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Wang X, Deng K, Zhang P, Chen Q, Magnuson JT, Qiu W, Zhou Y. Microplastic-mediated new mechanism of liver damage: From the perspective of the gut-liver axis. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 919:170962. [PMID: 38360312 DOI: 10.1016/j.scitotenv.2024.170962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 01/03/2024] [Accepted: 02/11/2024] [Indexed: 02/17/2024]
Abstract
Microplastics (MPs) are environmental contaminants that are present in all environments and can enter the human body, accumulate in various organs, and cause harm through the ingestion of food, inhalation, and dermal contact. The connection between bowel and liver disease and the interplay between gut, liver, and flora has been conceptualized as the "gut-liver axis". Microplastics can alter the structure of microbial communities in the gut and the liver can also be a target for microplastic invasion. Numerous studies have found that when MPs impair human health, they not only promote dysbiosis of the gut microbiota and disruption of the gut barrier but also cause liver damage. For this reason, the gut-liver axis provides a new perspective in understanding this toxic response. The cross-talk between MPs and the gut-liver axis has attracted the attention of the scientific community, but knowledge about whether MPs cause gut-liver interactions through the gut-liver axis is still very limited, and the effect of MPs on liver injury is not well understood. MPs can directly induce microbiota disorders and gut barrier dysfunction. As a result, harmful bacteria and metabolites in the gut enter the blood through the weak intestinal barrier (portal vein channel along the gut-liver axis) and reach the liver, causing liver damage (inflammatory damage, metabolic disorders, oxidative stress, etc.). This review provides an integrated perspective of the gut-liver axis to help conceptualize the mechanisms by which MP exposure induces gut microbiota dysbiosis and hepatic injury and highlights the connection between MPs and the gut-liver axis. Therefore, from the perspective of the gut-liver axis, targeting intestinal flora is an important way to eliminate microplastic liver damage.
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Affiliation(s)
- Xiaomei Wang
- Health Science Center, Ningbo University, Ningbo 315211, China; The First Affiliated Hospital of Ningbo University, Ningbo 315020, China
| | - Kaili Deng
- School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Pei Zhang
- Ningbo Hangzhou Bay Hospital, Ningbo 315336, China
| | - Qiqing Chen
- State Key Laboratory of Estuarine and Coastal Research, East China Normal University, Shanghai 200241, China
| | - Jason T Magnuson
- U.S. Geological Survey, Columbia Environmental Research Center, Columbia, MO 65201, USA
| | - Wenhui Qiu
- Guangdong Provincial Key Laboratory of Soil and Groundwater Pollution Control, School of Environmental Science and Engineering, Southern University of Science and Technology, Shenzhen 518055, China.
| | - Yuping Zhou
- The First Affiliated Hospital of Ningbo University, Ningbo 315020, China; Ningbo Key Laboratory of Translational Medicine Research on Gastroenterology and Hepatology, Ningbo 315020, China; Institute of Digestive Disease of Ningbo University, Ningbo 315020, China.
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van Lingen E, Tushuizen ME, Steenhuis MEJ, van Deynen T, Martens J, Morales DDI, van der Meulen-de Jong AE, Molendijk I, van der Marel S, Maljaars PWJ. Disease activity in inflammatory bowel disease patients is associated with increased liver fat content and liver fibrosis during follow-up. Int J Colorectal Dis 2022; 37:349-356. [PMID: 34791524 DOI: 10.1007/s00384-021-04065-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Liver steatosis is a frequently reported condition in patients with inflammatory bowel disease (IBD). Different factors, both metabolic and IBD-associated, are believed to contribute to the pathogenesis. The aim of our study was to calculate the prevalence of liver steatosis and fibrosis in IBD patients and to evaluate which factors influence changes in steatosis and fibrosis during follow-up. METHODS From June 2017 to February 2018, demographic and biochemical data was collected at baseline and after 6-12 months. Measured by transient elastography (FibroScan), liver steatosis was defined as Controlled Attenuation Parameter (CAP) ≥248 and fibrosis as liver stiffness value (Emed) ≥7.3 kPa. IBD disease activity was defined as C-reactive protein (CRP) ≥10 mg/l and/or fecal calprotectin (FCP) ≥150 μg/g. Univariate and multivariate regression analysis was performed; a p-value of ≤0.05 was considered significant. RESULTS Eighty-two out of 112 patients were seen for follow-up; 56% were male. The mean age was 43 ± 16.0 years, and mean BMI was 25.1 ± 4.7 kg/m2. The prevalence of liver steatosis was 40% and of fibrosis was 20%. At baseline, 26 patients (32%) had an active episode of IBD. Using a multivariate analysis, disease activity at baseline was associated with an increase in liver steatosis (B = 37, 95% CI 4.31-69.35, p = 0.027) and liver fibrosis (B = 1.2, 95% CI 0.27-2.14, p = 0.016) during follow-up. CONCLUSIONS This study confirms the relatively high prevalence of liver steatosis and fibrosis in IBD patients. We demonstrate that active IBD at baseline is associated with both an increase in liver steatosis and fibrosis during follow-up.
