AGA technical review on the evaluation of liver chemistry tests

Relationships between blood chromium exposure and liver injury: Exploring the mediating role of systemic inflammation in a chromate-exposed population

Hexavalent chromium and its compounds are prevalent pollutants, especially in the work environment, pose a significant risk for multisystem toxicity and cancers. While it is known that chromium accumulation in the liver can cause damage, the dose-response relationship between blood chromium (Cr) and liver injury, as well as the possible potential toxic mechanisms involved, remains poorly understood. To address this, we conducted a follow-up study of 590 visits from 305 participants to investigate the associations of blood Cr with biomarkers for liver injury, including serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), and direct bilirubin (DBIL), and to evaluate the mediating effects of systemic inflammation. Platelet (PLT) and the platelet-to-lymphocyte ratio (PLR) were utilized as biomarkers of systemic inflammation. In the linear mixed-effects analyses, each 1-unit increase in blood Cr level was associated with estimated effect percentage increases of 0.82% (0.11%, 1.53%) in TBIL, 1.67% (0.06%, 3.28%) in DBIL, 0.73% (0.04%, 1.43%) in ALT and 2.08% (0.29%, 3.87%) in AST, respectively. Furthermore, PLT mediated 10.04%, 11.35%, and 10.77% increases in TBIL, DBIL, and ALT levels induced by chromate, respectively. In addition, PLR mediated 8.26% and 15.58% of the association between blood Cr and TBIL or ALT. These findings shed light on the mechanisms underlying blood Cr-induced liver injury, which is partly due to worsening systemic inflammation.

Alanine aminotransferase predicts incident steatotic liver disease of metabolic etiology: Long life to the old biomarker!

Alanine aminotransferase (ALT) serum levels increase because of hepatocellular damage. Metabolic dysfunction-associated fatty liver disease (MAFLD), which identifies steatotic liver disease (SLD) associated with ≥ 2 metabolic abnormalities, has prominent sexual differences. The Metabolic Syndrome defines a cluster comprising abdominal obesity, altered glucose metabolism, dyslipidemia, and hypertension. Male sex, body mass index, glucose, lipids, ferritin, hypertension, and age independently predict ALT levels among blood donors. Over the last few decades, the reference range of ALT levels has been animatedly debated owing to attempts to update sex-specific reference ranges. With this backset, Chen et al have recently published a study which has two main findings. First, > 80% of individuals with MAFLD had normal ALT levels. Second, there was a linear increasing trend in the association between cumulative excess high-normal ALT levels and the rate of incident MAFLD. This study has biologically credible findings. However, it inaccurately considered sex differences in the MAFLD arena. Therefore, future studies on SLD owing to metabolic dysfunction should adopt locally determined and prospectively validated reference ranges of ALT and carefully consider sex differences in liver enzymes and MAFLD pathobiology.

Effects of multiple metals exposure on abnormal liver function: The mediating role of low-density lipoprotein cholesterol

Equilibration of metal metabolism is critical for normal liver function. Most epidemiological studies have only concentrated on the influence of limited metals. However, the single and synergistic impact of multiple-metal exposures on abnormal liver function (ALF) are still unknown. A cross-sectional study involving 1493 Chinese adults residing in Shenzhen was conducted. Plasma concentrations of 13 metals, including essential metals (calcium, copper, cobalt, iron, magnesium, manganese, molybdenum, zinc, and selenium) and toxic metals (aluminum, cadmium, arsenic, and thallium) were detected by the inductively coupled plasma spectrometry (ICP-MS). ALF was ascertained as any observed abnormality from albumin, alanine transaminase, aspartate transaminase, γ-glutamyl transpeptidase, and direct bilirubin. Diverse statistical methods were used to evaluate the single and mixture effect of metals, as well as the dose-response relationships with ALF risk, respectively. Mediation analysis was conducted to evaluate the role of blood lipids in the relation of metal exposure with ALF. The average age of subjects was 59.7 years, and 56.7 % were females. Logistic regression and the least absolute shrinkage and selection operator (LASSO) penalized regression model consistently suggested that increased levels of arsenic, aluminum, manganese, and cadmium were related to elevated risk of ALF; while magnesium and zinc showed protective effects on ALF (all p-trend < 0.05). The grouped weighted quantile sum (GWQS) regression revealed that the WQS index of essential metals and toxic metals showed significantly negative or positive relationship with ALF, respectively. Aluminum, arsenic, cadmium, and manganese showed linear whilst magnesium and zinc showed non-linear dose-response relationships with ALF risk. Mediation analysis showed that LDL-c mediated 4.41 % and 14.74 % of the relationship of plasma cadmium and manganese with ALF, respectively. In summary, plasma aluminum, arsenic, manganese, cadmium, magnesium, and zinc related with ALF, and LDL-c might underlie the pathogenesis of ALF associated with cadmium and manganese exposure. This study may provide critical public health significances in liver injury prevention and scientific evidence for the establishment of environmental standard.

Remotely controlled drug release in deep brain regions of non-human primates

Many areas of science and medicine would benefit from selective release of drugs in specific regions. Nanoparticle drug carriers activated by focused ultrasound-remotely applied, depth-penetrating energy-may provide such selective interventions. Here, we developed stable, ultrasound-responsive nanoparticles that can be used to release drugs effectively and safely in non-human primates. The nanoparticles were used to release propofol in deep brain visual regions. The release reversibly modulated the subjects' visual choice behavior and was specific to the targeted region and to the released drug. Gadolinium-enhanced MR imaging suggested an intact blood-brain barrier. Blood draws showed normal clinical chemistry and hematology. In summary, this study provides a safe and effective approach to release drugs on demand in selected deep brain regions at levels sufficient to modulate behavior.

Nonalcoholic Fatty Liver Disease: Changes in Gut Microbiota and Blood Lipids

Background and Aims

The global prevalence of nonalcoholic fatty liver disease (NAFLD) is 25%. This study aimed to explore differences in the gut microbial community and blood lipids between normal livers and those affected by NAFLD using 16S ribosomal deoxyribonucleic acid sequencing.

Methods

Gut microbiome profiles of 40 NAFLD and 20 non-NAFLD controls were analyzed. Information about four blood lipids and 13 other clinical features was collected. Patients were divided into three groups by ultrasound and FibroScan, those with a normal liver, mild FL (FL1), and moderate-to-severe FL (FL2). FL1 and FL2 patients were divided into two groups, those with either hyperlipidemia or non-hyperlipidemia based on their blood lipids. Potential keystone species within the groups were identified using univariate analysis and a specificity-occupancy plot. Significant difference in biochemical parameters ion NAFLD patients and healthy individuals were identified by detrended correspondence analysis and canonical correspondence analysis.

Results

Decreased gut bacterial diversity was found in patients with NAFLD. Firmicutes/Bacteroidetes decreased as NAFLD progressed. Faecalibacterium and Ruminococcus 2 were the most representative fatty-related bacteria. Glutamate pyruvic transaminase, aspartate aminotransferase, and white blood cell count were selected as the most significant biochemical indexes. Calculation of areas under the curve identified two microbiomes combined with the three biochemical indexes that identified normal liver and FL2 very well but performed poorly in diagnosing FL1.

Conclusions

Faecalibacterium and Ruminococcus 2, combined with glutamate pyruvic transaminase, aspartate aminotransferase, and white blood cell count distinguished NAFLD. We speculate that regulating the health of gut microbiota may release NAFLD, in addition to providing new targets for clinicians to treat NAFLD.

Liver toxicity in oncology trials and beyond: a simplified concept for management of hepatocellular drug-induced liver injury in patients with abnormal baseline liver tests

BACKGROUND

Management of side effects in clinical trials has to balance generation of meaningful data with risk for patients. A toxicity area requiring detailed management guidelines is drug-induced liver injury (DILI). In oncology trials, patients are often included despite baseline liver test abnormalities, for whom there is no consensus yet on levels of liver test changes that should trigger action, such as drug interruption or discontinuation.

METHODS

We provide an innovative approach to manage hepatocellular DILI in oncology trials for patients with abnormal baseline alanine aminotransferase (ALT) levels. The algorithm proposed is based on mathematical derivation of action thresholds from those generally accepted for patients with normal baselines.

RESULTS

The resulting algorithm is grouped by level of baseline abnormality and avoids calculation of baseline multiples. Suggested layered action levels are 4, 6, and 11 × Upper Limit of Normal (ULN) for patients with baseline ALT between 1.5 and 3 × ULN, and 6, 8, and 12 × ULN for patients with baseline ALT between 3 and 5 × ULN, respectively.

CONCLUSIONS

Our concept and resulting algorithm are consistent, transparent, and easy to follow, and the method for derivation from consensus-based thresholds may also be applicable to other drug toxicity areas.

Remotely controlled drug release in deep brain regions of non-human primates

Many areas of science and medicine would benefit from selective release of drugs in specific regions of interest. Nanoparticle drug carriers activated by focused ultrasound-remotely applied, depth-penetrating energy-may provide such selective interventions. Here, we developed stable, ultrasound-responsive nanoparticles that can be used to release drugs effectively and safely in non-human primates. The nanoparticles were used to release propofol in deep brain visual regions. The release reversibly modulated the subjects' visual choice behavior and was specific to the targeted region and to the released drug. Gadolinium-enhanced MRI imaging suggested an intact blood-brain barrier. Blood draws showed normal clinical chemistry and hematology. In summary, this study provides a safe and effective approach to release drugs on demand in selected deep brain regions at levels sufficient to modulate behavior.

