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Tang Q, Hu G, Sang Y, Chen Y, Wei G, Zhu M, Chen M, Li S, Liu R, Peng Z. Therapeutic targeting of PLK1 in TERT promoter-mutant hepatocellular carcinoma. Clin Transl Med 2024; 14:e1703. [PMID: 38769666 PMCID: PMC11106514 DOI: 10.1002/ctm2.1703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 04/16/2024] [Accepted: 05/06/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Hotspot mutations in the promoter of telomerase reverse transcriptase (TERT) gene are the most common genetic variants in hepatocellular carcinoma (HCC) and associated with poor prognosis of the disease. However, no drug was currently approved for treating TERT promoter mutation positive HCC patients. Here, we aim to explore the potential therapeutic strategy for targeting TERT promoter mutation in HCC. METHODS The Liver Cancer Model Repository database was used for screening potential drugs to selectively suppress the growth of TERT promoter mutant HCC cells. RNA-seq, CRISPR-Cas9 technology and siRNA transfection were performed for mechanistic studies. Cell counting kit-8 (CCK8) assay and the xenograft tumour models were used for cell growth detection in vitro and in vivo, respectively. Cell apoptosis and cell cycle arrest were analysed by Annexin V-FITC staining and/or propidium iodide staining. RESULTS PLK1 inhibitors were remarkably more sensitive to HCC cells harbouring TERT promoter mutation than wild-type cells in vitro and in vivo, which were diminished after TERT promoter mutation was edited to the wild-type nucleotide. Comparing the HCC cells with wild-type promoter of TERT, PLK1 inhibitors specifically downregulated Smad3 to regulate TERT for inducing apoptosis and G2/M arrest in TERT mutant HCC cells. Moreover, knockout of Smad3 counteracted the effects of PLK1 inhibitors in TERT mutant HCC cells. Finally, a cooperative effect of PLK1 and Smad3 inhibition was observed in TERT mutant cells. CONCLUSIONS PLK1 inhibition selectively suppressed the growth of TERT mutant HCC cells through Smad3, thus contributed to discover a novel therapeutic strategy to treat HCC patients harbouring TERT promoter mutations. KEY POINTS TERT promoter mutation confers sensitivity to PLK1 inhibitors in HCC. The selective growth inhibition of TERT mutant HCC cells induced by PLK1 inhibitor was mediated by Smad3. Combined inhibition of PLK1 and Smad3 showed a cooperative anti-tumor effect in TERT mutant HCC cells.
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Affiliation(s)
- Qin Tang
- Department of Radiation OncologyThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
- Institute of Precision MedicineThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Guanghui Hu
- Institute of Precision MedicineThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Ye Sang
- Institute of Precision MedicineThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Yulu Chen
- Institute of Precision MedicineThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Guangyan Wei
- Department of Radiation OncologyThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Meiyan Zhu
- Department of Radiation OncologyThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Mengke Chen
- Institute of Precision MedicineThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Shiyong Li
- Institute of Precision MedicineThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Rengyun Liu
- Institute of Precision MedicineThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Zhenwei Peng
- Department of Radiation OncologyThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
- Institute of Precision MedicineThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
- Cancer CenterThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
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Zhong X, Huang D, Chen R, Yao L, Ma R, Yu Y, Jiang Y, Kong L, Lu J, Li Y, Shi Y. Positive association between insulin resistance and fatty liver disease in psoriasis: evidence from a cross-sectional study. Front Immunol 2024; 15:1388967. [PMID: 38715604 PMCID: PMC11074461 DOI: 10.3389/fimmu.2024.1388967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/10/2024] [Indexed: 06/04/2024] Open
Abstract
Background Fatty liver disease (FLD) is a common comorbidity of psoriasis and is often referred to as non-alcoholic fatty liver disease (NAFLD). However, the role of inflammation or insulin resistance (IR) in FLD is inconclusive. The study aims to explore whether FLD in psoriasis patients is more related to insulin resistance or systemic inflammation level. Methods Data for this study were collected from the Shanghai Psoriasis Effectiveness Evaluation Cohort, a prospective cohort that examines psoriasis characteristics in the Chinese population. IR was assessed using the triglyceride glucose (TyG) and TyG-body mass index (TyG-BMI) indicators. Systemic non-specific inflammation was assessed using the neutrophil-to-lymphocyte ratio (NLR), derived neutrophil-to-lymphocyte ratio (dNLR), and systemic immune inflammation index (SII). Results The analysis included a total of 647 patients. Subsequent logistic regression analysis revealed that NLR, dNLR, and SII were not significantly associated with FLD in psoriasis patients, while TyG and TyG-BMI showed significant associations with FLD. Subgroup analysis indicated that in the majority of subgroups, TyG and TyG-BMI were significantly associated with FLD, particularly TyG-BMI. Excluding individuals with methotrexate and acitretin resulted in consistent findings with the main analysis. Further analysis revealed a significantly higher diagnosis rate of metabolic-associated fatty liver disease (MAFLD) compared to NAFLD. Conclusions Metabolic factors play a crucial role in FLD in patients with psoriasis, and TyG and TyG-BMI are potential predictors of FLD. Therefore, MAFLD can be recommend as a term to describe FLD in psoriasis patients. Trial registration https://www.chictr.org.cn/showproj.html?proj=58256, identifier ChiCTR2000036186. A multi-center clinical study of systemic treatment strategies for psoriasis in Chinese population. Registered 31 August 2020.
