Alcohol, smoking and the liver disease patient

The Association between Diet-Exercise Patterns and Cirrhosis: A Cross-Sectional Study from NHANES 2017-March 2020

BACKGROUND

Liver cirrhosis (LC) is one of the most significant causes of morbidity and mortality in patients with chronic liver disease worldwide. Nutrition may be an important component of primary prevention of chronic liver disease. Diet-exercise patterns frame the eating behaviors and exercise habits of people through statistical methods related to nutritional epidemiology, which can explore the relationship between living habits and diseases among diverse populations. The purpose of this study was to explore the association between diet-exercise patterns and cirrhosis, and provide guidance on preventive diets for liver patients.

METHODS

This study identified diet-exercise patterns via clustering analysis of principal components and assessed their association with cirrhosis through the population samples of the National Health and Nutrition Examination Survey (NHANES) from 2017 to March 2020.

RESULTS

We identified two diet-exercise patterns that were named the "prudent pattern" (consumption of various staple foods, eggs, meat, fruits and vegetables; less sedentary) and the "dangerous pattern" (higher consumption of desserts, nuts, milk, meat, alcoholic beverages; recreational activities). The t-test demonstrated a significant relationship between patterns and multiple foods. The simple logistic regression test showed a lower risk of cirrhosis in those in the "prudent pattern" (OR = 0.73, 95%CI = 0.59-0.93).

CONCLUSIONS

Two diet-exercise patterns associated with cirrhosis were identified: "prudent pattern" and "dangerous pattern". The results of this study may be useful for suggesting preventive diets for people at risk of cirrhosis.

Healthcare interactions prior to first hospital admission with alcohol-related liver disease

BACKGROUND AND AIMS

To examine the healthcare contacts of patients in the year before an index admission to hospital with alcohol-related liver disease (ArLD) to identify where opportunities for earlier identification of alcohol use disorders (AUD) and ArLD and intervention may occur.

METHODS

A retrospective cohort study using the regional database encompassing NHS organisations across North West London (344 general practitioner [GP] practices, 4 acute hospital trusts and 2 mental health and community health trusts). Patients who had an index admission with ArLD were identified through healthcare coding and compared with a control cohort. Healthcare contacts, blood tests and AUD testing in the year preceding admission were measured.

RESULTS

The ArLD cohort had 1494 participants with an index hospital admission with ArLD. The control cohort included 4462 participants. In the year preceding an index admission with ArLD, 91% of participants had at least one contact with primary care with an average of 2.97 (SD 2.45) contacts; 80% (n = 1199/1494) attended ED, 68% attended an outpatient clinic, and 42% (n = 628/1494) had at least one inpatient admission. Only 9% of the ArLD (137/1494) had formal testing for AUD. Abnormal bilirubin and platelets were more common in the ArLD than the control cohort 25% (138/560) and 28% (231/837), respectively, v 1% (12/1228) and 1% (20/1784).

CONCLUSIONS

Prior to an index admission with ArLD patients have numerous interactions with all healthcare settings, indicating missed opportunities for early identification and treatment.

Alcohol-associated liver disease: Epidemiology and management

Alcohol is the leading cause of preventable liver morbidity and mortality worldwide, as it is also the most frequent cause of advanced liver disease. Alcohol-associated liver disease (ALD) covers different phenotypes ranging from steatosis to the development of inflammation (steatohepatitis), fibrosis and ultimately, in a proportion of patients, the development of liver cirrhosis and its associated complications. ALD has a complex pathogenesis that includes the interplay of both genetic and environmental factors, yet the precise mechanisms are largely unknown. Alcohol-associated hepatitis (AH) is a severe clinical presentation of ALD, which is characterized by abrupt jaundice and clinical decompensations of liver disease. AH occurs in a percentage of patients with underlying ALD and active alcohol consumption. Currently, there are no approved targeted therapies able to interfere in the pathogenesis of ALD and halt the progression of the disease, therefore alcohol abstinence is the most effective measure to improve prognosis in this patient population. In this regard, alcohol cessation remains the first-line treatment in all stages of alcohol disease. In patients with advanced ALD nonresponding to medical therapy, liver transplantation is the only approach that improves prognosis, and it should be considered in patients with decompensated cirrhosis. In the last years, AH has emerged as a new indication of early liver transplantation in non-responders to medical therapy, with promising results in highly selected patients. In this review, we provide an update on the epidemiology, risk factors, natural history, diagnosis, pathogenesis, and current treatments for ALD, taking into account the importance of assessing and managing alcohol consumption as the etiological factor and the main driver of prognosis in patients with ALD.