Ferroptosis participated in inhaled polystyrene nanoplastics-induced liver injury and fibrosis

The emerging contaminant nanoplastics (NPs) have received considerable attention. Due to their tiny size and unique colloidal properties, NPs could more easily enter the body and cross biological barriers with inhalation exposure. While NPs-induced hepatotoxicity has been reported, the hepatic impact of inhaled NPs was still unknown. To close this gap, a 40 nm polystyrene NPs (PS-NPs) inhalation exposure mice model was developed to explore the hepatotoxicity during acute (1 week), subacute (4 weeks), and subchronic period (12 weeks), with four exposure doses (0, 16, 40, and 100 μg/day). Results showed that inhaled PS-NPs caused a remarkable increase of ALT, AST, and ALP with a decrease of CHE, indicating liver dysfunction. Various histological abnormalities and significantly higher levels of inflammation in a dose- and time-dependent manner were observed. Moreover, after 4 weeks and 12 weeks of exposure, Masson staining and upregulated expression of TGF-β, α-SMA, and Col1a1 identified that inhaled PS-NPs exposure triggered the progression of liver fibrosis with the exposure time prolonged. From the mechanistic perspective, transcriptome analysis revealed that ferroptosis was involved in PS-NPs-induced liver hepatotoxicity, and key features of ferroptosis were detected, including persistent oxidative stress, iron overload, increased LPO, mitochondria damage, and the expression changes of GPX4, TFRC, and Ferritin. And in vitro and in vivo recovery tests showed that ferroptosis inhibitor Fer-1 treatment alleviated liver injury and fibrosis. The above results confirmed the critical role of ferroptosis in PS-NPs-induced hepatotoxicity. Furthermore, to better conclude our findings and understand the mechanistic causality within it, an adverse outcome pathway (AOP) framework was established. In total, this present study conducted the first experimental assessment of inhalation exposure to PS-NPs on the liver, identified that continuous inhaled PS-NPs could cause liver injury and fibrosis, and PS-NPs- ferroptosis provided a novel mechanistic explanation.

Joint and interactive effects of metal mixtures on liver damage: Epidemiological evidence from repeated-measures study

BACKGROUND

The impact of heavy metals on liver function has been examined in numerous epidemiological studies. However, these findings lack consistency and longitudinal validation.

METHODS

In this study, we conducted three follow-up surveys with 426 participants from Northeast China. Blood and urine samples were collected, along with questionnaire information. Urine samples were analyzed for concentrations of four metals (chromium [Cr], cadmium [Cd], lead [Pb], and manganese [Mn]), while blood samples were used to measure five liver function indicators (alanine aminotransferase [ALT], aspartate aminotransferase [AST], albumin [ALB], globulin [GLB], and total protein [TP]). We utilized a linear mixed-effects model (LME) to explore the association between individual heavy metal exposure and liver function. Joint effects of metal mixtures were investigated using quantile g-computation and Bayesian kernel machine regression (BKMR). Furthermore, we employed BKMR and Marginal Effect models to examine the interaction effects between metals on liver function.

RESULTS

The LME results demonstrated a significant association between urinary heavy metals (Cr, Cd, Pb, and Mn) and liver function markers. BKMR results indicated positive associations between heavy metal mixtures and ALT, AST, and GLB, and negative associations with ALB and TP, which were consistent with the g-comp results. Synergistic effects were observed between Cd-Cr on ALT, Mn-Cr and Cr-Pb on ALB, while an antagonistic effect was found between Mn-Pb and Mn-Cd on ALB. Additionally, synergistic effects were observed between Mn-Cr on GLB and Cd-Cr on TP. Furthermore, a three-way antagonistic effect of Mn-Pb-Cr on ALB was identified.

CONCLUSION

Exposure to heavy metals (Cr, Cd, Mn, Pb) is associated with liver function markers, potentially leading to liver damage. Moreover, there are joint and interaction effects among these metals, which warrant further investigation at both the population and mechanistic levels.

Approach to Abnormal Liver Biochemistries in the Primary Care Setting

Liver biochemistries are commonly ordered in the primary care setting, and they may return abnormal even in an asymptomatic patient. Primary care physicians need to have a systematic way of interpreting any derangement in these tests so that further investigations, referrals, and management can be arranged appropriately. This review dwells into patterns of liver biochemistry derangement, common aetiologies to consider, history and examinations that are required, initial investigations to order, and when to refer urgently to the emergency department.

Alanine aminotransferase cutoffs for the pediatric fatty liver disease: Major impact of the reference population

OBJECTIVES AND STUDY

The often-recommended alanine aminotransferase (ALT) cutoffs (girls 21 U/l, boys 25 U/l) are based on a NHANES cohort. A novel concept of metabolic dysfunction associated steatotic liver disease (MASLD) emphasizes the role of ALT. We tested the prevalence of increased ALT and MASLD in children with overweight or obesity applying population-based and NHANES-based cut-offs.

METHODS

Six- to seventeen-year-old children underwent data collection in a prospective Physical Activity and Nutrition in Children (PANIC) study. ALT 95th percentiles were calculated from 1167 separate measurements considering various confounders. Test cohort comprised 1044 children with overweight/obesity.

RESULTS

ALT values increased at puberty onset (p = 0.031) and correlated negatively with age in girls (r = -0.222, p < 0.001). Particularly overall and central obesity increased ALT, whereas underweight or metabolic abnormalities had smaller effect. After applying the tested exclusions, the age-related ALT 95th percentiles were 24-29 U/l for girls and 29-32 U/l for boys. In 6-8-year-old children with overweight/obesity, the prevalence of increased ALT and MASLD were 21.6% and 2.4% with age-specific PANIC cutoffs. In older children, when NHANES-based cutoffs were used, there was a trend for higher prevalence of increased ALT and MASLD in all age groups for both sexes, reaching significance for increased ALT in 12-16-year-old boys (NHANES 63.5%, 95% confidence interval [CI]: 56.4%-70.0% vs. PANIC 47.1%, 95% CI [40.1%-54.2%]) and 9-11-year-old girls (60.0% [49.4%-69.8%] vs. 31.8% [22.8%-42.3%]), respectively. Increased ALT/MASLD were more common in boys than in girls, and in boys these increased with age, whereas in girls these peaked at age 9-12 years.

CONCLUSION

A reference population impacts on the prevalence of increased ALT and MASLD. Considering this help optimizing screening while avoiding unnecessary investigations and surveillance. The prospective part of this study is registered in clinicaltrials.gov; identifier NCT01803776.

Associations between inhalation of typical volatile and semi-volatile organic compounds in e-waste dismantling workers with liver function damage

Studies in cell culture and animal models suggest hepatotoxicity of some volatile organic compounds (VOCs) and semi-volatile organic compounds (SVOCs), however, their effects in human populations under real exposure conditions have never been clarified. In this cross-sectional study, 224 participants, 38 e-waste dismantling workers and 186 subjects residing near to the dismantling sites in southern China, were evaluated for personal inhalational exposure to 72 VOCs and 91 SVOCs according to site-specific atmospheric chemical concentrations and personal exposure time. Additionally, their serum samples were subjected to liver function tests (LFTs), including total protein (TP), albumin (ALB), globulin (GLB), aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transpeptidase (GGT), and bilirubin. Linear regression analysis of the VOC/SVOC levels against the LFTs results indicated that VOC exposure was negatively associated with the TP, ALB, GLB levels (indicating liver-specific protein synthesis functions), while positively associated with AST, ALT, GGT activities (marking liver damage). Somehow, SVOC exposure appeared to be positively associated with not only AST and ALT but also TP and ALB. These findings were supported by the quantile g-computation analysis and confirmed in the Bayesian kernel machine regression model. This study indicates that simultaneous inhalation of VOCs and SVOCs may impair human liver functions.

Efficacy of a single-dose albendazole against lancet liver fluke Dicrocoelium dendriticum and liver enzymes activity in naturally infected sheep

Infections with D. dendriticum are distributed worldwide and mostly associated with ruminant livestock. Depending on the length and strength of the infection it can be manifested with losses in milk production, reductions in milk and wool quality, decreased weight gains, reproductive performance and poor carcass quality. The objective of this study was to determine the efficacy of albendazole (ABZ) against the lancet liver fluke Dicrocoelium dendriticum in naturally infected sheep using parasitological methods. Twenty-four sheep were divided into four groups: two untreated control groups (C1, C2) and two treated groups (T1, T2), with six animals in each group. The sheep in the treated groups were administered a single oral dose (15 mg/kg bwt) of ABZ suspension. After ABZ treatment the animals were slaughtered on Day 14 (groups C1, T1) and Day 30 (groups C2, T2) and were necropsied. Coprological therapeutic ABZ efficacy reached 92.4% on Day 14 (P < 0.001) and 88.5% on Day 30 (P < 0.001). On Day 30, the serum activities of hepatic and cholestatic enzymes including serological analysis of total protein concentration (TP) and protein fractions were evaluated. Significant decrease of aspartate aminotransferase (AST) (P < 0.01) and gamma-glutamyltransferase (GGT) (P < 0.05) activity by 36.9% and 34.6%, respectively, were detected for sheep in T2 group. These enzymes showed a strong positive correlation to fluke burden: AST (r = 0.654) and GGT (r = 0.768), respectively (P < 0.05). Additionally, the electrophoretic analysis of serum total protein and protein fraction concentrations revealed minimal hypoproteinemia and hyperalbuminemia after ABZ treatment. The decrease of liver enzyme activities and their correlation with fluke burden may indicate recovery of hepatocellular and biliary damage following the reduction of fluke burdens after ABZ therapy. A decline in AST and GGT activity could serve as a valuable adjunct bioindicator of liver damage and fluke reduction after treatment of dicrocoeliosis in naturally infected sheep.

