Synthesis and functional characterization of a fluorescent peptide probe for non invasive imaging of collagen in live tissues

Advances in Noninvasive Molecular Imaging Probes for Liver Fibrosis Diagnosis

Liver fibrosis is a wound-healing response to chronic liver injury, which may lead to cirrhosis and cancer. Early-stage fibrosis is reversible, and it is difficult to precisely diagnose with conventional imaging modalities such as magnetic resonance imaging, positron emission tomography, single-photon emission computed tomography, and ultrasound imaging. In contrast, probe-assisted molecular imaging offers a promising noninvasive approach to visualize early fibrosis changes in vivo, thus facilitating early diagnosis and staging liver fibrosis, and even monitoring of the treatment response. Here, the most recent progress in molecular imaging technologies for liver fibrosis is updated. We start by illustrating pathogenesis for liver fibrosis, which includes capillarization of liver sinusoidal endothelial cells, cellular and molecular processes involved in inflammation and fibrogenesis, as well as processes of collagen synthesis, oxidation, and cross-linking. Furthermore, the biological targets used in molecular imaging of liver fibrosis are summarized, which are composed of receptors on hepatic stellate cells, macrophages, and even liver collagen. Notably, the focus is on insights into the advances in imaging modalities developed for liver fibrosis diagnosis and the update in the corresponding contrast agents. In addition, challenges and opportunities for future research and clinical translation of the molecular imaging modalities and the contrast agents are pointed out. We hope that this review would serve as a guide for scientists and students who are interested in liver fibrosis imaging and treatment, and as well expedite the translation of molecular imaging technologies from bench to bedside.

Electrospun skin dressings for diabetic wound treatment: a systematic review

Abstract

Diabetes mellitus is a metabolic disease characterized by persistent hyperglycemia associated with a lack of insulin production or insulin resistance. In diabetic patients, the capacity for healing is generally decreased, leading to chronic wounds. One of the most common treatments for chronic wounds is skin dressings, which serve as protection from infection, reduce pain levels, and stimulate tissue healing. Furthermore, electrospinning is one of the most effective techniques used for manufacturing skin dressings.

Objective

The purpose of this study was to perform a systematic review of the literature to examine the effects of electrospun skin dressings from different sources in the process of healing skin wounds using in vivo experiments in diabetic rats.

Methods

The search was carried out according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and the Medical Subject Headings (MeSH) descriptors were defined as "wound dressing," "diabetes," "in vivo," and "electrospun." A total of 14 articles were retrieved from PubMed and Scopus databases.

Results

The results were based mainly on histological analysis and macroscopic evaluation, demonstrating moderate evidence synthesis for all experimental studies, showing a positive effect of electrospun skin dressings for diabetic wound treatment.

Conclusion

This review confirms the significant benefits of using electrospun skin dressings for skin repair and regeneration. All the inks used were demonstrated to be suitable for dressing manufacturing. Moreover, in vivo findings showed full wound closure in most of the studies, with well-organized dermal and epidermal layers.

Radiotracers for Imaging of Fibrosis: Advances during the Last Two Decades and Future Directions

Fibrosis accompanies various pathologies, and there is thus an unmet medical need for non-invasive, sensitive, and quantitative methods for the assessment of fibrotic processes. Currently, needle biopsy with subsequent histological analysis is routinely used for the diagnosis along with morphological imaging techniques, such as computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US). However, none of these imaging techniques are sufficiently sensitive and accurate to detect minor changes in fibrosis. More importantly, they do not provide information on fibrotic activity on the molecular level, which is critical for fundamental understanding of the underlying biology and disease course. Molecular imaging technology using positron emission tomography (PET) offers the possibility of imaging not only physiological real-time activity, but also high-sensitivity and accurate quantification. This diagnostic tool is well established in oncology and has exhibited exponential development during the last two decades. However, PET diagnostics has only recently been widely applied in the area of fibrosis. This review presents the progress of development of radiopharmaceuticals for non-invasive detection of fibrotic processes, including the fibrotic scar itself, the deposition of new fibrotic components (fibrogenesis), or the degradation of existing fibrosis (fibrolysis).