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Affiliation(s)
- Xiaoyuan Zhong
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Psoriasis, Tongji University School of Medicine, Shanghai, China
| | - Dawei Huang
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Psoriasis, Tongji University School of Medicine, Shanghai, China
| | - Rongfen Chen
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Psoriasis, Tongji University School of Medicine, Shanghai, China
| | - Lingling Yao
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Psoriasis, Tongji University School of Medicine, Shanghai, China
| | - Rui Ma
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Psoriasis, Tongji University School of Medicine, Shanghai, China
| | - Yingyuan Yu
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Psoriasis, Tongji University School of Medicine, Shanghai, China
| | - Yuxiong Jiang
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Psoriasis, Tongji University School of Medicine, Shanghai, China
| | - Luyang Kong
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Psoriasis, Tongji University School of Medicine, Shanghai, China
| | - Jiajing Lu
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Psoriasis, Tongji University School of Medicine, Shanghai, China
| | - Ying Li
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Psoriasis, Tongji University School of Medicine, Shanghai, China
| | - Yuling Shi
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Psoriasis, Tongji University School of Medicine, Shanghai, China
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Liu K, Tang S, Liu C, Ma J, Cao X, Yang X, Zhu Y, Chen K, Liu Y, Zhang C, Liu Y. Systemic immune-inflammatory biomarkers (SII, NLR, PLR and LMR) linked to non-alcoholic fatty liver disease risk. Front Immunol 2024; 15:1337241. [PMID: 38481995 PMCID: PMC10933001 DOI: 10.3389/fimmu.2024.1337241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 02/15/2024] [Indexed: 04/10/2024] Open
Abstract
Background Systemic immune-inflammatory biomarkers including systemic immune inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) have been demonstrated to be associated with the risk and severity of various liver diseases. However, studies on their role and clinical significance in metabolic diseases, especially in nonalcoholic fatty liver disease (NAFLD), are limited and results are inconsistent. Methods 10821 adults aged 20 years or older were enrolled in this cross-sectional study, sourced from six cycles of the National Health and Nutrition Examination Survey (NHANES). Survey-weighted logistic regression was employed to investigate the correlation between systemic immune-inflammatory biomarkers (SII, NLR, PLR, and LMR) and NAFLD risk. Restricted cubic spline regression models and segmented regression models were used to describe nonlinear relationships and threshold effects. Subgroup and sensitivity analyses were also conducted. Results After adjusting for all confounding variables, there was a significant positive association observed between ln-transformed SII (OR= 1.46, 95% CI: 1.27-1.69, P <0.001), NLR (OR= 1.25, 95% CI: 1.05-1.49, P =0.015), LMR (OR= 1.39, 95% CI: 1.14-1.69, P = 0.002) with NAFLD. A nonlinear dose-response relationship with an inverted "U"-shaped threshold of 4.64 was observed between ln(PLR) and NAFLD risk. When ln(PLR) was below 4.64, each unit increase in ln(PLR) was associated with a 0.55-fold increase in the risk of NAFLD (OR= 1.55, 95% CI: 1.05-2.31, P <0.05). Conversely, when ln(PLR) exceeded 4.64, each unit increase in ln(PLR) was associated with a 0.40-fold decrease in the risk of NAFLD (OR= 0.60, 95% CI. 0.44-0.81, P <0.05). Conclusion ln-transformed SII, NLR, and LMR were linearly associated with NAFLD risk. ln(PLR) showed an inverted "U"-shaped nonlinear dose-response relationship with the risk of NAFLD.