Comparison of the effects of BDNF/TRKB signalling on metabolic biomarkers in the liver of sedentary and trained rats with normal and knockout BDNF genotypes

Introduction: The effect of brain-derived neurotrophic factor (BDNF) on the modulation of metabolic processes in the liver is poorly understood. Therefore, the aim of this study was to investigate whether hepatic concentrations or activities of metabolic biomarkers depend on altered BDNF/TrkB content in the liver, resulting from different BDNF genotypes of rats. In addition, it was assessed whether 5-week moderate endurance training modifies the levels of BDNF/Trk-B signaling and studied hepatic markers. Methods: Experiments were performed on wild-type and heterozygous BDNF knockout (HET, SD-Bdnf) rats, which were divided into four groups: control with normal genotype (Bdnf+/+), control with BDNF knockout genotype (Bdnf+/-), trained with normal genotype (Bdnf+/+T) and trained with BDNF knockout genotype (Bdnf +/-T). BDNF/TrkB concentrations as well as selected metabolic biomarkers including lipids-total cholesterol (CHOL), low-density lipoprotein (LDL), triglycerides (TG); enzymes-alanine aminotransferase (ALAT), aspartate aminotransferase (ASAT), gamma-glutamyl transferase (GGT), lactate dehydrogenase (LDH), alkaline phosphatase (ALP); hormones-insulin (INS) and leptin (LEPT) as well as interleukin-6 (IL-6) as regeneration indicator were measured directly in liver homogenates. Results and Discussion: The study showed that Bdnf+/- rats exhibited reduced BDNF/TrkB signaling (BDNF, p < 0.0001; Trk-B, p = 0.0005), altered lipid levels (CHOL, p < 0.0001; LDL, p < 0.0001; TG, p = 0.0006) and reduced hepatic ALAT (p = 0.0004) and GGT (p < 0.0001) activity, which may contribute to hepatic steatosis and obesity, as well as indicate impairment of specific metabolic pathways in the liver. Interestingly, endurance training did not alter hepatic BDNF and TrkB content, but improved ALAT (p = 0.0366) and ASAT (p = 0.0191) activities and increased hepatic IL-6 (p = 0.0422) levels in Bdnf +/- rats, suggesting enhanced liver regeneration in animals with BDNF allele loss.

Assessment of Biological Activities, Acute and Sub-chronic Toxicity of Liang (Gnetum gnemon var. tenerum) Leaves Powder, a Natural Product

Gnetum gnemon var. tenerum (Gnetaceae) is a shrub plant native to South-East Asia. In Thailand, Liang leaves are commonly consumed in South of Thailand as vegetable. According to literature, they have an antihyperglycemic capacity because of their rich chlorophyll, fiber, and protein. However, there is need to assess the safety since natural food products are not completely devoid of toxicity. This study aimed to assess the biological activities as well as the acute and sub-chronic oral toxicity of Liang leaves powder (LLP). The evaluation of LLP for acute oral toxicity was performed at dose level 2000 mg/kg body weight in Wistar rats while the sub-chronic oral toxicity of LLP was performed at the effective dose (1.47 g/kg) for antihyperglycemic property according to Organisation for Economic Co-operation and Development (OECD)-425. The results showed that LLP demonstrated anti-inflammatory activities. It also showed no clinical signs of toxic effects and mortality in rats throughout 90 d. Thus, LLP could be classified in GHS category 5 which are of relatively low acute toxicity and then the lethal dose, 50% (LD50) cut off at 5000 mg/kg body weight to infinity (∞). Administration of LLP to the experimental rats significantly increased (p < 0.05) the concentration of triglyceride and increased concentration of creatinine as a result of kidney malfunction was also noticed in the experimental rats. Hematological alteration was not noticed in the treated female rats, but red blood cell, hemoglobin and hematocrit concentrations significantly increased in the treated male rats. The study concludes that sub-chronic administration of 1.47 g/kg LLP is relatively safe.

Diagnostic significance of alanine aminotransferase isoenzymes in alcoholic and non-alcoholic fatty liver cancers

OBJECTIVES

Alanine aminotransferase (ALT) expression is highly elevated in the serum of patients with hepatocellular carcinoma. However, the role of ALT isoenzymes in the total ALT activity remains unclear. In the present study, we systematically investigated the role of ALT isoenzymes in alcoholic and non-alcoholic fatty liver cancer.

MATERIALS AND METHODS

The expression of ALT1 and ALT2 at the mRNA and protein levels in 25 paired primary liver cancer tissues was detected by reverse transcription quantitative PCR (RT-qPCR), Western blotting, and immunohistochemistry. Serum ALT activity was determined using an automated biochemical analyzer.

RESULTS

The mRNA and protein expression levels of ALT1 and ALT2 were lower in the tissues of alcoholic and non-alcoholic fatty liver cancers than in the paracancerous tissues. Notably, ALT2 was highly expressed in non-alcoholic fatty liver cancer tissues compared with alcoholic fatty liver cancer tissues. Total serum ALT activity was mainly contributed by ALT1 in alcoholic fatty liver cancer, whereas ALT1 contributed only marginally more to the total ALT activity than ALT2 in non-alcoholic fatty liver cancer. ALT2/ALT1 ratio can well discriminate normal control group, alcoholic liver cancer and non-alcoholic liver cancer.

CONCLUSION

ALT1 contributed more to the total ALT activity than ALT2 in both alcoholic and non-alcoholic fatty liver cancer. Serum ALT2 to ALT activity was higher in non-alcoholic fatty liver cancer than that in alcoholic fatty liver cancer. ALT2/ALT1 ratio has some diagnostic significance for alcoholic and non-alcoholic liver cancer.

Evaluation of the Clinical Characteristics of Dry Eye Secondary to Different Types of Liver Diseases

INTRODUCTION

This study compares the clinical characteristics of dry eye secondary to primary biliary cholangitis (PBC), drug-induced liver injury (DILI), and viral hepatitis B(HBV) to evaluate the ocular surface damage caused by different types of liver diseases.

METHODS

Thirty healthy people were included as control group. Sixty patients with dry eye secondary to different types of liver disease were included, including 19 cases of PBC, 18 cases of DILI, and 23 cases of HBV. All patients were evaluated by the SPEED questionnaire, corneal fluorescein staining (CFS), noninvasive tear breakup time (NIBUT), Schirmer I test (SIt), tear meniscus height test (TMH), the area of meibomian glands dropout (MG dropout), partial blinking rate (PBR), lipid layer thickness (LLT), meibum expressibility, and meibum quality.

RESULTS

There are statistical differences in ophthalmic examination results between different types of liver diseases and normal people (P < 0.05). Compared with DILI and HBV groups, the CFS score of PBC group score was higher (P < 0.05), the PBR was higher (P < 0.05), and the SIt was lower (P < 0.01). The TMH of PBC and DILI groups were significantly lower than the HBV group, and the difference was statistically significant (P < 0.05). Compared with the PBC group, the LLT of the DILI group decreased (P < 0.01). The area of meibomian glands dropout of the three groups had mild-to-moderate defects, but there was no significant statistical difference between groups (P > 0.05).The Meibum quality score in the DILI group was significantly higher than the HBV group (P < 0.05).

CONCLUSIONS

The PBC group was more prone to aqueous-deficient dry eye. The DILI group was more prone to obstructive meibomian gland dysfunction (MGD).The HBV group was more prone to nonobstructive MGD. The symptoms of dry eye in the PBC group are mild-to-moderate discomfort, but the degree of corneal damage is higher, indicating that the corneal sensitivity is reduced, which may be related to the high rate of partial blinking.

Impact of obesity on liver function tests: is nonalcoholic fatty liver disease the only player? A review article

Objectives

Obesity and nonalcoholic fatty liver disease (NAFLD) are common worldwide health problems with a strong relationship in between. NAFLD is currently the most common cause of abnormal liver function tests (LFT) because of obesity pandemic. The question is NAFLD the only player of abnormal LFT in obesity?

Methodology

This article reviews the most important topics regarding the derangements of LFT in obesity through a PubMed search strategy for all English-language literature.

Results

The reported abnormal LFT in obesity were increased serum levels of transaminases (alanine aminotransaminase, aspartate aminotransaminase), gamma glutamyl transferase, and alkaline phosphatase and decreased serum levels of bilirubin and albumin. Besides novel potential hepatic markers of NAFLD/NASH such as triglycerides/high-density lipoprotein cholesterol ratio, sex hormone-binding globulin, fibroblast growth factor 21, and markers of hepatocyte apoptosis i.e. cytokeratin 18 and microribonucleic acids (miRNAs). Beyond NAFLD, there are other underlying players for the abnormal LFT in obesity such as oxidative stress, inflammation, and insulin resistance.

Conclusion

Derangements of LFT in obesity are attributed to NAFLD but also to obesity itself and its related oxidative stress, insulin resistance, and chronic inflammatory state. Abnormal LFT predict more than just liver disease.

Short-Term Exposure to PM2.5 and O3 Impairs Liver Function in HIV/AIDS Patients: Evidence from a Repeated Measurements Study

Studies investigating the relationship between ambient air pollutants and liver function are scarce. Our objective was to examine the associations of acute exposure to PM2.5 and O3 with levels of hepatic enzymes in people living with HIV/AIDS (PWHA). Our study involved 163 PWHA, who were evaluated for serum hepatic enzymes up to four times within a year. We extracted daily average concentrations of PM2.5, PM2.5 components, and O3 for each participant, based on their residential address, using the Tracking of Air Pollution in China database. Linear mixed-effect models were utilized to assess the associations of acute exposure to PM2.5 and O3 with hepatic enzymes. Weighted quantile sum regression models were employed to identify the major constituents of PM2.5 that affect hepatic enzymes. The percent change of aspartate aminotransferase (AST) concentration was positively correlated with a 10 µg/m3 increase in PM2.5, ranging from 1.92 (95% CI: 3.13 to 4.38) to 6.09 (95% CI: 9.25 to 12.38), with the largest effect observed at lag06. Additionally, acute O3 exposure was related to increased levels of alanine aminotransferase (ALT), AST, and alkaline phosphatase (ALP) concentrations. Co-exposure to high levels of PM2.5 and O3 had an antagonistic effect on the elevation of AST. Further analysis revealed that SO42- and BC were major contributors to elevated AST concentration due to PM2.5 constituents. A stronger association was found between O3 exposure and ALT concentration in female PWHA. Our study found that short-term exposure to PM2.5 and O3 was associated with increased levels of hepatic enzymes, indicating that PM2.5 and O3 exposure may contribute to hepatocellular injury in PWHA. Our study also found that PWHA may be more vulnerable to air pollution than the general population. These findings highlight the relationship between air pollutants and liver function in PWHA, providing a scientific basis for the implementation of measures to protect susceptible populations from the adverse effects of air pollution. A reduction in the burning of fossil fuels and reduced exposure to air pollutants may be effective hazard reduction approaches.