Flounder fish (Paralichthys sp.) collagen a new tissue regeneration: genotoxicity, cytotoxicity and physical-chemistry characterization

Collagen dressings have been widely used as effective treatments for chronic wounds acting as barrier, protecting the area from infections and participating in the healing process. Collagen from fish skin is biocompatible, presents low immunogenicity and is able of stimulating wound healing. In this scenario, skin of flounder fish (Paralichthys sp.) may constitute a promising source for collagen. Then, our hypothesis is that fish collagen is able of increasing cell proliferation, with no cytotoxicity. In this context, the aim of the present study was to investigate the physicochemical and morphological properties of collagen using scanning electron microscopy (SEM), Energy dispersive X-ray spectroscopy (EDS), mass loss and pH. Moreover, the cytotoxicity and genotoxicity of collagen were studied using in vitro studies (cell viability, comet assay and micronucleus assay). Fish collagen showed no variation of pH and mass weight, with characteristic peaks of collagen in FTIR. Furthermore, all the extracts presented cell viability at least over 50% and no cytotoxicity was observed. Regarding genotoxicity data, the results showed that only the extract of 100% showed higher values in comparison with negative control group for CHO-K1 cell line as depicted by comet and micronucleus assays. Based on the results, it is suggested that fish collagen is biocompatible and present non-cytotoxicity in the in vitro studies, being considered a suitable material for tissue engineering proposals.

Fish collagen for skin wound healing: a systematic review in experimental animal studies

Collagen extracted from fishes has been appearing as an alternative for commercial porcine and bovine collagen and it has been considered interesting especially for membrane manufacturing in tissue engineering. Despite the positive in vitro effects of fish collagen membranes, there is still no understanding of all the benefits that this natural biomaterial plays in the wound healing process, due to the lack of compilation of the results obtained in animal studies. In this sense, the purpose of this study was to perform a systematic review of the literature to examine the effects of fish collagen membranes for skin wound healing in experimental models of skin wound. The search was carried out according to the orientations of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), and the descriptors of the Medical Subject Headings (MeSH) were defined: "fish," collagen," "skin," and "in vivo". A total of 10 articles were retrieved from the databases PubMed and Scopus. After the elegibility analyses, this review covers the different origins of fish collagen reported in the different papers from the beginning of 2015 through the middle of 2021. The results were based mainly on histological analysis and macroscopic evaluation, and fish skin collagen was responsible for improving the wound healing rate and the process of reepithelization and collagen deposition. In conclusion, fish skin collagen has shown positive results in in vivo studies and may be a potential biomaterial in tissue engineering.

Comparison of Different Methods for Spongin-like Collagen Extraction from Marine Sponges (Chondrilla caribensis and Aplysina fulva): Physicochemical Properties and In Vitro Biological Analysis

This study aimed to compare different protocols (Protocol 1: P1; Protocol 2: P2; Protocol 3: P3; Protocol 4: P4) for the extraction of spongin-like collagen (SC) from marine sponges. The SEM micrographs demonstrated a fibrillar structure for the extracts from Chondrilla caribensis and the nodular/particulate aggregates for Aplysina fulva. FTIR showed for all samples peaks similar to collagen for both species. For C. caribensis, the extracts obtained using P2, P3, and P4 protocols presented higher values of extraction yield, TPQ, and GAGs. P2 and P4 showed higher values of SC concentration and for antioxidant analysis. For A. fulva, P2, P3, and P4 provided a higher extraction yield besides an increase in the antioxidant assay. For both species, no difference was observed for Col quantification and TPQ analysis; also, higher values of GAGs were found using P2 and P4. Fibroblast proliferation observed for C. caribensis was lower for P1 on day 1 and for P2 and P3 on day 3 (for 50%) compared to the control group. There was a significant reduction in fibroblast cell proliferation for all A. fulva extracts evaluated. It can be concluded that protocols P2 and P4 were more efficient for extracting SC from C. caribensis.

USPIO-PEG nanoparticles functionalized with a highly specific collagen-binding peptide: a step towards MRI diagnosis of fibrosis