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Affiliation(s)
- Ke Liu
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Shiyun Tang
- The National Clinical Trial Center of Chinese Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Chenhao Liu
- Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Jianli Ma
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Xiyu Cao
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Xiuli Yang
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Yi Zhu
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Ke Chen
- Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
- People's Hospital of Xinjin District, Chengdu, Sichuan, China
| | - Ya Liu
- Department of Endocrinology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Chuantao Zhang
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Yi Liu
- Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
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Săsăran MO, Muntean C, Lupu A, Lupu VV. Neutrophils: tissue and circulating signatures of pediatric non-alcoholic fatty liver disease. Front Cell Dev Biol 2024; 11:1336033. [PMID: 38239291 PMCID: PMC10794720 DOI: 10.3389/fcell.2023.1336033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 12/18/2023] [Indexed: 01/22/2024] Open
Abstract
The recent rise in non-alcoholic fatty liver disease (NAFLD) among children and adolescents led to a thorough investigation of the peculiarities of the cellular infiltrate which characterize the disease at young ages. This review aims to highlight the key involvement of neutrophils in the pathogenesis of pediatric NAFLD and the potential biomarker role of neutrophil-to-lymphocyte ratio (NLR) in the same pediatric disorder. Neutrophils, which are first responders to inflammation, constitute an abundant component of an infiltrate which is particularly disposed within the portal area of children with NAFLD. The involvement of neutrophils in triggering liver fibrosis has been related amongst others to reactive oxygen species (ROS) production, to the stimulation of hepatic stellate cells, and to their synthesis of neutrophil elastase. As immune imbalance characterizes NAFLD, potentially emerging non-invasive biomarkers such as NLR have been proposed for the detection and prognosis of NAFLD. In adults, several studies asserted the role of NLR in the prediction of advancing liver fibrosis and mortality in subjects with NAFLD. In children, data is scarce with contradicting findings, as some studies failed to identify significant shifting in NLR values in children with NAFLD when compared with obese controls without liver impairment. However, NLR seems to significantly increase in children with obesity and different degrees of NAFLD when compared to healthy counterparts and their changes seem to be reversible with weight loss. Still, paucity of pediatric studies calls for future research addressing the role of NLR in predicting NAFLD development and progression in children with obesity.
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Affiliation(s)
- Maria Oana Săsăran
- Department of Pediatrics 3, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Targu Mures, Romania
| | - Carmen Muntean
- Department of Pediatrics 1, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Targu Mures, Romania
| | - Ancuța Lupu
- Department of Pediatrics, University of Medicine and Pharmacy Gr. T. Popa Iași, Iași, Romania
| | - Vasile Valeriu Lupu
- Department of Pediatrics, University of Medicine and Pharmacy Gr. T. Popa Iași, Iași, Romania
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Zhu H, Zheng M, He H, Lei H, Tai W, Yang J. High neutrophil-lymphocyte ratio indicates a worse response to ursodeoxycholic acid in primary biliary cholangitis: a retrospective cohort study. BMC Gastroenterol 2023; 23:400. [PMID: 37978445 PMCID: PMC10657125 DOI: 10.1186/s12876-023-03031-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 11/05/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Primary biliary cholangitis (PBC) is a chronic cholestatic liver disease characterized by inflammation of the interlobular bile ducts. Ursodeoxycholic acid (UDCA) is the only FDA approved first-line therapy for PBC, but up to 40% of patients with PBC have an incomplete response to UDCA. Neutrophil-to-lymphocyte (NLR) has been used to predict prognosis in various liver diseases. There is limited evidence on the treatment response to UDCA in PBC patients. Our study aimed to evaluate the relationship between NRL and the response to UDCA treatment in PBC patients. METHODS A total of 257 primary biliary cholangitis (PBC) patients treated with UDCA (13-15 mg/kg/d) were enrolled in this retrospective study. The response to treatment was evaluated based on alkaline phosphatase levels ≤1.67 times the upper limit of the normal value after 12 months of UDCA treatment. Multivariable logistic regression analysis was performed to investigate the association between NLR at baseline and the response to 12 months of UDCA treatment after adjusting for important confounding variables. The stability of the results was evaluated by unadjusted and adjusted models. RESULTS The results of multiple regression analysis showed that NLR at baseline was positively associated with the nonresponse to UDCA treatment after adjustments for potential confounders (age, sex, BMI, hypertension, arterial plaque, thyroid disease, jaundice, albumin, globulin, total bile acid, ALP, GGT, LDLC, total cholesterol, hemoglobin, and APTT) (OR = 1.370, 95% CI 1.066-1.761). These results reveal that NLR is an independent risk factor for UDCA treatment nonresponse. CONCLUSIONS Our results suggest that PBC patients with a high NLR had a worse response to UDCA therapy.
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Affiliation(s)
- Huiling Zhu
- Department of Gastroenterology, Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Mengyao Zheng
- Department of Gastroenterology, Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Haiyu He
- Department of Gastroenterology, Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Hongtao Lei
- School of Public Health Kunming Medical University, Kunming, China
| | - Wenlin Tai
- Clinical Lab, Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jinhui Yang
- Department of Gastroenterology, Second Affiliated Hospital of Kunming Medical University, Kunming, China.