Quality standards for the management of alcohol-related liver disease: consensus recommendations from the British Association for the Study of the Liver and British Society of Gastroenterology ARLD special interest group

OBJECTIVE

Alcohol-related liver disease (ALD) is the most common cause of liver-related ill health and liver-related deaths in the UK, and deaths from ALD have doubled in the last decade. The management of ALD requires treatment of both liver disease and alcohol use; this necessitates effective and constructive multidisciplinary working. To support this, we have developed quality standard recommendations for the management of ALD, based on evidence and consensus expert opinion, with the aim of improving patient care.

DESIGN

A multidisciplinary group of experts from the British Association for the Study of the Liver and British Society of Gastroenterology ALD Special Interest Group developed the quality standards, with input from the British Liver Trust and patient representatives.

RESULTS

The standards cover three broad themes: the recognition and diagnosis of people with ALD in primary care and the liver outpatient clinic; the management of acutely decompensated ALD including acute alcohol-related hepatitis and the posthospital care of people with advanced liver disease due to ALD. Draft quality standards were initially developed by smaller working groups and then an anonymous modified Delphi voting process was conducted by the entire group to assess the level of agreement with each statement. Statements were included when agreement was 85% or greater. Twenty-four quality standards were produced from this process which support best practice. From the final list of statements, a smaller number of auditable key performance indicators were selected to allow services to benchmark their practice and an audit tool provided.

CONCLUSION

It is hoped that services will review their practice against these recommendations and key performance indicators and institute service development where needed to improve the care of patients with ALD.

Association between smoking and non-alcoholic fatty liver disease in Southeast Asia

An estimated 8 million people die each year from tobacco smoking, with an increasing frequency recently being observed in Southeast Asian countries, which is a preventable risk factor for mortality. NAFLD, fibrosis, advancement of hepatocellular carcinoma, and prognosis for those with severe liver disease are all negatively influenced. NAFLD and cigarette usage seem to be a direct link. Oxidative stress and oncogenic signals have been implicated in cancer development in animal models and human clinical trials. The elevated risk of cardiovascular disease and malignancies in those with steatohepatitis and those who have had liver transplants is exacerbated by smoking. We found that smoking cessation may increase treatment response and fibrosis regression rates, decrease hepatocellular carcinoma incidence, and improve liver transplant outcomes. In the last segment, we'll look at electronic cigarettes, a hot subject in public health right now, as well as additional repercussions of smoking.

Research Progress on the Pharmacological Action of Schisantherin A

Schisantherin A (Sch A) is a dibenzocyclooctadiene lignan monomer isolated from the fruit of Schisandra chinensis (Turcz.) Baill. (S. chinensis). At present, many studies have shown that Sch A has a wide range of pharmacological effects, including its anti-Parkinson and anti-inflammatory effects and ability to protect the liver, protect against ischemia-reperfusion (I/R) injury, suppress osteoclast formation, and improve learning and memory. Its mechanism may be related to the antioxidant, anti-inflammatory, and antiapoptotic properties of Sch A through the MAPK, NF-κB, AKT/GSK3β, and PI3K/AKT pathways. This is the first review of the recent studies on the pharmacological mechanism of Sch A.

Association between liver cirrhosis and peri-implant diseases: a case-control study on implant- and patient-related risk factors

OBJECTIVE

The objective of this study was to evaluate the potential association between liver cirrhosis and peri-implant diseases, as well as the influence of different risk indicators on this association.

METHODS

This case-control study included 64 cases with liver cirrhosis and 128 controls without liver diseases that presented the same socio-demographic and economic profile. The specific inclusion criteria were the following: aged group of 35-55 years and presenting at least one osseointegrated implant functioning for >5 years. A full-mouth peri-implant and periodontal examination was performed and risk variables were recorded. The association between risk variables and the occurrence of peri-implant diseases was tested through univariate analysis and multivariate logistic regression, stratified by alcohol status. Additionally, a mediation analysis was performed to examine the mediating effect of age with peri-implantitis.