Fibrosis is characterized by a pathologic deposition of collagen I, leading to impaired function of organs. Tissue biopsy is the gold standard method for the diagnosis of fibrosis but this is an invasive procedure, subject to sampling errors. Several non-invasive techniques such as magnetic resonance imaging (MRI) using non-specific probes have been developed but they are not fully satisfying as they allow diagnosis at a late stage. In this study, collagelin, a collagen-binding peptide has been covalently linked using click chemistry to pegylated Ultra Small Super Paramagnetic Iron Oxide Nanoparticles (USPIO-PO-PEG-collagelin NPs) with the aim of diagnosing fibrosis at an early stage by MRI. USPIO-PO-PEG-collagelin NPs showed a high affinity for collagen I, two times higher than that of free collagelin whereas not peptide labeled USPIO NPs (USPIO-PO-PEG-yne) did not present any affinity. NPs were not toxic for macrophages and fibroblasts. Diffusion through collagen hydrogels concentrated at 3 and 10 mg mL-1 revealed a large accumulation of USPIO-PO-PEG-collagelin NPs within the collagen network after 72 hours, ca. 3 times larger than that of unlabeled USPIO, thereby evidencing the specific targeting of collagen I. Moreover, the quantity of USPIO-PO-PEG-collagelin NPs accumulated within hydrogels was proportional to the collagen concentration. Subsequently, the NPs diffusion through collagen hydrogels was monitored by MRI. The MRI T2 time relaxation decreased much more significantly with depth for USPIO-PO-PEG-collagelin NPs compared to unlabeled ones. Taken together, these results show that USPIO-PEG-collagelin NPs are promising as effective MRI nanotracers for molecular imaging of fibrosis at an early stage.

Py3-FITC: a new fluorescent probe for live cell imaging of collagen-rich tissues and ionocytes

Polypyrrole-based polyamides are used as sequence-specific DNA probes. However, their cellular uptake and distribution are affected by several factors and have not been extensively studied in vivo. Here, we generated a series of fluorescence-conjugated polypyrrole compounds and examined their cellular distribution using live zebrafish and cultured human cells. Among the evaluated compounds, Py3-FITC was able to visualize collagen-rich tissues, such as the jaw cartilage, opercle and bulbus arteriosus, in early-stage living zebrafish embryos. Then, we stained cultured human cells with Py3-FITC and found that the staining became more intense as the amount of collagen was increased. In addition, Py3-FITC-stained HR cells, which represent a type of ionocyte on the body surface of living zebrafish embryos. Py3-FITC has low toxicity, and collagen-rich tissues and ionocytes can be visualized when soaked in Py3-FITC solution. Therefore, Py3-FITC may be a useful live imaging tool for detecting changes in collagen-rich tissue and ionocytes, including their mammalian analogues, during both normal development and disease progression.

Collagen from Marine Sources and Skin Wound Healing in Animal Experimental Studies: a Systematic Review

Collagen (Col) from marine organisms has been emerging as an important alternative for commercial Col and it has been considered highly attractive by the industry. Despite the positive effects of Col from marine origin, there is still limited understanding of the effects of this natural biomaterial in the process of wound healing in animal studies. In this context, the purpose of this study was to perform a systematic review of the literature to examine the effects of Col from different marine species in the process of skin tissue healing using experimental models of skin wound. The search was carried out according to the orientations of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), and the descriptors of the Medical Subject Headings (MeSH) were defined: "marine collagen," "spongin," "spongin," "skin," and "wound." A total of 42 articles were retrieved from the databases PubMed and Scopus. After the eligibility analyses, this review covers the different marine sources of Col reported in 10 different papers from the beginning of 2011 through the middle of 2019. The results were based mainly on histological analysis and it demonstrated that Col-based treatment resulted in a higher deposition of granulation tissue, stimulation of re-epitalization and neoangiogenesis and increased amount of Col of the wound, culminating in a more mature morphological aspect. In conclusion, this review demonstrates that marine Col from different species presented positive effects on the process of wound skin healing in experimental models used, demonstrating the huge potential of this biomaterial for tissue engineering proposals.

Radiolabelling and positron emission tomography imaging of a high-affinity peptide binder to collagen type 1

INTRODUCTION

Pathological formation of fibrosis, is an important feature in many diseases. Fibrosis in liver and pancreas has been associated to metabolic disease including type 1 and 2 diabetes. The current methods for detecting and diagnosing fibrosis are either invasive, or their sensitivity to detect fibrosis in early stage is limited. Therefore, it is crucial to develop non-invasive methods to detect, stage and study the molecular processes that drive the pathology of liver fibrosis. The peptide LRELHLNNN was previously identified as a selective binder to collagen type I with an affinity of 170 nM. Radiolabelled LRELHLNNN thus constitute a potential PET tracer for fibrosis.

