of CAR on serum levels of bilirubin and on the bilirubin clearance pathway in ALD by serological survey, western blotting and reverse transcription-quantitative polymerase chain reaction. The results showed that chronic ethanol ingestion impaired the nuclear translocation of CAR, which was accompanied by elevated serum levels of bilirubin, suppression of the expression of hepatic and renal organic anion transporting polypeptide (OATP) 1A1 and hepatic multidrug resistance-associated protein 2 (MRP2), and induction of the expression of UDP-glucuronosyltransferase (UGT) 1A1. The activation of CAR by TCPOBOP and PB resulted in downregulation of the serum levels of bilirubin followed by selective upregulation of the expression levels of OATP1A1, OATP1A4, UGT1A1 and MRP2 in ALD. These results revealed the bilirubin transport regulatory mechanisms and highlighted the importance of CAR in modulating the bilirubin clearance pathway in the ALD mouse model.