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Admission neutrophil-to-lymphocyte ratio predicts length of hospitalization and need for ICU admission in adults with Status Epilepticus. Seizure 2023; 106:80-84. [PMID: 36803830 DOI: 10.1016/j.seizure.2023.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Status epilepticus (SE) is a time-dependent neurological emergency. The current study evaluated the prognostic value of admission neutrophil-to-lymphocyte ratio (NLR) in patients with status epilepticus. METHODS In this retrospective observational cohort study we included all consecutive patients discharged from our neurology unit with the clinical or EEG diagnosis of SE from 2012 to 2022. Stepwise multivariate analysis was conducted to test the association of NLR with length of hospitalization, need for Intensive Care Unit (ICU) admission and 30 days mortality. Receiver operating characteristic (ROC) analysis was performed to identify the best cutoff for NLR to identify patients who will need ICU admission. RESULTS A total of 116 patients were enrolled in our study. NLR was correlated with length of hospitalization (p = 0.020) and need for ICU admission ( p = 0.046). In addition, the risk of ICU admission increased in patients with intracranial hemorrhage and length of hospitalization was correlated with C-reactive protein-to-albumin ratio (CRP/ALB). ROC analysis identified a NLR of 3.6 as best cutoff value to discriminate need of ICU admission (area under the curve [AUC]=0.678; p = 0.011; Youden's index=0.358; sensitivity, 90.5%, specificity, 45.3%). DISCUSSION In patients with SE admission NLR could be a predictor of length of hospitalization and need for ICU admission.
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Pinčáková K, Krastev G, Haring J, Mako M, Mikulášková V, Bošák V. Low Lymphocyte-to-Monocyte Ratio as a Possible Predictor of an Unfavourable Clinical Outcome in Patients with Acute Ischemic Stroke after Mechanical Thrombectomy. Stroke Res Treat 2022; 2022:9243080. [PMID: 36536620 PMCID: PMC9759396 DOI: 10.1155/2022/9243080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/20/2022] [Accepted: 11/23/2022] [Indexed: 09/10/2024] Open
Abstract
Background Although considerable progress has been made in the treatment of acute ischemic stroke (AIS), the clinical outcome of patients is still significantly influenced by the inflammatory response that follows stroke-induced brain injury. The aim of this study was to evaluate the potential use of complete blood count parameters, including indices and ratios, for predicting the clinical outcome in AIS patients undergoing mechanical thrombectomy (MT). Methods This single-centre retrospective study is consisted of 179 patients. Patient data including demographic characteristics, risk factors, clinical data, laboratory parameters on admission, and clinical outcome were collected. Based on the clinical outcome assessed at 3 months after MT by the modified Rankin Scale (mRS), patients were divided into two groups: the favourable group (mRS 0-2) and unfavourable group (mRS 3-6). Stepwise multivariate logistic regression analysis was used to detect an independent predictor of the unfavourable clinical outcome. Results An unfavourable clinical outcome was detected after 3 months in 101 patients (54.4%). Multivariate logistic regression analysis confirmed that the lymphocyte-to-monocyte ratio (LMR) was an independent predictor of unfavourable clinical outcome at 3 months (odds ratio = 0.761, 95% confidence interval 0.625-0.928, and P = 0.007). The value of 3.27 was chosen to be the optimal cut-off value of LMR. This value could predict the unfavourable clinical outcome with a 74.0% sensitivity and a 54.4% specificity. Conclusion The LMR at the time of hospital admission is a predictor of an unfavourable clinical outcome at 3 months in AIS patients after MT.
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Affiliation(s)
- Katarína Pinčáková
- Department of Laboratory Medicine, Faculty of Health and Social Care, Trnava University in Trnava, 918 43 Trnava, Slovakia
- Department of Haematology, Faculty Hospital Trnava, 917 75 Trnava, Slovakia
| | - Georgi Krastev
- Jessenius Medical Faculty in Martin, Comenius University in Bratislava, 036 01 Martin-Záturčie, Slovakia
- Department of Neurology, Faculty Hospital Trnava, 917 75 Trnava, Slovakia
| | - Jozef Haring
- Department of Neurology, Faculty Hospital Trnava, 917 75 Trnava, Slovakia
- Faculty of Medicine, Comenius University in Bratislava, 813 72 Bratislava, Slovakia
| | - Miroslav Mako
- Jessenius Medical Faculty in Martin, Comenius University in Bratislava, 036 01 Martin-Záturčie, Slovakia
- Department of Neurology, Faculty Hospital Trnava, 917 75 Trnava, Slovakia
| | - Viktória Mikulášková
- Department of Laboratory Medicine, Faculty of Health and Social Care, Trnava University in Trnava, 918 43 Trnava, Slovakia
| | - Vladimír Bošák
- Department of Laboratory Medicine, Faculty of Health and Social Care, Trnava University in Trnava, 918 43 Trnava, Slovakia
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