RESULTS

A high prevalence of peri-implantitis (29.7%) was observed among cases when compared to controls (18.0%). Individuals with cirrhosis presented ~2.5 higher chance of having peri-implantitis than controls (p<0.001). Significant variables associated with the occurrence of peri-implantitis in the final logistic model were the following: cirrhosis, alcohol use, age (>55 years), male sex, smoking, periodontitis, and number of ≤14.

CONCLUSIONS

An important risk association between liver cirrhosis and peri-implantitis was reported. Future studies with a larger sample size controlling for the patient- and implant-related confounders are needed to better understand the link between peri-implantitis and liver cirrhosis.

CLINICAL RELEVANCE

Cirrhosis individuals, age, and periodontitis, as well as alcohol use and smoking interaction, should be considered as potential risk indicators for peri-implantitis.

Association between serum ferritin, incident primary liver cancer, and chronic liver disease mortality in the Linxian Nutrition Intervention Trials: A nested case-control study

BACKGROUND AND AIM

Previous studies suggest that serum ferritin may be associated with higher risk of liver cancer. However, additional studies of the association are needed. It is also not clear whether serum ferritin is associated with mortality from chronic liver disease (CLD).

METHODS

We performed a nested case-control study in the Linxian Nutrition Intervention Trials. Baseline serum ferritin was measured for 226 incident primary liver cancer cases, 281 CLD mortalities diagnosed, and 1061 age-matched, gender-matched, and trial-matched controls. We used multivariable logistic regression models to calculate odds ratios and 95% confidence intervals. Subgroup analysis and interaction tests were performed by age, gender, alcohol drinking, hepatitis B virus seropositivity (HBV+)/hepatitis C virus seropositivity (HCV+), and trial.

RESULTS

Participants with serum ferritin in the highest quartile, as compared with those in the lowest quartile, had an increased risk of CLD mortality (odds ratio = 1.72, 95% confidence interval = 1.12, 2.64, P-trend < 0.01). Moreover, the association with higher serum ferritin was stronger among alcohol drinkers and those who were HCV+ (P-interaction < 0.05). For incident liver cancer, risk estimates were above one but were not statistically significant.

CONCLUSION

In this study, higher levels of serum ferritin at baseline were associated with subsequent mortality from CLD, particularly if combined with alcohol drinking or viral hepatitis. Further work is warranted to confirm our findings.

Evaluation of molecular markers GSTM1 and GSTT1 and clinical factors in breast cancer: case-control study and literature review

The study was conducted to evaluate the frequency of polymorphisms in GSTM1 and GSTT1 genes in patients with breast cancer compared with individuals without history of cancer, and the association of these polymorphisms with clinical/epidemiological parameters.There were evaluated 752 women (219 patients and 533 controls). Molecular analysis was performed by the Polymerase Chain Reaction (PCR). Statistical analysis was used multiple logistic regression and descriptive statistics.Age ≥50 years (OR =3.22, 95% CI =2.30 - 4.51, p <0.001) and alcohol consumption (OR =1.60, 95% CI =1.13 - 2.27, p = 0.008) were associated to the development of breast cancer, while smoking and null genotypes GSTM1 and GSTT1 presented no association. GSTM1 and GSTT1 polymorphisms presented no relationship with the clinical and histopathological parameters or molecular subtypes of breast cancer. Ninety-two percent of tumors were invasive ductal, 66% were grade II, 65% were larger than 2 cm, the stages II (35.3%) and III (31.2%) were the most prevalent, and 47.7% were molecular subtype luminal B.Individuals aged ≥50 years and alcohol consumers have more chance to developing breast cancer. GSTM1 and GSTT1 polymorphisms are not associated to the risk of breast cancer.

Polymorphisms in xenobiotic metabolism-related genes in patients with hepatocellular carcinoma: a case-control study