Real-World Primary Care Data Comparing ALT and FIB-4 in Predicting Future Severe Liver Disease Outcomes

BACKGROUND

Alanine aminotransferase (ALT) has long provided a cue for chronic liver disease (CLD) diagnostic evaluation, but the Fibrosis-4 Index (FIB-4), a serologic score used for predicting advanced fibrosis risk in CLD, may provide an alternative signal.

OBJECTIVE

Compare the predictive performance of FIB-4 with ALT for severe liver disease (SLD) events while adjusting for potential confounders.

DESIGN

Retrospective cohort study of primary care electronic health record data from 2012 to 2021.

PATIENTS

Adult primary care patients with at least two sets of ALT and other lab values necessary for calculating two unique FIB-4 scores, excluding those patients with an SLD prior to their index FIB-4 value.

MAIN MEASURES

The occurrence of an SLD event, a composite of cirrhosis, hepatocellular carcinoma, and liver transplantation, was the outcome of interest. Categories of ALT elevation and FIB-4 advanced fibrosis risk were the primary predictor variables. Multivariable logistic regression models were developed to evaluate the association of FIB-4 and ALT with SLD, and the areas under the curve (AUC) for each model were compared.

KEY RESULTS

The cohort of 20,828 patients included 14% with an abnormal index ALT (≥40 IU/L) and 8% with a high-risk index FIB-4 (≥2.67). During the study period, 667 (3%) patients suffered an SLD event. Adjusted multivariable logistic regression models demonstrated an association between high-risk FIB-4 (OR 19.34; 95%CI 15.50-24.13), persistently high-risk FIB-4 (OR 23.85; 95%CI 18.24-31.17), abnormal ALT (OR 7.07; 95%CI 5.81-8.59), and persistently abnormal ALT (OR 7.58; 95%CI 5.97-9.62) with SLD outcomes. The AUC of the index FIB-4 (0.847, p < 0.001) and combined FIB-4 (0.849, p < 0.001) adjusted models exceeded the index ALT adjusted model (0.815).

CONCLUSIONS

High-risk FIB-4 scores demonstrated superior performance compared to abnormal ALT in predicting future SLD outcomes.

Biosynthesized Nanosilver from Ginger Extract Exhibits Antioxidant and Hepatic Responses during Eimeria papillata Infection

Although several anticoccidial medications have long been used to prevent coccidiosis, their adverse effects necessitate the use of alternative control methods. In this study, Eimeria papillate was used to infect the mouse jejunum, and the response of the liver to induced coccidiosis on treatment with nanosilver synthesized from Zingiber officinale (NS) and the reference anticoccidial drug amprolium was compared. Mice were infected with 1000 sporulated oocysts to induce coccidiosis. NS was able to inhibit the sporulation of E. papillate by approximately 73%, and also, the NS treatment improved the liver function in mice, as proven by lower levels of the liver enzymes AST, ALT, and ALP. Furthermore, treatment with NS improved the parasite-induced liver histological injury. Also, glutathione and glutathione peroxidase levels increased following treatment. Moreover, the concentrations of metal ions, Fe, Mg, and Cu, were studied, where only the Fe concentration was affected after treatment of the E. papillate-infected mice with Bio-NS. The presence of phenolic and flavonoid compounds in NS is thought to be responsible for its positive effects. Overall, the current study found that NS outperformed amprolium in E. papillata-induced mice.

Dietary supplementation with casein/cyanidin-3-O-glucoside nanoparticles alters the gut microbiota in high-fat fed C57BL/6 mice

This study aims to investigate the dietary intervention effect of casein/cyanidin-3-O-glucoside nanoparticles (Cs-C3G) on high-fat-diet (HFD)induced gut microbiota disorders. In HFD-fed C57BL/6mice, Cs-C3G has ameliorated HFD-caused fat accumulation and liver oxidative stress. Cs-C3G as a dietary supplementation can restore the abundance and diversity of gut microbiota with descending the ratio of Firmicutes to Bacteroidetes, increasing some beneficial microorganisms, and reducing some opportunistic pathogenic bacteria. In general, Cs-C3G has a effect on regulating the disturbance of gut microbiota, and then prevents HFD-induced obesity and liver damage.

Polystyrene Microplastics Induce Oxidative Stress in Mouse Hepatocytes in Relation to Their Size

Microplastics have become a new type of environmental pollutant that can accumulate in various tissues and organs of the body and cause chronic damage. In this study, two different size polystyrene microplastics (PS-MPs, 5 μm and 0.5 μm) exposure models were established in mice to investigate the effects of PS-MPs with different particle sizes on oxidative stress in the liver. The results showed that PS-MPs exposure caused a decrease in body weight and liver-to-body weight. The hematoxylin and eosin staining and transmission electron microscopy results showed that exposure to PS-MPs led to the disorganized cellular structure of liver tissue, nuclear crinkling, and mitochondrial vacuolation. The extent of damage in the 5 μm PS-MP exposure group was more extensive when compared with the other group. The evaluation of oxidative-stress-related indicators showed that PS-MPs exposure exacerbated oxidative stress in hepatocytes, especially in the 5 μm PS-MPs group. The expression of oxidative-stress-related proteins sirtuin 3(SIRT3) and superoxide dismutase (SOD2) was significantly reduced, and the reduction was more pronounced in the 5 μm PS-MPs group. In conclusion, PS-MPs exposure led to oxidative stress in mouse hepatocytes and caused more severe damage in the 5 μm PS-MPs group when compared with the 0.5 μm PS-MPs group.

Incidental hypertransaminasemia in children-a stepwise approach in primary care

Children with elevated liver enzymes are occasionally discovered through laboratory work-up from different clinical scenarios. Although the majority will have transient and/or benign conditions, a subgroup will have underlying liver disorders. The differential diagnosis is broad and therefore, a systematic approach is of utmost importance. In this article, we reviewed the most recent and relevant literature to provide a comprehensive overview of the main disease processes that cause hypertransaminasemia in children. Ultimately, we propose a practical stepwise approach to guide primary care physicians in the evaluation of abnormal liver enzymes in asymptomatic children. The first step is to obtain a complete history along with a thorough physical examination to exclude red flags, which should dictate urgent consultation with a paediatric gastroenterologist or hepatologist.  Conclusion: Hypertransaminasemia is a challenging scenario in the primary care setting. The aetiology can be broad, ranging from hepatic and extrahepatic to transient versus chronic liver disease. Timely referral to a specialised centre is of paramount importance for conducting targeted research and to not miss the chance of identifying a progressive, but still asymptomatic, treatable liver disease. What is Known: • Elevated liver enzyme is a challenging scenario in the primary care setting. • There are few studies guiding the evaluation of asymptomatic hypertransaminasemia in the paediatric population and a standardised approach is lacking. What is New: • We propose a practical stepwise approach to guide primary care physicians in the evaluation of abnormal liver enzymes.

The relationship between homoarginine and liver biomarkers: a combination of epidemiological and clinical studies

Homoarginine (hArg) is a non-essential cationic amino acid which inhibits hepatic alkaline phosphatases to exert inhibitory effects on bile secretion by targeting intrahepatic biliary epithelium. We analyzed (1) the relationship between hArg and liver biomarkers in two large population-based studies and (2) the impact of hArg supplementation on liver biomarkers. We assessed the relationship between alanine transaminase (ALT), aspartate aminotransferase (AST), γ-glutamyltransferase (GGT), alkaline phosphatases (AP), albumin, total bilirubin, cholinesterase, Quick's value, liver fat, and Model for End-stage Liver Disease (MELD) and hArg in appropriately adjusted linear regression models. We analyzed the effect of L-hArg supplemention (125 mg L-hArg daily for 4 weeks) on these liver biomarkers. We included 7638 individuals (men: 3705; premenopausal women: 1866, postmenopausal women: 2067). We found positive associations for hArg and ALT (β 0.38 µkatal/L 95% confidence interval (CI): 0.29; 0.48), AST (β 0.29 µkatal/L 95% CI 0.17; 0.41), GGT (β 0.033 µkatal/L 95% CI 0.014; 0.053), Fib-4 score (β 0.08 95% CI 0.03; 0.13), liver fat content (β 0.016% 95% CI 0.006; 0.026), albumin (β 0.030 g/L 95% CI 0.019; 0.040), and cholinesterase (β 0.003 µkatal/L 95% CI 0.002; 0.004) in males. In premenopausal women hArg was positively related with liver fat content (β 0.047% 95%CI 0.013; 0.080) and inversely with albumin (β - 0.057 g/L 95% CI - 0.073; - 0.041). In postmenopausal women hARG was positively associated with AST (β 0.26 µkatal/L 95% CI 0.11; 0.42). hArg supplementation did not affect liver biomarkers. We summarize that hArg may be a marker of liver dysfunction and should be explored further.

Pathophysiological Aspects of Muscle Atrophy and Osteopenia Induced by Chronic Constriction Injury (CCI) of the Sciatic Nerve in Rats

Skeletal muscle atrophy is a condition characterized by a loss of muscle mass and muscle strength caused by an imbalance between protein synthesis and protein degradation. Muscle atrophy is often associated with a loss of bone mass manifesting as osteoporosis. The aim of this study was to evaluate if chronic constriction injury (CCI) of the sciatic nerve in rats can be a valid model to study muscle atrophy and consequent osteoporosis. Body weight and body composition were assessed weekly. Magnetic resonance imaging (MRI) was performed on day zero before ligation and day 28 before sacrifice. Catabolic markers were assessed via Western blot and Quantitative Real-time PCR. After the sacrifice, a morphological analysis of the gastrocnemius muscle and Micro-Computed Tomography (Micro-CT) on the tibia bone were performed. Rats that underwent CCI had a lower body weight increase on day 28 compared to the naive group of rats (p < 0.001). Increases in lean body mass and fat mass were also significantly lower in the CCI group (p < 0.001). The weight of skeletal muscles was found to be significantly lower in the ipsilateral hindlimb compared to that of contralateral muscles; furthermore, the cross-sectional area of muscle fibers decreased significantly in the ipsilateral gastrocnemius. The CCI of the sciatic nerve induced a statistically significant increase in autophagic and UPS (Ubiquitin Proteasome System) markers and a statistically significant increase in Pax-7 (Paired Box-7) expression. Micro-CT showed a statistically significant decrease in the bone parameters of the ipsilateral tibial bone. Chronic nerve constriction appeared to be a valid model for inducing the condition of muscle atrophy, also causing changes in bone microstructure and leading to osteoporosis. Therefore, sciatic nerve constriction could be a valid approach to study muscle-bone crosstalk and to identify new strategies to prevent osteosarcopenia.