METHOD

LRELHLNNN was conjugated to a DOTA/NOTA moiety via a PEG2-linker. DOTA-PEG2-LRELHLNNN was labelled with Gallium-68 and NOTA- PEG2-LRELHLNNN with aluminium fluoride-18. Biodistribution of [68Ga]Ga-DOTA-PEG2-LRELHLNNN and [18F]AlF-NOTA-PEG2-LRELHLNNN was performed in healthy rats ex vivo and in vivo. The 68Ga-labelled analogue was evaluated in a mouse model of liver fibrosis by PET/MRI-imaging. The human predicted dosimetry of the tracers was extrapolated from rat ex vivo biodistribution studies at 10, 20, 40, 60, 120, 180 min (only fluoride-18) post-injection.

RESULTS

The peptides were successfully radiolabelled with gallium-68 and aluminium fluoride-18, respectively. The biodistribution of [68Ga]Ga-DOTA-PEG2-LRELHLNNN and [18F]AlF-NOTA-PEG2-LRELHLNNN was favorable showing rapid clearance and low background binding in organs where fibrosis may develop. Binding of [68Ga]Ga-DOTA-PEG2-LRELHLNNN to fibrotic liver was higher than surrounding tissues in mice with induced hepatic fibrosis. However, the binding was in the range of SUV 0.3, indicating limited targeting of the tracer to liver. The extrapolated human predicted dosimetric profiles of [68Ga]Ga-DOTA-PEG2-LRELHLNNN and [18F]AlF-NOTA-PEG2-LRELHLNNN were beneficial, potentially allowing at least three PET examinations annually.

CONCLUSIONS

We describe the modification, radiolabelling and evaluation of the collagen type I binding peptide LRELHLNNN. The resulting radiotracer analogues demonstrated suitable biodistribution and dosimetry. [68Ga]Ga-DOTA-PEG2-LRELHLNNN exhibited binding to hepatic fibrotic lesions and is a promising tool for PET imaging of fibrosis.

ADVANCES IN KNOWLEDGE

Validation of a new collagen targeting PET tracer.

IMPLICATIONS FOR PATIENT CARE

Early, non-invasive diagnosis and stratification of fibrosis in order to improve the diagnosis, staging and treatment of patients with diseases involving fibrosis.

Tendon Extracellular Matrix Assembly, Maintenance and Dysregulation Throughout Life

In his Lissner Award medal lecture in 2000, Stephen Cowin asked the question: "How is a tissue built?" It is not a new question, but it remains as relevant today as it did when it was asked 20 years ago. In fact, research on the organization and development of tissue structure has been a primary focus of tendon and ligament research for over two centuries. The tendon extracellular matrix (ECM) is critical to overall tissue function; it gives the tissue its unique mechanical properties, exhibiting complex non-linear responses, viscoelasticity and flow mechanisms, excellent energy storage and fatigue resistance. This matrix also creates a unique microenvironment for resident cells, allowing cells to maintain their phenotype and translate mechanical and chemical signals into biological responses. Importantly, this architecture is constantly remodeled by local cell populations in response to changing biochemical (systemic and local disease or injury) and mechanical (exercise, disuse, and overuse) stimuli. Here, we review the current understanding of matrix remodeling throughout life, focusing on formation and assembly during the postnatal period, maintenance and homeostasis during adulthood, and changes to homeostasis in natural aging. We also discuss advances in model systems and novel tools for studying collagen and non-collagenous matrix remodeling throughout life, and finally conclude by identifying key questions that have yet to be answered.

Collagen membranes for skin wound repair: A systematic review

Membranes or skin dressing are common treatments for skin wound injuries, collagen being one the most effective materials for their manufacturing. Many different sources of collagen with diverse methods of extraction and processing have been used, with evidence of positive effects on the stimulation of skin wound healing. In spite of these factors, there is still limited understanding of the interaction between collagen membranes and biological tissues, especially due to the series of different types of collagen origin. In this context, this study aimed to conduct a systematic review of the available literature examining the effect of various collagen membranes for accelerating skin wound healing in experimental animal models and clinical trials. The present review was performed from March to May of 2020 searching in two databases (PubMed and Scopus). The following Medical Subject Headings (MeSH) descriptors were used: "collagen", "dressing", "membranes", "skin" and "wound". After the eligibility assessment, 16 studies were included and analyzed. The studies demonstrated that collagen was obtained predominantly from bovine and porcine sources, by acetic acid and/or enzyme dissolution. Additionally, most of the studies demonstrated that the membranes were processed mainly by freeze-drying or lyophilization methods. All the in vivo and clinical trial studies evidenced positive outcomes in the wound healing process, thus confirming that collagen membranes are one of the most efficient treatment for skin wounds, highlighting the enormous potential of this biomaterial to be used for skin tissue engineering purposes.