This study was performed to investigate the relationship between polymorphisms in microsomal epoxide hydrolase (mEH; Tyr113His and His139Arg substitution) and glutathione S-transferase (GST; GSTM1 deletion, GSTT1 deletion, and GSTP1.Ala114Val substitution) and their correlation with clinico-histopathological features in hepatocellular carcinoma (HCC).We evaluated environmental risk factors and genetic alterations in 556 individuals (86 cases and 470 controls). PCR multiplex for GSTM1 and GSTT1, polymerase chain reaction and restriction fragment length polymorphism (PCR-RFLP) for GSTP1, and real-time PCR for mEH were performed. Statistical analyses were performed using multiple logistic regression tests.Age over 48 years (p < 0.001) and alcohol consumption (p = 0.021) were the predictors of increased risk of developing HCC. GSTP1.Ala114Val for all regression models (p < 0.05), except the recessive model, and the GSTT1 null genotype (odds ratio [OR] = 0.43, 95% confidence interval [CI] = 0.21-0.87, p = 0.019) were predictors of an increased risk of developing HCC. Polymorphic GSTT1, GSTM1, GSTP1.Ala114Val, and mEH.His139Arg and wild-type mEH.Tyr113His (OR = 5.04; 95% CI = 1.59-16.04; p = 0.006) were associated with HCC.Age over 48 years, alcohol consumption, and the presence of polymorphic variants of GSTP1 and GSTT1 were associated with the risk of developing HCC.

Alcohol Use By Women in Serbia-A First Report

INTRODUCTION

Alcoholism is a growing problem with increasing incidence on in women. The aim of our study was to evaluate drinking habits in women using Alcohol Use Disorders Identification Test (AUDIT), and to look for differences in relations to respondents' demographic, behavioral, and medical characteristics.

METHODS

This cross-sectional study included 327 adult women who did not visit a physician due to liver enzymes abnormalities or any other significant health issue. All subjects filled in a questionnaire consisting of socio-demographic survey and the AUDIT.

RESULTS

The statistically significant influence of the respondents' age on the answers to the AUDIT was observed in Q1-Q5, Q7, and Q8, and in alcohol use risk groups. It was observed that women with a university degree use alcohol more often, compared to those who have attended primary, or middle school. The effect of responders' employment status demonstrated a statistically significant difference in response to Q3, Q5, Q7, and Q8, and in alcohol use risk groups. We found that marital status contributes to drinking patterns. We found statistically significant difference to the answers on Q1-Q3, Q5, Q7, and Q8. The effect of offspring on the answers on the AUDIT was analyzed and a statistically significant difference was noted in the answers to the Q1-Q3, Q5, Q7, Q8, and in alcohol use risk groups.

CONCLUSION

Alcohol use among women is commonly and severely overlooked. Our results showed younger women, the unemployed, those in domestic partnerships, single ones and those with no children deserve increased surveillance.

Identification of Key Biological Processes, Pathways, Networks, and Genes with Potential Prognostic Values in Hepatocellular Carcinoma Using a Bioinformatics Approach

Aim: Hepatocellular carcinoma (HCC), as one primary liver cancer type, accounts for 75%-85% of liver cancer cases. HCC is the second leading cause of cancer death in East Asia and sub-Saharan Africa and the sixth most common in western countries. Identification of key genes would facilitate the development of therapies and improve the prognosis outcomes of HCC patients. This study was to identify the key biological processes, pathways, and key genes in HCC. Methods: Data were downloaded from Broad GDAC. Differentially expressed genes (DEGs) and weighted gene coexpression network (WGCNA) were analyzed by DESeq2 and WGCNA, respectively. Gene ontology (GO) and KEGG enrichment analyses were performed on all DEGs and the coexpressed genes in two significant modules. Kaplan-Meier plotter online database was used to identify the potential prognostic genes in HCC. Finally, GEO database was used to validate the analysis of gene expression of Broad GDAC data. Results: The authors identified the dark gray and red modules as the significant modules in HCC based on WGCNA. GO and KEGG enrichment of the two significant modules identified the mitochondrion-mediated metabolic processes and pathways, and the cell cycle as the key biological processes and pathways in HCC. Subsequently, 28 hub genes were screened out by constructing protein-protein interaction network using Metascape. Finally, three genes (NDUFAF6, CKAP5, and DSN1 genes) were identified to be potential prognostic and key genes in HCC based on Kaplan-Meier survival analysis, GEO dataset validation, and literature review. Conclusions: The authors found that mitochondrion-mediated metabolic processes and the cell cycle were the key biological processes and pathways in HCC. NDUFAF6, CKAP5, and DSN1 genes were valuable genes with the potential to be prognosis biomarkers and targeted therapies in HCC.

