Co-Medication and Nutrition in Hepatocellular Carcinoma: Potentially Preventative Strategies in Hepatocellular Carcinoma

Prevention in Hepatology

The prevention of liver disease has improved significantly in the last few decades, to the point that it can now be considered a true success story. The wide variety of interventions, including comprehensive vaccination strategies, novel medications, lifestyle changes, and even preventive surgeries, have reduced the morbidity and mortality of chronic liver diseases. However, the prevalence of chronic liver diseases is increasing worldwide. Currently, fatty liver disease alone is estimated to be present in as much as 30% of the adult population. Furthermore, there is a trend towards increasing incidences of chronic hepatitis B, and a global lack of success in efforts to eliminate chronic hepatitis C. Thus, improving and efficiently rolling out existing and successful prevention strategies for chronic liver diseases will play an essential role in healthcare throughout the upcoming decades. In this review, we summarize the current options and concepts for preventing chronic liver diseases, highlight their limitations, and provide an outlook on probable future developments to improve awareness, integrated care, and the analysis of big data.

[Intersectoral management of patients with abnormal liver enzymes and non-alcoholic fatty liver disease (NAFLD)]

The prevalence of fatty liver disease has increased significantly in Germany in recent years. With an estimated 18 million German citizens being affected, it is now among the most prevalent diseases. Furthermore, it is also considered a relevant and independent risk factor for other common cardiovascular diseases such as heart attack or stroke. Finally, diabetes mellitus promotes the development of and an unfavorable course of fatty liver disease. Given the high prevalence and complications, the German healthcare system is reaching its limits.Therefore, close coordination of all healthcare providers and specialists involved in the treatment of these patients is essential. In an expert consensus involving private practice and hospital doctors from the fields of gastroenterology, endocrinology, cardiology, general practitioners and laboratory physicians, as well as in close coordination with patient representatives, we have designed a concept for the care of these patients in the German healthcare system. Necessary developments are also addressed. In addition to being useful as a practical guideline, this should also support health policy work, especially in the development of practical care solutions at the medical level.

Efficacy of Co-Medications in Patients with Alcoholic Liver Disease

BACKGROUND

Alcoholic liver disease (ALD) is still increasing and leads to acute liver injury but also liver cirrhosis and subsequent complications such as liver failure or hepatocellular carcinoma (HCC). As most patients fail to achieve alcohol abstinence, it is essential to identify alternative treatment options in order to improve the outcome of ALD patients.

METHODS

Evaluating two large cohorts of patients with ALD from the USA and Korea with a total of 12,006 patients, we investigated the effect on survival of aspirin, metformin, metoprolol, dopamine, and dobutamine drugs in patients with ALD between 2000 and 2020. Patient data were obtained through the "The Observational Health Data Sciences and Informatics consortium," an open-source, multi-stakeholder, and interdisciplinary collaborative effort.

RESULTS

The use of aspirin (p = 0.000, p = 0.000), metoprolol (p = 0.002, p = 0.000), and metformin (p = 0.000, p = 0.000) confers a survival benefit for both AUSOM- and NY-treated cohorts. Need of catecholamines dobutamine (p = 0.000, p = 0.000) and dopamine (p = 0.000, p = 0.000) was strongly indicative of poor survival. β-Blocker treatment with metoprolol (p = 0.128, p = 0.196) or carvedilol (p = 0.520, p = 0.679) was not shown to be protective in any of the female subgroups.

CONCLUSION

Overall, our data fill a large gap in long-term, real-world data on patients with ALD, confirming an impact of metformin, acetylsalicylic acid, and β-blockers on ALD patient's survival. However, gender and ethnic background lead to diverse efficacy in those patients.

Statin use is associated with better post-operative prognosis among patients with hepatitis B virus-related hepatocellular carcinoma

BACKGROUND

The high postoperative recurrence rate of hepatocellular carcinoma (HCC) is a significant challenge. Patient metabolic factors are potential disease modifiers and should be examined as risk factors for postoperative prognosis. Here, we assessed the association between long-term statin use and HCC recurrence after surgical resection of hepatitis B virus (HBV)-related HCC.

METHODS

Patients who initially underwent curative resection for HBV-related HCC between 2005 and 2015 were recruited and followed up until December 2019. Patients were classified into statin user and non-statin user groups based on whether or not they had been prescribed statins for ≥2 years. The primary outcome was HCC recurrence, and the secondary outcome was liver-related mortality. The cumulative incidence by statin use was estimated using the Kaplan-Meier method and compared using the log-rank test. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using multivariable Cox regression.

RESULTS

Among 5653 patients with a median 6.1 years of follow-up, HCC recurrence and liver-related mortality occurred in 1603 and 316 patients, respectively. The 5-year cumulative incidence of HCC recurrence in the statin user group (15.9%) was significantly lower than that in the non-user group (21.3%; p = .019). From multivariable Cox regression analysis, statin use was significantly associated with a reduced risk of HCC recurrence (aHR 0.77, 95% CI: 0.61-0.98; p = .035) and liver-related mortality (aHR 0.48, 95% CI: 0.25-0.90; p = .023).