Case report: Pharmacokinetics of pembrolizumab in a patient with stage IV non-small cell lung cancer after a single 200 mg administration

Background

Pembrolizumab is a well-tolerated biologic agent with a potentially stable and durable anti-tumor response. Unfortunately, discontinuation of therapy can occur as a consequence of immune-related adverse effects (irAEs). These irAEs appear independent of dose and exposure. However, such irAEs might also result from pembrolizumab's highly specific mechanism of action and current dosing regimens. However, the currently available pharmacokinetic (PK) and pharmacodynamic (PD) data to reassess dosing strategies are insufficient.To highlight the importance of additional PK/PD studies, we present a case describing the complexity of pembrolizumab's PK/PD after a single 200 mg pembrolizumab dose in a treatment-naive patient with non-small cell lung cancer (NSCLC).

Case description

A 72-year-old man with stage IV NSCLC presented hepatotoxic symptoms 19 days after receiving the first 200 mg pembrolizumab dose. Hence, pembrolizumab therapy was paused, and prednisolone therapy was initiated, which successfully inhibited the toxic effect of pembrolizumab. However, repeated flare-ups due to prednisolone tapering suggest that the toxic effect of pembrolizumab outlasts the presence of pembrolizumab in the bloodstream. This further suggests that the T-cell-mediated immune response outlasts the programmed cell death protein 1 (PD-1) receptor occupancy by pembrolizumab, which challenges the need for the current fixed-interval strategies and their stop criteria.Furthermore, a validated ELISA quantified pembrolizumab levels in 15 samples within 123 days after administration. A shift in the pembrolizumab clearance rate was evident ensuing day 77 (0.6 µg/mL) after administration. Pembrolizumab levels up to day 77 (9.1-0.6 µg/mL) strongly exhibited a linear, first-order clearance (R² = 0.991), whereas after day 77, an accelerated non-linear clearance was observed. This transition from a linear to non-linear clearance was most likely a result of full target receptor saturation to non-full target receptor saturation, in which the added effect of target-mediated drug disposition occurs. This suggests that pembrolizumab's targets were fully saturated at levels above 0.6 µg/mL, which is 43 to 61 times lower than the steady-state trough levels (C_trough,ss) of the currently registered fixed-dosing regimens (3-5).

Association between aspartate aminotransferase to alanine aminotransferase ratio and the risk of diabetes in Chinese prediabetic population: A retrospective cohort study

Background

Accumulating evidence has revealed that the aspartate aminotransferase to alanine aminotransferase (AST/ALT) ratio is a promising novel biomarker for insulin resistance (IR) and metabolic diseases. However, research on the association between the AST/ALT ratio and the incidence of diabetes progressing from prediabetes remains lacking. Herein, this study aimed to evaluate the relationship between the baseline AST/ALT ratio and risks of diabetes in patients with prediabetes.

Methods

This was a retrospective cohort study involving a total of 82,683 participants across 32 regions and 11 cities in China from 2010 to 2016. Data was obtained based on the DATADRYAD database from the health check screening program. Participants were stratified according to the interquartile range of the AST/ALT ratio (groups Q1 to Q4). The Cox proportional hazard model and smooth curve fitting were used to explore the relationship between the baseline AST/ALT ratio and the risk of diabetes in prediabetic patients. In addition, subgroup analysis was used to further validate the stability of the results.

Results

The mean age of the selected participants was 49.9 ± 14.0 years, with 66.8% of them being male. During the follow-up period 1,273 participants (11.3%) developed diabetes progressing from prediabetes during the follow-up period. Participants who developed diabetes were older and were more likely to be male. The fully-adjusted Cox proportional hazard model revealed that the AST/ALT ratio was negatively associated with the risk of diabetes in prediabetic patients (HR = 0.40, 95% CI: 0.33 to 0.48, P < 0.001). Higher AST/ALT ratio groups (Q4) also presented with a lower risk of progressing into diabetes (HR = 0.35, 95% CI: 0.29 to 0.43, P < 0.001, respectively) compared with the lowest quintile group (Q1). Through subgroup analysis and interaction tests, it was found that the association stably existed in all subgroup variables, and there were a stronger interactive effects in people with age < 45 years, and TG ≤ 1.7 mmol/L in the association between AST/ALT ratio and diabetes incidences in patients with prediabetes (P for interaction < 0.05).

Conclusion

According to our study, a higher AST/ALT ratio is associated with a lower risk of progressing into diabetes from prediabetes. Regular monitoring of AST/ALT ratio dynamics and corresponding interventions can help prevent or slow prediabetes progression for diabetes.

Association of Hematological and Biochemical Parameters with Serological Markers of Acute Dengue Infection during the 2022 Dengue Outbreak in Nepal

Background

Nepal faced a major dengue outbreak in 2022. The majority of hospitals and laboratories had limited resources for dengue confirmation and had to rely on rapid dengue diagnostic tests. The purpose of the study is to find the predictive hematological and biochemical parameters in each serological phase of dengue infection (NS1 and IgM) that may assist in dengue diagnosis, severity assessment, and patient management via the use of rapid serological tests.

Method

A laboratory-based cross-sectional study was conducted among dengue patients. Rapid antigen (NS1) and serological test (IgM/IgG) was performed to diagnose positive dengue cases. Furthermore, hematological and biochemical investigations were carried out and compared between NS1 and/or IgM-positive participants. A logistic regression analysis was used to identify the validity of the hematological and biochemical characteristics for dengue diagnosis as well as patient management. Receiver-operating characteristic (ROC) curve analysis was used to define the best cut-off, sensitivity, and specificity.

Result

Multiple logistic regression showed thrombocytopenia (OR_A = 1.000; p = 0.006), leukopenia (OR_A = 0.999; p < 0.001), glucose level (OR_A = 1.028; p = 0.029), aspartate aminotransferase (OR_A = 1.131; p = 0.001), and monocytosis (OR_A = 2.332; p = 0.020) as significant parameters in the NS1-only positive group. Similarly, thrombocytopenia (OR_A = 1.000; p = 0.001), glucose level (OR_A = 1.037; p = 0.004), and aspartate aminotransferase (OR_A = 1.141; p < 0.001) were significant in IgM-only positive patients. Moreover, thrombocytopenia (OR_A = 1.000; p < 0.001), leukopenia (OR_A = 0.999; p < 0.001), glucose (OR_A = 1.031; p = 0.017), aspartate aminotransferase (OR_A = 1.136; p < 0.001), and lymphopenia (OR_A = 0.520; p = 0.067) were independent predictors in both NS1 + IgM positive groups. Platelets consistently demonstrated a higher area under the curve with increased sensitivity and specificity throughout all models, while aspartate aminotransferase (AUC = 0.811) and glucose (AUC = 0.712) demonstrated better results when single IgM positivity was observed. The total leukocyte count performed better when both NS1 + IgM were positive (AUC = 0.814).

Conclusion

Hence, thrombocytopenia, elevated AST, high glucose level, leukopenia with monocytosis, and leukopenia with lymphopenia may predict dengue diagnosis and its severity during an active infection. Therefore, these laboratory parameters can be used to complement less sensitive rapid tests, improve dengue diagnosis, and help with proper patient management.

Modulation of gut microbiota and lipid metabolism in rats fed high-fat diets by Ganoderma lucidum triterpenoids

Ganoderma lucidum triterpenoids (GP) have been reported to help prevent and improve hyperlipidemia. Modulation of the gut microbiota was proposed as underlying factor as well as a novel measure to prevent and treat hyperlipidemia. The effects of GP on high-fat diet (HFD)-induced hyperlipidemia and gut microbiota modulation were determined in rats. Ultra-performance liquid chromatography tandem quadrupole time-of-flight mass spectrometry (UPLC-QTOF MS-MS) indicated that GP were enriched with ganoderic acids G, B, H, A, and F. After feeding with GP supplementation, serum lipid levels including total triglyceride, total cholesterol, and low-density-lipoprotein cholesterol were significantly decreased in hyperlipidemic rats. Furthermore, administration of GP also has reversed the HFD-induced gut microbiota dysbiosis, including a significant increase in Alloprevotella and reduced proportion of Blautia. The result above suggests that GP would be developed as a functional food to ameliorate lipid metabolic disorders and hyperlipidemia.

Prognostic potential of liver injury in patients with dilated cardiomyopathy: a retrospective study

Background

Liver injury (LI) has been frequently observed in patients with dilated cardiomyopathy (DCM), whereas its prognostic value remains blurry. We attempted to appraise the prognostic effect of LI in patients with DCM.

Methods

This retrospective study included 523 patients with DCM. LI was defined as a threefold increase in aspartate transaminase (≥ 135 U/L) or alanine transaminase (≥ 180 U/L) or a twofold increase in total bilirubin (≥ 41 umol/L) during hospitalization. The population was segmented into non-liver injury (NLI) group and LI group based on liver function test data. To balance differences in covariates at baseline, 1:1 propensity score matching (PSM) was performed.