Assessment of risk factors, and racial and ethnic differences in hepatocellular carcinoma

Despite improved screening and surveillance guidelines, significant race/ethnicity‐specific disparities in hepatocellular carcinoma (HCC) continue to exist and disproportionately affect minority and disadvantaged populations. This trend indicates that social determinants, genetic, and environmental factors are driving the epidemic at the population level. Race and geography had independent associations with risk of mortality among patients with HCC. The present review discusses the risk factors and issues related to disparities in HCC. The underlying etiologies for these disparities are complex and multifactorial. Some of the risk factors for developing HCC include hepatitis B (HBV) and hepatitis C (HCV) viral infection, nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, smoking and alcohol consumption. In addition, population genetics; socioeconomic and health care access; treatment and prevention differences; and genetic, behavioral, and biological influences can contribute to HCC. Acculturation of ethnic minorities, insurance status, and access to health care may further contribute to the observed disparities in HCC. By increasing awareness, better modalities for screening and surveillance, improving access to health care, and adapting targeted preventive and therapeutic interventions, disparities in HCC outcomes can be reduced or eliminated.

Paeonol ameliorates murine alcohol liver disease via mycobiota-mediated Dectin-1/IL-1β signaling pathway

Alcoholic liver disease (ALD) is caused by long-term consumption of alcohol and has become an important social and medical problem. Intestinal fungal flora (mycobiota) play an important role in ALD, so we used the mycobiota as an entry point to explore the mechanism of action of Paeonol against ALD. Here, we found that Paeonol is effective against ALD inflammatory lesions and relieves liver fat lesions. Furthermore, we found that after the treatment of Paeonol, the fungal dysbiosis is improved, and the fungal abundance is reduced, and the translocation of β-glucan to the liver and its mediated Dectin-1/IL-1β signaling pathway is blocked. Our study shows that paeonol ameliorated acute ALD-related inflammatory injury to the liver by alleviating intestinal fungal dysbiosis and inhibiting the mycobiota-mediated Dectin-1/IL-1β signaling pathway.

Periodontitis in individuals with liver cirrhosis: A case-control study

AIM

The aim of this study was to evaluate the association between liver cirrhosis and periodontitis.

METHODS

This case-control study included 294 individuals, 98 cases with liver cirrhosis and 196 controls. A full-mouth periodontal examination was performed and plaque index, probing depth, clinical attachment level and bleeding on probing were recorded. The association of risk variables with periodontitis was tested through univariate analysis and multivariate logistic regression, stratified by alcohol status.

RESULTS

A high prevalence of periodontitis was observed among cases (62.2%) when compared to controls (41.8%). Individuals with cirrhosis presented a chance ~2 higher of having periodontitis than controls (OR = 2.28; 95% CI 1.39-3.78; p < .001). Significant variables associated with periodontitis in the final logistic models were as follows: (a) no/occasional alcohol use model-number of teeth up 14, age ≥45-55 years, male sex and smoking; (b) moderate and intensive alcohol use models-cirrhosis, number of teeth up 14, age ≥45-55 years, male sex and smoking.

CONCLUSIONS

An important risk association between liver cirrhosis and periodontitis was observed. Additionally, the intensive alcohol use significantly increased the risk for periodontitis.

Integrated traditional Chinese and Western medicine in hepatocellular carcinoma treatment

As the branches of oncology become more and more detailed, its deficiencies gradually appear in clinical work in recent years. With the development of modern medicine, individualized treatment of hepatocellular carcinoma (HCC) has already been more emphasized in clinical work. This article reviews the diagnosis and treatment of HCC, which can be regarded as an organic systemic disease, based on a concept of integrated medicine. It is suggested that simply eliminating cancer lesions does not mean curing HCC. In clinical practice, it is necessary to use integrative thoughts such as basic study combined with clinical practice, medicine with pharmacy, traditional Chinese medicine with Western medicine, local with whole, etc, so as to find new integrative methods for diagnosis and treatment of HCC.

Liver Transplantation for Alcoholic Liver Disease: An Update

Alcoholic liver disease is a serious and increasing contributor to the global liver disease burden. Extensive selection criteria, including a minimum abstinence period, has previously been used to secure good outcomes but new research questions the effectiveness of abstinence periods and has recommended changes in integrated alcohol use treatment to effectively prevent relapse. Patients have unique health concerns, including posttransplantation risks of malignancy and metabolic complications, but overall very good long-term outcomes. Severe alcoholic hepatitis has been increasingly treated with early transplantation without a set sobriety period, with overall favorable outcomes, even with respect to recidivism.