A novel apoA-I mimetic peptide suppresses atherosclerosis by promoting physiological HDL function in apoE-/- mice

BACKGROUND AND PURPOSE

Apolipoprotein A-I (apoA-I) mimetic peptides (AAMPs) are short peptides that can mimic the physiological effects of apoA-I, including the suppression of atherosclerosis by reversely transporting peripheral cholesterol to the liver. As the hydrophobicity of apoA-I is considered important for its lipid transport, novel AAMPs were designed and synthesized in this study by gradually increasing the hydrophobicity of the parent peptide, and their anti-atherosclerotic effects were tested.

EXPERIMENTAL APPROACH

Seventeen new AAMPs (P1-P17) with incrementally increased hydrophobicity were designed and synthesized by replacing the amino acids 221-240 of apoA-I (VLESFKVSFLSALEEYTKKL). Their effects on cholesterol efflux were evaluated. Their cytotoxicity and haemolytic activity were also measured. The in vitro mechanism of the action of the new peptides was explored. Adult apolipoprotein E^-/- mice were used to evaluate the anti-atherosclerotic activity of the best candidate, and the mechanistic basis of its anti-atherosclerotic effects was explored.

KEY RESULTS

Seventeen new AAMPs (P1-P17) were synthesized, and their cholesterol efflux activity and cytotoxicity were closely related to their hydrophobicity. P12 (FLEKLKELLEHLKELLTKLL) was the best candidate and most strongly promoted cholesterol efflux among the non-toxic peptides (P1-P12). With its phospholipid affinity, P12 facilitated cholesterol transport through the ATP-binding cassette transporter A1. In vivo, P12 exhibited prominent anti-atherosclerotic activity via coupling with HDL.

CONCLUSION AND IMPLICATIONS

P12 featured adequate hydrophobicity, which ensured its efficient binding with cytomembrane phospholipids, cholesterol and HDL, and provided a basis for its ability to reversely transport cholesterol and treat atherosclerosis.

Light induced intramolecular energy and electron transfer events in carbazole–corrole and phenothiazine-corrole dyads

We report two corrole based donor–acceptor (D–A) dyads, Cbz-Cor and Ptz-Cor to understand the energy/electron transfer reactions. In these D–A systems, the donor, either carbazole (Cbz) or phenothiazine (Ptz), is covalently connected at the meso-phenyl position of 10-(phenyl)-5,15-bis-(pentafluorophenyl)corrole (Ph-Cor) by C–N linkage. Both the dyads were characterized by 1H NMR, MALDI-TOF MS, UV-vis, electrochemical, computational methods, study state fluorescence and TCSPC techniques. A comparison of absorption spectra with their reference monomeric compounds (Cbz-Ph, Ptz-Ph and Ph-Cor) revealed minimal ground-state interactions between chromophores in both dyads. Fluorescence studies suggested that singlet–singlet energy transfer from 1Cbz* to corrole is the major photochemical pathway in the Cbz-Cor dyad with a quenching efficiency of [Formula: see text]99%. Detailed analysis of the data suggests that Forster’s dipole–dipole mechanism does not adequately explain this energy transfer. However, at a 410 nm excitation, florescence quenching is detected in Ptz-Cor (49%) supporting a photo induced electron transfer (PET) process from the ground state of PTZ to the excited state of corrole macrocycle. The electron-transfer rates ([Formula: see text] of Ptz-Cor are found in the range [Formula: see text] to [Formula: see text] and are concluded to be solvent dependent.