CONCLUSION

Long-term statin use was significantly associated with reduced risk of HCC recurrence and liver-related mortality after curative resection of HBV-related HCC.

Management of NAFLD in primary care settings

Non-alcoholic fatty liver disease (NAFLD) affects at least 25% of the general population and is an increasingly important cause of cirrhosis and hepatocellular carcinoma. Although it is the research focus of the hepatology field, it is clear that primary care physicians are seeing the majority of NAFLD patients and are in a pivotal position to provide quality care. In this article, we review the role of primary care in the management of NAFLD. NAFLD is common in patients with diabetes, obesity and other metabolic risk factors. Abdominal ultrasonography is the most commonly used method to diagnose fatty liver. Simple fibrosis scores have high negative predictive values in excluding advanced liver fibrosis and future liver-related events and can be used in primary care as initial evaluation. An abnormal result should be followed by subsequent workup or specialist referral. Primary care is the ideal setting to institute multidisciplinary care, especially the involvement of dietitians and physical activity trainers in lifestyle intervention, as well as initiating the discussion of bariatric surgery in patients with severe obesity. Although specific drug treatment for steatohepatitis would require a more precise diagnosis, metabolic drugs that improve both steatohepatitis and cardiovascular outcomes (e.g. glucagon-like peptide-1 receptor agonists) may be considered in patients with NAFLD.

Overexpressed Histocompatibility Minor 13 was Associated with Liver Hepatocellular Carcinoma Progression and Prognosis

Among primary liver carcinoma cases, the proportion of liver hepatocellular carcinoma (LIHC) cases is 75%-85%. Current treatments for LIHC include chemotherapy, surgical excision, and liver transplantation, which are effective for early LIHC treatment. Nevertheless, the early symptoms of liver carcinoma are atypical, so a large proportion of LIHC patients are diagnosed at an advanced stage. Histocompatibility minor 13 (HM13), located in the endoplasmic reticulum, is responsible for catalysing the hydrolysis of some signal peptides after cleavage from the precursor protein. Here, we studied the role of HM13 in LIHC development through bioinformatics analysis. Database analysis showed that HM13 was of great significance for LIHC tumorigenesis. Compared to normal liver tissues, HM13 expression was increased to a greater extent in LIHC tissues. After analysis of Kaplan‒Meier plotter and Gene Expression Profiling Interactive Analysis (GEPIA) datasets, we discovered that highly expressed HM13 exhibited an association with shorter overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS). We conducted Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses to analyse HM13-related genes, and the data indicated that these genes obviously participated in rRNA processing, ribosome biogenesis, spliceosome, Huntington's disease, and ATP-dependent helicase activity. The Cell Counting Kit-8 (CCK-8) assay and Transwell assay showed that reducing HM13 expression hindered LIHC cell proliferation, migration, and invasion. In conclusion, these findings indicate that HM13 is a biomarker and is related to the poor prognosis of LIHC. Our results are conducive to discovering new targets for LIHC treatment.

Machine-learning algorithms based on personalized pathways for a novel predictive model for the diagnosis of hepatocellular carcinoma

BACKGROUND

At present, the diagnostic ability of hepatocellular carcinoma (HCC) based on serum alpha-fetoprotein level is limited. Finding markers that can effectively distinguish cancer and non-cancerous tissues is important for improving the diagnostic efficiency of HCC.

RESULTS

In this study, we developed a predictive model for HCC diagnosis using personalized biological pathways combined with a machine learning algorithm based on regularized regression and carry out relevant examinations. In two training sets, the overall cross-study-validated area under the receiver operating characteristic curve (AUROC), the area under the precision-recall curve and the Brier score of the diagnostic model were 0.987 [95%confidence interval (CI): 0.979-0.996], 0.981 and 0.091, respectively. Besides, the model showed good transferability in external validation set. In TCGA-LIHC cohort, the AUROC, AURPC and Brier score were 0.992 (95%CI: 0.985-0.998), 0.967 and 0.112, respectively. The diagnostic model has accomplished very impressive performance in distinguishing HCC from non-cancerous liver tissues. Moreover, we further analyzed the extracted biological pathways to explore molecular features and prognostic factors. The risk score generated from a 12-gene signature extracted from the characteristic pathways was correlated with some immune related pathways and served as an independent prognostic factor for HCC.

CONCLUSION

We used personalized biological pathways analysis and machine learning algorithm to construct a highly accurate HCC diagnostic model. The excellent interpretable performance and good transferability of this model enables it with great potential for personalized medicine, which can assist clinicians in diagnosis for HCC patients.