Results

Patients with LI had lower survival rate, compared with those with NLI (44.6% vs. 73.8%, P < 0.001). Similar results were also found in age (age > 50, 39.6% vs. 70.9%, P < 0.001; age ≤ 50, 51.3% vs. 79.5%, P < 0.001) and gender stratified analysis (male, 46.2% vs. 74.4%, P < 0.001; female 35.7% vs. 72.0%, P = 0.001). After PSM, the survival rate of patients with LI remained lower than those with NLI (44.6% vs. 64.1%, P = 0.019). Multivariable Cox regression analysis manifested that LI (hazard ratio [HR]: 1.692, 95% confidence interval [CI] 1.194–2.398, P = 0.003; HR: 1.675, 95% CI 1.078–2.604, P = 0.022, respectively) showed potent predictive effect on all-cause mortality in patients with DCM, both before and after PSM.

Conclusions

The occurrence of LI herald adverse outcomes in patients with DCM and attention to LI may be conducive to risk stratification and management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-022-00876-9.

Amanitin intoxication: effects of therapies on clinical outcomes - a review of 40 years of reported cases

BACKGROUND AND AIMS

Amanita phalloides poisoning causes severe liver damage which may be potentially fatal. Several treatments are available, but their effectiveness has not been systematically evaluated. We performed a systematic review to investigate the effect of the most commonly used therapies: N-acetylcysteine (NAC), benzylpenicillin (PEN), and silibinin (SIL) on patient outcomes. In addition, other factors contributing to patient outcomes are identified.

METHODS

We searched MEDLINE and Embase for case series and case reports that described patient outcomes after poisoning with amanitin-containing Amanita mushrooms. We extracted clinical characteristics, treatment details, and outcomes. We used the liver item from the Poisoning Severity Score (PSS) to categorize intoxication severity.

RESULTS

We included 131 publications describing a total of 877 unique cases. The overall survival rate of all patients was 84%. Patients receiving only supportive care had a survival rate of 59%. The use of SIL or PEN was associated with a 90% (OR 6.40 [3.14-13.04]) and 89% (OR 5.24 [2.87-9.56]) survival rate, respectively. NAC/SIL combination therapy was associated with 85% survival rate (OR 3.85 [2.04, 7.25]). NAC/PEN/SIL treatment group had a survival rate of 76% (OR 2.11 [1.25, 3.57]). Due to the limited number of cases, the use of NAC alone could not be evaluated. Additional analyses in 'proven cases' (amanitin detected), 'probable cases' (mushroom identified by mycologist), and 'possible cases' (neither amanitin detected nor mushroom identified) showed comparable results, but the results did not reach statistical significance. Transplantation-free survivors had significantly lower peak values of aspartate aminotransferase (AST), alanine aminotransferase (ALT), total serum bilirubin (TSB), and international normalized ratio (INR) compared to liver transplantation survivors and patients with fatal outcomes. Higher peak PSS was associated with increased mortality.

CONCLUSION

Based on data available, no statistical differences could be observed for the effects of NAC, PEN or SIL in proven poisonings with amanitin-containing mushrooms. However, monotherapy with SIL or PEN and combination therapy with NAC/SIL appear to be associated with higher survival rates compared to supportive care alone. AST, ALT, TSB, and INR values are possible predictors of potentially fatal outcomes.

Circulating Epstein-Barr virus DNA associated with hepatic impairment and its diagnostic and prognostic role in patients with gastric cancer

Epstein–Barr virus (EBV) infection may affect all tissues and organs of the body. Little is known about the impact of this entity on its systematic incorporation in patients with gastric cancer (GC). This study enrolled a total of 113 GC patients with EBV infection (EBVaGC) and 167 GC patients without EBV infection (EBVnGC). It was found that the CRP levels (indicative of inflammatory status) were significantly increased in EBVaGC compared with those in EBVnGC (12.11 mg/L vs. 5.72 mg/L, P = 0.008), but WBC and neutrophils counts were similar in both groups (P > 0.05). Consistent elevations in the levels of liver enzymes, ALP and GGT, with incompatible alterations in ALT or AST were observed in EBVaGC. Slightly prolonged coagulation indices, PT and INR, and decreased albumin consistently suggested impaired synthesis capability of the liver in EBVaGC (all P < 0.05). The level of circulating EBV DNA was positively correlated with the level of GGT, tumor marker CA72-4 and the lymphocyte infiltration in tumor tissues (all P < 0.05). Of note, the EBV associated high-lymphocyte infiltrated tissues presented rich CD8 + T cells. Circulating EBV DNA further showed a predictive role in distinguishing EBVaGC from EBVnGC (AUC 0.79, 95% CI 0.73 to 0.85, P < 0.001), and was associated closely with better overall survival (HR 0.45, 95% CI 0.21 to 0.96, P = 0.039). EBV infection in patients with gastric cancer may be linked to hepatic impairment and immune response. Circulating cell-free EBV DNA is not only a biomarker for the screening of an EBV-related GC subtype but is also an independently prognosis factor for the long-term survival benefit in GC patients.

Biomarkers in Liver Disease

Symptoms and signs of liver diseases are highly variable depending on the etiology, disease stage, and type of liver involvement. There are different types of liver diseases; causes of liver diseases may be viral, toxic, metabolic, or autoimmune. However, in some cases, liver disease can develop as a result of diseases of other organs or systems. It is almost impossible to differentiate all of these solely on the basis of clinical symptoms and findings. Furthermore, the early stages of liver disease may be completely asymptomatic, or in some cases, the disease may progress with only subtle and non-specific symptoms. Therefore, biomarkers have a critical role in screening, diagnosis, staging, and evaluation of therapeutic response to treatment in liver diseases.

Relationship between different hepatitis B virus infection status and gestational diabetes mellitus prevalence among pregnant women with chronic HBV infection: A retrospective study

To investigate the relationships between different hepatitis B virus (HBV) infection status and gestational diabetes mellitus (GDM) and analyse the potential risk factors, we conducted an observational retrospective study in HBV-infected pregnant women to compare the differences of GDM prevalence and clinical outcomes between groups divided by HBV infection status. Spearman's correlation coefficient was used to evaluate the correlations among hepatitis B e antigen (HBeAg), HBV DNA and liver function. Logistic regression model was used to analyse the risk factors. In all, 1390 HBsAg-positive pregnant women were enrolled. HBeAg titre and HBV DNA, ALT and AST were correlated (r = 0.743, p < 0.001; r = 0.813, p < 0.001). Overall GDM prevalence was 21%. GDM prevalence of HBV-infected women with abnormal liver function was higher than those with normal liver function (26.8% vs. 20%, p = 0.027). Age over 35 years and abnormal liver function over 5 times ULN and 1-2 times ULN were independent risk factors for GDM prevalence with odds ratio (OR) of 1.858 (95% CI 1.227-2.815), 1.589 (95% CI 1.023-2.468) and 2.203 (95% CI 1.029-4.718), respectively. GDM prevalence in HBV-infected pregnancies with abnormal liver function was higher than those with normal liver function. Age over 35 years and abnormal liver function were independent risk factors for GDM in HBV-infected women.

Diagnostik erhöhter Leberwerte in der Primärversorgung – Befunde einer Studienreihe aus haus- und fachärztlicher Perspektive

Hintergrund In der Primärversorgung treten Leberwerterhöhungen häufig als Zufallsbefund in Erscheinung. Neben der Beachtung von Symptomen ist für eine effektive Abklärung entscheidend, welche Leberwerte als Indikatoren einbezogen und wann Patient*innen zur weiterführenden Diagnostik überwiesen werden. Ebenso kommt es auf eine geregelte Zusammenarbeit zwischen haus- und fachärztlicher Versorgungsebene an. Bislang fehlt es für den deutschsprachigen Raum an belastbaren Erkenntnissen über den Status quo hinsichtlich der Abklärung (unklarer) Leberwerterhöhungen im niedergelassenen und hausärztlichen Bereich. Der Überblicksartikel komprimiert die Bilanz einer explorativen Studienreihe, deren Ziel darin bestand, eine Bestandsaufnahme hinsichtlich des Status quo der hausarztbasierten Diagnostik (unklar) erhöhter Leberwerte zu leisten. Aus den Ergebnissen werden Ansatzpunkte einer Optimierung abgeleitet.

Methodik Zwischen 2017 und 2021 wurden 4 schriftliche Befragungen von Hausärzt*innen und gastroenterologischen Fachärzt*innen in verschiedenen Bundesländern durchgeführt. Die vorliegende Studienbilanz diskutiert die Gesamtbefunde komprimiert auf übergeordneter Ebene, geht jedoch auch auf spezifische Befunde ein.

Ergebnisse Mit Blick auf Abklärung erhöhter Leberwerte zeigen sich diverse Herausforderungen und Problematiken. So ziehen Hausärzt*innen stark unterschiedliche Laborparameter heran (95% γ-GT, 65% AST, 63% ALT), die sich in verschiedenen Clustern bündeln. Im Fall erhöhter Leberwerte präferiert eine Mehrheit der Hausärzt*innen ein kontrolliertes Zuwarten (66%), macht allerdings im Alltag oft aufgrund von diagnostischen Unsicherheiten von direkten Überweisungen zu Spezialist*innen Gebrauch (40%). In der Zusammenarbeit mit gastroenterologischen Fachärzt*innen bestehen aus hausärztlicher Sicht Schnittstellenprobleme, die u.a. mit der im Vorfeld geleisteten Abklärung sowie dem Überweisungszeitpunkt einhergehen. Sowohl Haus- als auch Fachärzt*innen erachten die Einführung eines evidenzbasierten Diagnosealgorithmus als wichtigen Ansatz für die Verbesserung der Früherkennung sowie eine bessere Koordination zwischen den Versorgungsebenen (80% bzw. 85%).

Diskussion Es sollte darauf hingewirkt werden, zu einer stärkeren Professionalisierung und Vereinheitlichung der primärärztlichen Diagnostik beizutragen und die Zusammenarbeit mit gastroenterologischen Spezialisten besser zu strukturieren. Dazu zählen ein breiteres Angebot von Fortbildungsformaten, die Entwicklung eines validierten Diagnosepfads und die feste Verankerung einer leberwertassoziierten Blutuntersuchung im Rahmen des Check-ups. Auch die Entwicklung einer hausarztbasierten Leitlinie zum Umgang mit erhöhten Leberwerten erscheint ratsam.