Fibrosis and alcohol-related liver disease

Histological fibrosis stage is one of the most important prognostic factors in compensated and decompensated alcohol-related liver disease (ALD). Morphological assessment of fibrosis is useful for patient stratification, enabling individualised management, and for evaluation of treatment effects in clinical studies. In contrast to most chronic liver diseases where fibrosis is portal-based, fatty liver disease (FLD) of alcoholic or non-alcoholic aetiology (NAFLD) is associated with a centrilobular pattern of injury which leads to perivenular fibrosis and/or pericellular fibrosis. Progression of FLD drives expansive pericellular fibrosis, linking vascular structures and paving the way for the development of cirrhosis. At the cirrhotic stage, ongoing tissue damage leads to increasing fibrosis severity due to parenchymal loss and proliferation of fibrous scars. Histologic fibrosis staging systems have been devised, based on topography and the extent of fibrosis, for most chronic liver diseases. The utility of histological staging is reflected in different risks associated with individual fibrosis stages which cannot be reliably distinguished by non-invasive fibrosis assessment. In contrast to NAFLD, ALD-specific staging systems that enable the standardised prognostication required for clinical management and trials are lacking. Although morphological similarities between NAFLD and ALD exist, differences in clinical and histological features may substantially limit the utility of established NAFLD-specific staging systems for prognostication in ALD. This review summarises morphological features of fibrosis in ALD and compares them to other chronic liver diseases, particularly NAFLD. ALD-related fibrosis is examined in the context of pathogenetic mechanisms of fibrosis progression, regression and clinical settings that need to be considered in future prognostically relevant ALD staging approaches.

Alcoholic liver disease

Alcoholic liver disease (ALD) is the most prevalent type of chronic liver disease worldwide. ALD can progress from alcoholic fatty liver (AFL) to alcoholic steatohepatitis (ASH), which is characterized by hepatic inflammation. Chronic ASH can eventually lead to fibrosis and cirrhosis and in some cases hepatocellular cancer (HCC). In addition, severe ASH (with or without cirrhosis) can lead to alcoholic hepatitis, which is an acute clinical presentation of ALD that is associated with liver failure and high mortality. Most individuals consuming >40 g of alcohol per day develop AFL; however, only a subset of individuals will develop more advanced disease. Genetic, epigenetic and non-genetic factors might explain the considerable interindividual variation in ALD phenotype. The pathogenesis of ALD includes hepatic steatosis, oxidative stress, acetaldehyde-mediated toxicity and cytokine and chemokine-induced inflammation. Diagnosis of ALD involves assessing patients for alcohol use disorder and signs of advanced liver disease. The degree of AFL and liver fibrosis can be determined by ultrasonography, transient elastography, MRI, measurement of serum biomarkers and liver biopsy histology. Alcohol abstinence achieved by psychosomatic intervention is the best treatment for all stages of ALD. In the case of advanced disease such as cirrhosis or HCC, liver transplantation may be required. Thus, new therapies are urgently needed.

Recent advances in understanding liver fibrosis: bridging basic science and individualized treatment concepts

Hepatic fibrosis is characterized by the formation and deposition of excess fibrous connective tissue, leading to progressive architectural tissue remodeling. Irrespective of the underlying noxious trigger, tissue damage induces an inflammatory response involving the local vascular system and the immune system and a systemic mobilization of endocrine and neurological mediators, ultimately leading to the activation of matrix-producing cell populations. Genetic disorders, chronic viral infection, alcohol abuse, autoimmune attacks, metabolic disorders, cholestasis, alterations in bile acid composition or concentration, venous obstruction, and parasite infections are well-established factors that predispose one to hepatic fibrosis. In addition, excess fat and other lipotoxic mediators provoking endoplasmic reticulum stress, alteration of mitochondrial function, oxidative stress, and modifications in the microbiota are associated with non-alcoholic fatty liver disease and, subsequently, the initiation and progression of hepatic fibrosis. Multidisciplinary panels of experts have developed practice guidelines, including recommendations of preferred therapeutic approaches to a specific cause of hepatic disease, stage of fibrosis, or occurring co-morbidities associated with ongoing loss of hepatic function. Here, we summarize the factors leading to liver fibrosis and the current concepts in anti-fibrotic therapies.