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Affiliation(s)
- E van Lingen
- Department of Gastroenterology and Hepatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands.
| | - M E Tushuizen
- Department of Gastroenterology and Hepatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - M E J Steenhuis
- Department of Gastroenterology and Hepatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - T van Deynen
- Department of Gastroenterology and Hepatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - J Martens
- Department of Gastroenterology and Hepatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - D Diaz-Infante Morales
- Department of Gastroenterology and Hepatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - A E van der Meulen-de Jong
- Department of Gastroenterology and Hepatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - I Molendijk
- Department of Gastroenterology and Hepatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - S van der Marel
- Department of Gastroenterology and Hepatology, Haaglanden Medical Center (HMC), The Hague, The Netherlands
| | - P W J Maljaars
- Department of Gastroenterology and Hepatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
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Liu B, Zeng Q, Chen H, Liao J, Bai Y, Han Q, Qiao N, Wang S, Mehmood K, Hussain R, Ahmed BZ, Tang Z, Zhang H, Li Y. The hepatotoxicity of altrazine exposure in mice involves the intestinal microbiota. CHEMOSPHERE 2021; 272:129572. [PMID: 33485040 DOI: 10.1016/j.chemosphere.2021.129572] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/16/2020] [Accepted: 01/04/2021] [Indexed: 05/15/2023]
Abstract
Atrazine (ATR), a bio accumulative herbicide is frequently used in agriculture to control unwanted weeds. Due to continuous application, atrazine persists in the environment and causes deleterious impacts including neurotoxicity, hepatotoxicity, and gut microbiota disorders. Therefore, this study for the first time reports the variation in the gut microbiota, induction of process of apoptosis and autophagy in mice induced by ATR. Results indicated that TUNEL-positive hepatocytes suggestive of apoptosis were increased in livers of different experimental mice. Results on metabolic analysis in liver tissues indicated an overall change in seventy-six metabolites particularly Uridine 5'-diphosphate, Propenoylcarnitine and Chinenoside V resulting in generation of energy-related metabolic disorders and imbalance of oxidation/autoxidation status. Results on gut microbiome inquisition showed that ATR changed the richness and diversity of gut microbiota of mice and number of Firmicutes. Moreover, results also revealed that ATR induced apoptosis via disruption of apoptotic (Bax, Bcl2, and Casp3) and autophagy (LC3/Map1lc3a, Beclin 1/Becn1 and P62/Sqstm1) genes. Results of our experimental study confirmed that changes in gut microbiota play a significant role in process of gut immune regulation and inflammation via different metabolites. In conclusion, the findings of our study provide a new idea for the involvement of mechanisms of detoxification in liver and inquisition of gut microbiota plays crucial role in regulation of physiological activities through liver-gut axis to mitigate toxic effects in animals.
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Affiliation(s)
- Bingxian Liu
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, 510642, China
| | - Qiwen Zeng
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, 510642, China
| | - Hanming Chen
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, 510642, China
| | - Jianzhao Liao
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, 510642, China
| | - Yuman Bai
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, 510642, China
| | - Qingyue Han
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, 510642, China
| | - Na Qiao
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, 510642, China
| | - Shuzhou Wang
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, 510642, China
| | - Khalid Mehmood
- Faculty of Veterinary and Animal Sciences, The Islamia University of Bahawalpur, 63100, Pakistan
| | - Riaz Hussain
- Faculty of Veterinary and Animal Sciences, The Islamia University of Bahawalpur, 63100, Pakistan
| | - Bhutto Zohaib Ahmed
- Labela University of Agriculture, Water, and Marine Sciences, Uthal, Balochistan, Pakistan
| | - Zhaoxin Tang
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, 510642, China.
| | - Hui Zhang
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, 510642, China.
| | - Ying Li
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, 510642, China.