Epimedium koreanum Nakai–Induced Liver Injury—A Mechanistic Study Using Untargeted Metabolomics

Epimedii Folium is widely used worldwide as an herbal supplement, and the risk of its induced liver damage has emerged in recent years. Our preliminary study has found that, among several Epimedii Folium species specified in the Chinese Pharmacopoeia, Epimedium koreanum Nakai has a more severe propensity for hepatotoxicity. However, the mechanism of hepatotoxicity of Epimedium koreanum Nakai is still unclear. In this study, untargeted metabolomics was performed to analyze the serum and liver tissue to explore the mechanism of hepatotoxicity of Epimedium koreanum Nakai. The results of experiments in vivo showed that, after 28 days of exposure to Epimedium koreanum Nakai ethanol extract (EEE), the liver weight, levels of AST, ALP, TBIL, etc. in serum of rats in the EEE group were significantly increased, as well as severe cytoplasmic vacuolation appeared in the liver tissue, which suggested that EEE has significant hepatotoxicity. Subsequently, the results of metabolomics revealed significant changes in the metabolic profile in the liver and serum of rats after EEE exposure, in which metabolites in serum such as flavin mononucleotide, phenylacetylglycine, glutathione, l-tryptophan, and sphingomyelin were able to accurately identify liver injury caused by EEE and could be used as serum markers to reflect EEE-induced liver injury. The KEGG pathway enrichment analysis revealed that EEE caused extensive effects on rats' metabolic pathways. Some of the most affected pathways included glutathione metabolism, glutamate metabolism pathway, primary bile acid biosynthesis pathway, and sphingolipid metabolism pathway, which were all directed to the biological process of ferroptosis. Then, the main markers related to ferroptosis in the liver were examined, and the results demonstrated that the content of malondialdehyde was significantly increased, the activity of superoxide dismutase was significantly reduced, the ferroptosis inhibitory proteins GPX4 and System xc− were significantly downregulated, and the ferroptosis-promoting protein ACSL4 was significantly up-regulated. Judging from these results, we concluded that the mechanism of hepatotoxicity of Epimedium koreanum Nakai was probably related to the induction of ferroptosis in hepatocytes.

Aloe vera ameliorates hyperlipidemia, enhances endogenous antioxidant activity and regulates liver function in high fat diet fed mice

BACKGROUND: Prolonged high fat diet consumption was reported to cause metabolic disorders including obesity, NAFLD and insulin resistance. NAFLD is one of the common causes of liver failure with lipid accumulation and inflammation as the major driving forces for its progression. OBJECTIVE: The study was aimed at evaluating the benefits of Aloe vera supplementation on lipid profiles, antioxidant properties, liver function as well as the histology of liver, heart and brain on high fat diet induced toxicity in BALB/c mice. METHODS: Eighteen mice were divided into three groups (n = 6). Group 1 received normal diet (Vital feed), group 2 received high fat diet (HFD) i.e. 70 g of normal diet plus 30 g of margarine, while group 3 received high fat diet plus Aloe vera (HFD+AV) i.e. 80 g of HFD plus 20 g of Aloe vera gel. The mice were fed for 10 weeks and euthanized thereafter. The liver function, lipid profiles, antioxidant properties as well as liver, brain and heart histology were evaluated. RESULTS: The levels of cholesterol, triglycerides and low density lipoprotein were significantly increased (P <  0.05) in the HFD treated mice compared to the control. Liver catalase and superoxide dismutase activities were significantly increased (P <  0.05) in HFD+AV treated mice compared to the control and HFD treated mice. The liver of HFD+AV treated mice showed normal architecture while those of HFD treated mice showed numerous hepatic vacuoles indicative of fat droplets. CONCLUSIONS: Aloe vera supplementation regulated liver function and prevents hyperlipidemia. The resultant effect increased antioxidant activities thereby preventing liver injury and brain damage.

A Prediction Model of the Incidence of Nonalcoholic Fatty Liver Disease With Visceral Fatty Obesity: A General Population-Based Study

Objective:

This study aimed to distinguish the risk variables of nonalcoholic fatty liver disease (NAFLD) and to construct a prediction model of NAFLD in visceral fat obesity in Japanese adults.

Methods

This study is a historical cohort study that included 1,516 individuals with visceral obesity. All individuals were randomly divided into training group and validation group at 70% (n = 1,061) and 30% (n = 455), respectively. The LASSO method and multivariate regression analysis were performed for selecting risk factors in the training group. Then, overlapping features were selected to screen the effective and suitable risk variables for NAFLD with visceral fatty obesity, and a nomogram incorporating the selected risk factors in the training group was constructed. Then, we used the C-index, calibration plot, decision curve analysis, and cumulative hazard analysis to test the discrimination, calibration, and clinical meaning of the nomogram. At last, internal validation was used in the validation group.

Results

We contract a nomogram and validated it using easily available and cost-effective parameters to predict the incidence of NAFLD in participants with visceral fatty obesity, including ALT, HbA1c, body weight, FPG, and TG. In training cohort, the area under the ROC was 0.863, with 95% CI: 0.84–0.885. In validation cohort, C-index was 0.887, with 95%CI: 0.857–0.888. The decision curve analysis showed that the model's prediction is more effective. Decision curve analysis of the training cohort and validation cohort showed that the predictive model was more effective in predicting the risk of NAFLD in Japanese patients with visceral fatty obesity. To help researchers and clinicians better use the nomogram, our online version can be accessed at https://xy2yyjzyxk.shinyapps.io/NAFLD/.

Conclusions

Most patients with visceral fatty obesity have a risk of NALFD, but some will not develop into it. The presented nomogram can accurately identify these patients at high risk.

Evaluation of elevated liver values in primary care - a series of studies on the status quo of care in Germany with special reference to alcoholic liver disease

BACKGROUND

In primary care, elevated liver values often appear as incidental findings. As well considering the presenting symptoms, key factors in effective diagnosis are which liver values to include as indicators and when to refer patients for further diagnostics. It is also important that there is coordinated collaboration between GPs and specialists. There has hitherto been a lack of reliable findings on the status quo regarding the evaluation of (abnormally) elevated liver values in primary care.

METHODS

Between 2017 and 2021, four written explorative surveys of GPs and gastroenterological specialists were conducted in various German states, aimed at taking stock of the current status of GP-based diagnostics of (abnormally) elevated liver values. In addition, interviews were conducted with 14 GPs and gastroenterological specialists. This review article discusses the overall findings of the series of studies in a condensed manner at a higher level. The article aims to derive starting points for optimising the diagnosis of liver cirrhosis in primary care.

RESULTS

There are various challenges and problems associated with the evaluation of elevated liver values. For example, GPs draw on very different laboratory parameters, which are combined in different clusters. When elevated liver values are found, a majority of GPs prefer a controlled wait-and-see period, but often make use of direct referrals to specialists due to diagnostic uncertainties. GPs report interface problems with gastroenterological specialists, which are associated, among other things, with the preliminary evaluation that has been made and the timing of referral. Both GPs and specialists consider the introduction of an evidence-based diagnostic algorithm to be an important starting point for improving early detection and better coordination between healthcare levels.

CONCLUSIONS

Efforts should be made to contribute to greater professionalisation and standardisation of primary care diagnostics and to better structure the interaction with gastroenterological specialists. These include a wider range of training formats, the development of a validated diagnostic pathway and the mandating of a liver function test as part of the check-up. The development of a GP-based guideline for managing elevated liver values also seems advisable.

Part 1: Disease of the Heart and Liver: A Relationship That Cuts Both Ways

The heart and the liver display multifaceted, complex interactions that can be divided into cardiac effects of liver disease, hepatic effects of heart disease, and disease processes affecting both organs. In part 1 of this 2 part series, we discuss how acute and chronic heart failure can have devastating effects on the liver, such as acute cardiogenic liver injury and congestive hepatopathy. On the other hand, primary liver disease, such as cirrhosis, can lead to a plethora of cardiac insults representative in cirrhotic cardiomyopathy as systolic dysfunction, diastolic dysfunction, and electrophysiological disturbances. Nonalcoholic fatty liver disease has long been associated with cardiovascular events that increase mortality. The management of both disease processes changes when the other organ system becomes involved. This consideration is important with regard to a variety of interventions, most notably transplantation of either organ, as risk of complications dramatically rises in the setting of both heart and liver disease (discussed in part 2). As our understanding of the intricate communication between the heart and liver continues to expand so does our management.

Trends in indirect liver function marker testing in Wales from 2000 to 2017 and their association with age and sex: an observational study

Objective

If non-invasive markers of liver fibrosis were recorded frequently enough in clinical practice, it might be feasible to use them for opportunistic community screening for liver disease. We aimed to determine their current pattern of usage in the national primary care population in Wales.

Design

Using the Secure Anonymised Information Linkage (SAIL) Databank at Swansea University (2000–2017), we quantified the frequency of common liver blood tests (aspartate aminotransferase (AST), alanine aminotransferase (ALT), platelet count and albumin) used in fibrosis marker algorithms. We examined measurement variation by age and sex.

Results

During the 18-year study period, there were 2 145 178 adult patients with at least one blood test available for analysis. Over the study period, the percentage of SAIL patients receiving an ALT test in each year increased from 2% to 33%, with platelet count and albumin measurement increasing by a similar factor. AST testing, although initially rising, had decreased to 1% by the end of the study. AST and ALT values varied by age and sex, particularly in males with the upper normal range of ALT values decreasing rapidly from 90 U/L at age 30 to 45 U/L by age 80.

Conclusion

The reduction in AST testing to only 1% of the adult population limits the use of many non-invasive liver marker algorithms. To enable widespread screening, alternative algorithms for liver fibrosis that do not depend on AST should be developed. Liver fibrosis markers should be modified to include age-specific and sex-specific normal ranges.