Live Imaging of Type I Collagen Assembly Dynamics in Osteoblasts Stably Expressing GFP and mCherry-Tagged Collagen Constructs

Type I collagen is the most abundant extracellular matrix protein in bone and other connective tissues and plays key roles in normal and pathological bone formation as well as in connective tissue disorders and fibrosis. Although much is known about the collagen biosynthetic pathway and its regulatory steps, the mechanisms by which it is assembled extracellularly are less clear. We have generated GFPtpz and mCherry-tagged collagen fusion constructs for live imaging of type I collagen assembly by replacing the α2(I)-procollagen N-terminal propeptide with GFPtpz or mCherry. These novel imaging probes were stably transfected into MLO-A5 osteoblast-like cells and fibronectin-null mouse embryonic fibroblasts (FN-null-MEFs) and used for imaging type I collagen assembly dynamics and its dependence on fibronectin. Both fusion proteins co-precipitated with α1(I)-collagen and remained intracellular without ascorbate but were assembled into α1(I) collagen-containing extracellular fibrils in the presence of ascorbate. Immunogold-EM confirmed their ultrastuctural localization in banded collagen fibrils. Live cell imaging in stably transfected MLO-A5 cells revealed the highly dynamic nature of collagen assembly and showed that during assembly the fibril networks are continually stretched and contracted due to the underlying cell motion. We also observed that cell-generated forces can physically reshape the collagen fibrils. Using co-cultures of mCherry- and GFPtpz-collagen expressing cells, we show that multiple cells contribute collagen to form collagen fiber bundles. Immuno-EM further showed that individual collagen fibrils can receive contributions of collagen from more than one cell. Live cell imaging in FN-null-MEFs expressing GFPtpz-collagen showed that collagen assembly was both dependent upon and dynamically integrated with fibronectin assembly. These GFP-collagen fusion constructs provide a powerful tool for imaging collagen in living cells and have revealed novel and fundamental insights into the dynamic mechanisms for the extracellular assembly of collagen. © 2018 American Society for Bone and Mineral Research.

Cardiac Fibrosis and Arrhythmogenesis

Myocardial injury, mechanical stress, neurohormonal activation, inflammation, and/or aging all lead to cardiac remodeling, which is responsible for cardiac dysfunction and arrhythmogenesis. Of the key histological components of cardiac remodeling, fibrosis either in the form of interstitial, patchy, or dense scars, constitutes a key histological substrate of arrhythmias. Here we discuss current research findings focusing on the role of fibrosis, in arrhythmogenesis. Numerous studies have convincingly shown that patchy or interstitial fibrosis interferes with myocardial electrophysiology by slowing down action potential propagation, initiating reentry, promoting after-depolarizations, and increasing ectopic automaticity. Meanwhile, there has been increasing appreciation of direct involvement of myofibroblasts, the activated form of fibroblasts, in arrhythmogenesis. Myofibroblasts undergo phenotypic changes with expression of gap-junctions and ion channels thereby forming direct electrical coupling with cardiomyocytes, which potentially results in profound disturbances of electrophysiology. There is strong evidence that systemic and regional inflammatory processes contribute to fibrogenesis (i.e., structural remodeling) and dysfunction of ion channels and Ca2+ homeostasis (i.e., electrical remodeling). Recognizing the pivotal role of fibrosis in the arrhythmogenesis has promoted clinical research on characterizing fibrosis by means of cardiac imaging or fibrosis biomarkers for clinical stratification of patients at higher risk of lethal arrhythmia, as well as preclinical research on the development of antifibrotic therapies. At the end of this review, we discuss remaining key questions in this area and propose new research approaches. © 2017 American Physiological Society. Compr Physiol 7:1009-1049, 2017.

Strategies and endpoints of antifibrotic drug trials: Summary and recommendations from the AASLD Emerging Trends Conference, Chicago, June 2014

There is an urgent need to develop antifibrotic therapies for chronic liver disease, and clarify which endpoints in antifibrotic trials will be acceptable to regulatory agencies. The American Association for the Study of Liver Diseases sponsored an endpoints conference to help accelerate the efficient testing of antifibrotic agents and develop recommendations on clinical trial design for liver fibrosis. In this review, we summarize the salient and novel elements of this conference and provide directions for future clinical trial design. The article follows the structure of the conference and is organized into five areas: (1) antifibrotic trial design; (2) preclinical proof-of-concept studies; (3) pharmacological targets, including rationale and lessons to learn; (4) rational drug design and development; and (5) consensus and recommendations on design of clinical trials in liver fibrosis. Expert overviews and collaborative discussions helped to summarize the key unmet needs and directions for the future, including: (1) greater clarification of at-risk populations and study groups; (2) standardization of all elements of drug discovery and testing; (3) standardization of clinical trial approaches; (4) accelerated development of improved noninvasive markers; and (5) need for exploration of potential off-target toxicities of future antifibrotic drugs.