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Moreno-Gonzalez M, Beraza N. The Role of the Microbiome in Liver Cancer. Cancers (Basel) 2021; 13:2330. [PMID: 34066064 PMCID: PMC8150469 DOI: 10.3390/cancers13102330] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/30/2021] [Accepted: 05/03/2021] [Indexed: 12/11/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common malignancy occuring in the context of chronic liver disease and is one of the main causes of cancer-derived death worldwide. The lack of effective treatments, together with the poor prognosis, underlines the urge to develop novel and multidisciplinary therapeutics. An increasing body of evidence shows that HCC associates with changes in intestinal microbiota abundance and composition as well as with impaired barrier function, leading to the release of bacteria and their metabolites to the liver. These factors trigger a cascade of inflammatory responses contributing to liver cirrhosis and constituting an ideal environment for the progression of HCC. Interestingly, the use of bacteriotherapy in human and preclinical studies of chronic liver disease and HCC has been shown to successfully modify the microbiota composition, reducing overall inflammation and fibrosis. In this review, we explore the existing knowledge on the characterisation of the intestinal microbial composition in humans and experimental murine chronic liver disease and HCC, as well as the use of antibiotics and bacteriotherapy as therapeutic options.
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Affiliation(s)
- Mar Moreno-Gonzalez
- Gut Microbes and Health Institute Strategic Programme, Quadram Institute Bioscience, Norwich Research Park, Norwich NR4 7UQ, UK;
| | - Naiara Beraza
- Gut Microbes and Health Institute Strategic Programme, Quadram Institute Bioscience, Norwich Research Park, Norwich NR4 7UQ, UK;
- Food Innovation and Health Institute Strategic Programme, Quadram Institute Bioscience, Norwich Research Park, Norwich NR4 7UQ, UK
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Changes of Gut-Microbiota-Liver Axis in Hepatitis C Virus Infection. BIOLOGY 2021; 10:biology10010055. [PMID: 33451143 PMCID: PMC7828638 DOI: 10.3390/biology10010055] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/02/2021] [Accepted: 01/08/2021] [Indexed: 12/12/2022]
Abstract
Simple Summary Gut microbiota alteration is linked to many health disorders including hepatitis C virus (HCV) infection. This dysbiosis in turn impacts the coordination between the gut and the liver that is known as the gut–liver-axis. Here, we discuss the latest findings regarding the changes in gut microbiota structure and functionality post HCV infection and its treatment regimens. In addition, we underline the contribution of the microbiota alterations to HCV associated liver complications. Abstract The gut–liver-axis is a bidirectional coordination between the gut, including microbial residents, the gut microbiota, from one side and the liver on the other side. Any disturbance in this crosstalk may lead to a disease status that impacts the functionality of both the gut and the liver. A major cause of liver disorders is hepatitis C virus (HCV) infection that has been illustrated to be associated with gut microbiota dysbiosis at different stages of the disease progression. This dysbiosis may start a cycle of inflammation and metabolic disturbance that impacts the gut and liver health and contributes to the disease progression. This review discusses the latest literature addressing this interplay between the gut microbiota and the liver in HCV infection from both directions. Additionally, we highlight the contribution of gut microbiota to the metabolism of antivirals used in HCV treatment regimens and the impact of these medications on the microbiota composition. This review sheds light on the potential of the gut microbiota manipulation as an alternative therapeutic approach to control the liver complications post HCV infection.