Postoperative liver function tests can predict anastomotic dysfunction after bile duct injury repair

Liver function tests help in the follow-up of postoperative patients with iatrogenic bile duct injury. There is not clear evidence regarding their predictive role on anastomosis dysfunction. We describe our experience with postoperative liver function tests and a predictive model of long-term patency after repair. This is retrospective cohort study of patients with bilioenteric anastomosis for bile duct injury and their long-term follow-up. A binomial logistic regression model was performed to ascertain the effects of the grade of bile duct injury and liver function test in the postoperative period. A total of 329 patients were considered for the analysis. In the logistic regression model two predictor variables were statistically significant for anastomosis stenosis: type of bilioenteric anastomosis and alkaline phosphatase levels. A ROC curve analysis was made for alkaline phosphatase with an area under the curve of 0.758 (95% CI 0.67-0.84). A threshold of 323 mg/dL was established (OR 6.0, 95% CI 2.60-13.83) with a sensitivity of 75%, specificity of 67%, PPV of 20%, NPV of 96%, PLR of 2.27 and NLR of 0.37. Increased alkaline phosphatase (above 323 mg/dL) after the fourth operative week was found to be a predictor of long-term dysfunction.

Activation of pyroptosis and ferroptosis is involved in the hepatotoxicity induced by polystyrene microplastics in mice

Microplastics (MPs) are new environmental pollutants and have received widespread attention in recent years, but the toxicity of the MPs remains to be fully elucidated. To explore the effect of MPs on hepatotoxicity in mice and unravel the mechanism of pyroptosis and ferroptosis in the process of liver injury, we treated mice with 5.0 μm polypropylene microplastics (MPs) at 0.1, 0.5 and 1 mg/mL for 4 weeks. Results revealed that MPs could damage liver structure and function with broken and reduced mitochondrial cristae, as well as increased levels of aspartate minotransferase (AST), alanine aminotransferase (ALT), AST/ALT, alkaline phosphatase (ALP) and lactate dehydrogenase (LDH). Treatment with MPs resulted in pyroptosis as evidenced by increasing expressions of interleukin IL-1β, IL-18. Additionally, MPs were shown to induce the NOD-like receptor protein 3 (NLRP3) inflammasomes and apoptosis associated speck-like protein (ASC) containing a caspase recruitment domain activation in liver tissue, enabling activation of Caspase-1-dependent signaling pathway induced by inflammatory stimuli resulting from oxidative stress. In addition, the increase of malondialdehyde (MDA) and decrease of glutathione (GSH) and superoxide dismutase (SOD) in the liver indicated that MPs could induce oxidative damage. Moreover, MPs induced lipid peroxidation in the liver of mice could activate the expression of ferroptosis related proteins, including iron metabolism, such as transferrin receptor (TFRC) was active but ferritin heavy chain 1 (FTH1) was inhibited; amino acid metabolism, such as XCT system and glutathione peroxidase 4 (GPX4) were inhibited; lipid metabolism, such as acyl-CoA synthetase long-chain family member 4 (ACSL4) was inhibited. Collectively, these findings evidenced that pyroptosis and ferroptosis occurred in MPs-induced liver injury accompanied by intense oxidative stress and inflammation.

The Concept of Indeterminable NASH Inducted by Preoperative Diet and Metabolic Surgery: Analyses of Histopathological and Clinical Features

Practitioners routinely perform intraoperative liver biopsies during laparoscopic sleeve gastrectomy (LSG) to evaluate nonalcoholic fatty liver disease (NAFLD). In some patients, hepatocyte ballooning, inflammation, and fibrosis without steatosis are observed, even in the absence of other etiologies. We call this finding indeterminable nonalcoholic steatohepatitis (Ind-NASH). In this study, we clarified the prevalence, as well as histopathological and clinical features, of Ind-NASH through intraoperative liver biopsy in Japanese patients presenting with severe obesity. We enrolled 63 patients who had undergone LSG and intraoperative liver biopsy. In patients diagnosed with histopathological NASH, we performed protocol liver biopsies at 6 and 12 months after LSG. We statistically analyzed these histopathological findings and clinical parameters and found the prevalence rate of Ind-NASH discovered through intraoperative biopsy to be 15.9%. Protocol liver biopsy also revealed that Ind-NASH was an intermediate condition between NASH and normal liver. The clinical features of patients with Ind-NASH are a higher body weight compared to NASH (134.9 kg vs. 114.7 kg; p = 0.0245), stronger insulin resistance compared to nonalcoholic fatty liver (homeostasis model assessment–insulin resistance: 7.1 vs. 4.9; p = 0.0188), and mild liver dysfunction compared to NASH. Patients with Ind-NASH observed positive weight-loss effects from a preoperative diet compared to the postoperative course (percentage total weight loss: 32.0% vs. 26.7%; p < 0.0001). Patients with Ind-NASH may also be good candidates for metabolic surgery owing to their good treatment response; therefore, efforts should be made by specialists in the near future to deeply discuss and define Ind-NASH.

Preclinical Evaluation of Dimethyl Itaconate Against Hepatocellular Carcinoma via Activation of the e/iNOS-Mediated NF-κB-Dependent Apoptotic Pathway

Hepatocellular carcinoma (HCC) is one of the most common tumors affecting a large population worldwide, with the fifth and seventh greatest mortality rates among men and women, respectively, and the third prime cause of mortality among cancer victims. Dimethyl itaconate (DI) has been reported to be efficacious in colorectal cancer by decreasing IL-1β release from intestinal epithelial cells. In this study, diethylnitrosamine (DEN)-induced HCC in male albino Wistar rats was treated with DI as an anticancer drug. The function and molecular mechanism of DI against HCC in vivo were assessed using histopathology, enzyme-linked immunosorbent assay (ELISA), and Western blot studies. Metabolomics using ¹H-NMR was used to investigate metabolic profiles. As per molecular insights, DI has the ability to trigger mitochondrial apoptosis through iNOS- and eNOS-induced activation of the NF-κB/Bcl-2 family of proteins, CytC, caspase-3, and caspase-9 signaling cascade. Serum metabolomics investigations using ¹H-NMR revealed that aberrant metabolites in DEN-induced HCC rats were restored to normal following DI therapy. Furthermore, our data revealed that the DI worked as an anti-HCC agent. The anticancer activity of DI was shown to be equivalent to that of the commercial chemotherapeutic drug 5-fluorouracil.

Association between urine metals and liver function biomarkers in Northeast China: A cross-sectional study

BACKGROUND

After heavy metals enter the body, they affect a variety of organs, particularly the main metabolic organ, the liver. Moreover, people are more likely to be exposed to multiple metals than to a single metal. We explored the associations between exposure to a heavy metal mixture and liver function biomarkers.

METHODS

This study involved 1171 residents living in areas with or without heavy metal exposure in northeast China. Urine concentrations of chromium (Cr), cadmium (Cd), lead (Pb), and manganese (Mn) were measured. Total protein (TP), albumin (ALB), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) were used as biomarkers of liver function. A generalized linear model (GLM), quantile g-computation, and Bayesian kernel machine regression (BKMR) were used to explore the associations between the four metals and liver function.

RESULTS

GLM analysis revealed that Cr level was negatively associated with TP (β = - 0.57; 95% CI: - 0.89, - 0.26) and ALB (β = - 0.27; 95% CI: - 0.47, - 0.07) levels, and Cd level was positively associated with AST (β = 1.04; 95% CI: 0.43, 1.65) and ALT (β = 0.94; 95% CI: 0.08, 1.79) levels. ALB (β = 0.26; 95% CI: 0.10, 0.41) and ALT (β = 0.52; 95% CI: 0.02, 1.02) levels were positively associated with urine Mn concentration. The quantile g-computation indicated that exposure to a mixture of the four metals was significantly associated with TP (β = - 0.56; 95% CI: - 0.94, - 0.18) and ALT (β = 0.84; 95% CI: 0.04, 1.63) levels. Among the metals, Cr had the strongest effect on TP and Cd had that on AST. The BKMR model indicated that mixed metal exposure was negatively associated with TP and ALB levels and positively associated with ALT and AST levels.

CONCLUSION

Exposure to mixtures of heavy metals may influence liver function. Cr and Cd may be the largest contributors.

Modest alcohol intake and mortality in individuals with elevated alanine aminotransferase levels: a nationwide cohort study

BACKGROUND

Alanine aminotransferase (ALT) levels are widely used to screen liver disease, and many asymptomatic individuals show elevated ALT levels. As elevated ALT level indicates liver injury, even a small amount of alcohol intake may be harmful in subjects with elevated ALT levels, but there is limited evidence of the effect of light to moderate amount of alcohol intake in this subgroup.

METHODS

A cohort of 367,612 men and women without established liver diseases (including chronic viral hepatitis, alcohol-associated liver disease, cirrhosis, liver transplantation, or rare forms of liver disease) who underwent at least 1 health screening exam between 2009 and 2015 were assessed for liver-related and all-cause mortality. Elevated ALT levels were defined as ≥ 34 U/L for men and 25 U/L for women.

RESULTS

In participants with normal ALT levels, the fully-adjusted hazard ratios (95% CI) for liver-related mortality comparing light and moderate drinkers to non-drinkers were 0.73 (0.51-1.05), and 1.06 (0.73-1.52), respectively. In participants with elevated ALT levels, the corresponding hazard ratios were 1.57 (1.08-2.28), and 2.09 (CI 1.46-2.99), respectively (p value for alcohol intake by ALT interaction < 0.01). For all-cause mortality, the fully-adjusted hazard ratios comparing light and moderate drinkers to non-drinkers in participants with normal ALT levels were 0.72 (0.66-0.77), and 0.89 (0.82-0.97), respectively. In participants with elevated ALT levels, the corresponding hazard ratios were 0.93 (0.81-1.08), and 1.31 (1.14-1.50), respectively (p value for alcohol intake by ALT interaction < 0.01).

CONCLUSIONS

Small amounts of alcohol intake were associated with increased liver-related and all-cause mortality among individuals with elevated ALT levels. Subjects with elevated ALT levels should be advised complete abstinence from alcohol.