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Jadhav K, Cohen TS. Can You Trust Your Gut? Implicating a Disrupted Intestinal Microbiome in the Progression of NAFLD/NASH. Front Endocrinol (Lausanne) 2020; 11:592157. [PMID: 33193105 PMCID: PMC7641624 DOI: 10.3389/fendo.2020.592157] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 09/28/2020] [Indexed: 02/06/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a spectrum of disorders, ranging from fatty liver to a more insulin resistant, inflammatory and fibrotic state collectively termed non-alcoholic steatohepatitis (NASH). In the United States, 30%-40% of the adult population has fatty liver and 3%-12% has NASH, making it a major public health concern. Consumption of diets high in fat, obesity and Type II diabetes (T2D) are well-established risk factors; however, there is a growing body of literature suggesting a role for the gut microbiome in the development and progression of NAFLD. The gut microbiota is separated from the body by a monolayer of intestinal epithelial cells (IECs) that line the small intestine and colon. The IEC layer is exposed to luminal contents, participates in selective uptake of nutrients and acts as a barrier to passive paracellular permeability of luminal contents through the expression of tight junctions (TJs) between adjacent IECs. A dysbiotic gut microbiome also leads to decreased gut barrier function by disrupting TJs and the gut vascular barrier (GVB), thus exposing the liver to microbial endotoxins. These endotoxins activate hepatic Toll-like receptors (TLRs), further promoting the progression of fatty liver to a more inflammatory and fibrotic NASH phenotype. This review will summarize major findings pertaining to aforementioned gut-liver interactions and its role in the pathophysiology of NAFLD.
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Affiliation(s)
| | - Taylor S. Cohen
- Microbiome Discovery, Microbial Sciences, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, United States
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Li C, Niu Z, Zou M, Liu S, Wang M, Gu X, Lu H, Tian H, Jha R. Probiotics, prebiotics, and synbiotics regulate the intestinal microbiota differentially and restore the relative abundance of specific gut microorganisms. J Dairy Sci 2020; 103:5816-5829. [PMID: 32418689 DOI: 10.3168/jds.2019-18003] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/05/2020] [Indexed: 12/16/2022]
Abstract
Fermented milk is an effective carrier for probiotics, the consumption of which improves host health. The beneficial effects of probiotics, prebiotics, and synbiotics on gut dysbiosis have been reported previously. However, the way in which specific probiotics, prebiotics, and synbiotics regulate intestinal microbes remains unclear. Therefore, the probiotics Lactobacillus rhamnosus AS 1.2466 and Lactobacillus delbrueckii ssp. bulgaricus ATCC 11842 and the prebiotics xylooligosaccharide and red ginseng extracts were fed to mice to determine their effects on the intestinal microbiota. Then, mice were administered xylooligosaccharide and L. rhamnosus (synthesis) by gavage, and the number of L. rhamnosus was determined in the intestine at different times. The results show that probiotics and prebiotics can quickly reduce the Firmicutes/Bacteroidetes ratio, inhibit harmful bacteria (such as Klebsiella and Escherichia coli), and accelerate the recovery of beneficial intestinal microorganisms (such as Lactobacillus). In a complex intestinal microecology, different probiotics and prebiotics have different effects on specific intestinal microorganisms that cannot be recovered in the short term. In addition, after 20 d of intragastric xylooligosaccharide addition at 0.12 g/kg of body weight, L. rhamnosus colonization in the mouse ileum was 7.48 log cfu/mL, which was higher than in the low-dose group, prolonging colonization time and increasing the number of probiotics in the intestine. Therefore, this study demonstrated that probiotics and prebiotics can promote the balance of intestinal microbiota by regulating specific microbes in the intestine, and the effects of a suitable combination of synbiotics are beneficial, laying the foundation for the development of new dairy products rich in synbiotics.
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Affiliation(s)
- Chen Li
- College of Food Science and Technology, Agricultural University of Hebei, Baoding, Hebei, 071000, China
| | - Zhihua Niu
- College of Food Science and Technology, Agricultural University of Hebei, Baoding, Hebei, 071000, China
| | - Meijuan Zou
- College of Food Science and Technology, Agricultural University of Hebei, Baoding, Hebei, 071000, China
| | - Suyue Liu
- College of Food Science and Technology, Agricultural University of Hebei, Baoding, Hebei, 071000, China
| | - Miaoshu Wang
- New Hope Tensun (Hebei) Dairy Co. Ltd., Baoding, Hebei, 071000, China
| | - Xinxi Gu
- College of Food Science and Technology, Agricultural University of Hebei, Baoding, Hebei, 071000, China
| | - Haiqiang Lu
- College of Food Science and Technology, Agricultural University of Hebei, Baoding, Hebei, 071000, China
| | - Hongtao Tian
- College of Food Science and Technology, Agricultural University of Hebei, Baoding, Hebei, 071000, China; National Engineering Research Center for Agriculture in Northern Mountainous Areas, Baoding, Hebei, 071000, China.
| | - Rajesh Jha
- Department of Human Nutrition, Food and Animal Sciences, College of Tropical Agriculture and Human Resources, University of Hawaii at Manoa, Honolulu 96822.
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Wang SZ, Yu YJ, Adeli K. Role of Gut Microbiota in Neuroendocrine Regulation of Carbohydrate and Lipid Metabolism via the Microbiota-Gut-Brain-Liver Axis. Microorganisms 2020; 8:microorganisms8040527. [PMID: 32272588 PMCID: PMC7232453 DOI: 10.3390/microorganisms8040527] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/10/2020] [Accepted: 04/03/2020] [Indexed: 02/06/2023] Open
Abstract
Gut microbiota play an important role in maintaining intestinal health and are involved in the metabolism of carbohydrates, lipids, and amino acids. Recent studies have shown that the central nervous system (CNS) and enteric nervous system (ENS) can interact with gut microbiota to regulate nutrient metabolism. The vagal nerve system communicates between the CNS and ENS to control gastrointestinal tract functions and feeding behavior. Vagal afferent neurons also express receptors for gut peptides that are secreted from enteroendocrine cells (EECs), such as cholecystokinin (CCK), ghrelin, leptin, peptide tyrosine tyrosine (PYY), glucagon-like peptide-1 (GLP-1), and 5-hydroxytryptamine (5-HT; serotonin). Gut microbiota can regulate levels of these gut peptides to influence the vagal afferent pathway and thus regulate intestinal metabolism via the microbiota-gut-brain axis. In addition, bile acids, short-chain fatty acids (SCFAs), trimethylamine-N-oxide (TMAO), and Immunoglobulin A (IgA) can also exert metabolic control through the microbiota-gut-liver axis. This review is mainly focused on the role of gut microbiota in neuroendocrine regulation of nutrient metabolism via the microbiota-gut-brain-liver axis.
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Affiliation(s)
- Shu-Zhi Wang
- Institute of Pharmacy and Pharmacology, University of South China, Hengyang 421001, China;
- Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, University of South China, Hengyang 421001, China
- Molecular Medicine, Research Institute, The Hospital for Sick Children and Department of Physiology, University of Toronto, Toronto, ON M5G 1X8, Canada
| | - Yi-Jing Yu
- Molecular Medicine, Research Institute, The Hospital for Sick Children and Department of Physiology, University of Toronto, Toronto, ON M5G 1X8, Canada
| | - Khosrow Adeli
- Molecular Medicine, Research Institute, The Hospital for Sick Children and Department of Physiology, University of Toronto, Toronto, ON M5G 1X8, Canada
- Correspondence: ; Tel.: +1-416-813-8682; Fax: +1-416-813-6257
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Hendrikx T, Schnabl B. Indoles: metabolites produced by intestinal bacteria capable of controlling liver disease manifestation. J Intern Med 2019; 286:32-40. [PMID: 30873652 DOI: 10.1111/joim.12892] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Alterations in the bacteria that reside in our gastrointestinal tract play a role in the pathogenesis and progression of many disorders including liver and gastrointestinal diseases. Both qualitative (composition) and quantitative (amount) changes in gut microbes are associated with increased susceptibility to liver disease. Importantly, the intestinal microbiota is involved in the regulation of many host signalling pathways via the generation of different metabolites. Hence, dysbiosis influences disease development and progression by directly affecting the host-bacteria metabolic interaction. Microbe-derived harmful metabolites can translocate to distant organs due to increased intestinal permeability as observed during dysbiosis. Contrary, certain bacterial metabolites such as tryptophan metabolites contribute to intestinal and systemic homeostasis. Here, we provide an overview of current evidence describing to what extent microbial metabolites modulate the development of chronic liver diseases such as alcoholic steatohepatitis and nonalcoholic fatty liver disease with a special emphasis on indoles.
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Affiliation(s)
- T Hendrikx
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - B Schnabl
- Department of Medicine, University of California San Diego, La Jolla, CA, USA.,Department of Medicine, VA San Diego Healthcare System, San Diego, CA, USA
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