The Benefits and Risks of Antioxidant Treatment in Liver Diseases

Metabolic Dysfunction-Associated Steatotic Liver Disease: Pathogenetic Links to Cardiovascular Risk

Metabolic dysfunction-associated steatotic liver disease (MASLD) is correlated with an increased cardiovascular risk, independent of other traditional risk factors. The mechanisms underlying this pathogenic link are complex yet remain incompletely elucidated. Among these, the most significant are visceral adiposity, low-grade inflammation and oxidative stress, endothelial dysfunction, prothrombotic status, insulin resistance, dyslipidemia and postprandial hyperlipemia, gut dysbiosis, and genetic mutations. Cardiovascular diseases are the leading cause of death in patients with MASLD. These patients have an increased incidence of coronary artery disease, carotid artery disease, structural and functional cardiac abnormalities, and valvulopathies, as well as arrhythmias and cardiac conduction disorders. In this review, we present the latest data on the association between MASLD and cardiovascular risk, focusing on the pathogenic mechanisms that explain the correlation between these two pathologies. Given the high rates of cardiovascular morbidity and mortality among patients with MASLD, we consider it imperative to raise awareness of the risks associated with this condition within the general population. Further research is essential to clarify the mechanisms underlying the increased cardiovascular risk linked to MASLD. This understanding may facilitate the identification of new diagnostic and prognostic biomarkers for these patients, as well as novel therapeutic targets.

Metabolic dysfunction-associated fatty liver disease: current therapeutic strategies

The definition of "Metabolic Associated Fatty Liver Disease - MAFLD" has replaced the previous definition of Nonalcoholic Fatty Liver Disease (NAFLD), because cardiometabolic criteria have been added for the prevention of cardiological risk in these patients. This definition leads to an in-depth study of the bidirectional relationships between hepatic steatosis, Type 2 Diabetes Mellitus (T2DM), Cardiovascular Disease (CVD) and/or their complications. Lifestyle modification, which includes correct nutrition combined with regular physical activity, represents the therapeutic cornerstone of MAFLD. When therapy is required, there is not clear accord on how to proceed in an optimal way with nutraceutical or pharmacological therapy. Numerous studies have attempted to identify nutraceuticals with a significant benefit on metabolic alterations and which contribute to the improvement of hepatic steatosis. Several evidences are supporting the use of silymarin, berberine, curcumin, Nigella sativa, Ascophyllum nodosum, and Fucus vesiculosus, vitamin E, coenzyme Q10 and Omega-3. However, more evidence regarding the long-term efficacy and safety of these compounds are required. There is numerous evidence that highlights the use of therapies such as incretins or the use of Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) inhibitors or other similar therapies which, by assisting existing therapies for pathologies such as diabetes, hypertension, insulin resistance, have given a breakthrough in prevention and the reduction of cardiometabolic risk. This review gave an overview of the current therapeutic strategies that are expected to aid in the treatment and prevention of MAFLD.

LI-RADS Classification and Outcomes of Hepatocellular Carcinoma Treated With Transcatheter Arterial Chemoembolization Plus Radiofrequency Ablation

AIM

The aim of this study was to clarify the usefulness of the Liver Imaging Reporting and Data System (LI-RADS) for predicting a patient's prognosis after transcatheter arterial chemoembolization (TACE) combined with radiofrequency ablation (TACE-RFA) for hepatocellular carcinoma (HCC) of Barcelona-Clinic Liver Cancer (BCLC) stage 0 or A.

PATIENTS AND METHODS

We retrospectively analyzed cases of patients with HCC who underwent TACE-RFA (Jan 2005 to Dec 2015). Nodules were categorized based on their LI-RADS v2018 core. The LI-RADS category was assigned to each nodule using dynamic contrast-enhanced computed tomography. LR-3, LR-4 and LR-5 nodules were extracted. The overall (OS) and recurrence-free (RFS) survival was assessed among patients with BCLC 0 and BCLC A disease.

RESULTS

Of the 64 nodules extracted, 22 were LR-3 or -4 (mean±standard deviation=14.8±6.7 mm) and 42 were LR-5 (17.1±6.9 mm). Regarding OS, there was no significant difference between those with LR-3 or -4 and LR-5 (p=0.278). In terms of RFS, there was a significant difference between those with LR-3 or -4 and those with LR-5 (p=0.03). In particular, patients with BCLC A with LR-5 nodules had significantly poorer RFS than those with LR-3 or -4 (p=0.016) nodules.

CONCLUSION

For patients with BCLC A, LR-3 or -4 nodules are associated with a better prognosis than LR-5 nodules.

Risk of hepatitis B reactivation: From biologic therapies for psoriasis to immunosuppressive therapies for COVID‑19 (Review)

The cytokine storm from the evolution of severe cases of COVID-19, requiring strong immunosuppressive therapies, has raised the issue of reactivation of hepatitis B virus (HBV) infections in these patients. An analysis of the first observational studies in patients with COVID-19 and immunosuppressive therapy and HBV infection along with special clinical cases was presented, as well as personal experience on a series of cases (a group of 958 patients with COVID-19), compared with the analysis of studies performed on patients with HBV infection that underwent biological therapies for psoriasis and personal experience (a group of 81 psoriasis patients treated with biological therapies). Clinical studies have revealed that HBV reactivation in patients undergoing biological therapies for psoriasis, can be prevented with monitoring and treatment protocols and thus, these therapies have been demonstrated to be safe and effective. In COVID-19, immunosuppressive therapies are short-lived but in high doses, and the conclusions of clinical trials are contradictory, but there are published cases of HBV reactivation, which requires a unitary attitude in the prevention of HBV reactivation in these patients. An algorithm was presented for monitoring and treatment of HBV infection for patients with psoriasis treated with biological therapy and the conditions when this protocol can be used for patients with COVID-19 and immunosuppressive therapy.

Benefits of crenotherapy in digestive tract pathology (Review)

Balneotherapy, a branch of physical and rehabilitation medicine using the natural factors of balneal resorts for therapeutical purposes to modulate the symptoms of numerous diseases, represents a non-pharmaceutical therapeutic alternative, easily accepted by patients and used both preventively and curatively. Crenotherapy, a branch of balneotherapy, is the method in which mineral waters are used as a therapeutic internal cure by ingestion. This procedure is performed in spa resorts (where these natural resources exist), and the ingestion of mineral water takes place at the source (spring), in the quantities recommended by the medical rehabilitation physician, according to specific regimens for the condition to be treated. Depending on their physical and chemical composition, the therapeutic mineral waters fall into several categories, having clear indications for certain pathologies. Hypotonic, isotonic, or slightly hypertonic mineral waters are recommended in diseases of the digestive tract and hepatobiliary conditions. Over time, studies have been conducted to determine the effect of these types of treatments, highlighting the complex influence of crenotherapy on the gastrointestinal tract, with favorable results, therefore the use of mineral water intake in various pathologies being recommended. The current review focuses on the existing literature data and refers to the main progress made in understanding the benefit, indications, and crenotherapy procedures in the management of gastrointestinal disorders.

Effects of dehydroepiandrosterone (DHEA) supplementation on cortisol, leptin, adiponectin, and liver enzyme levels: A systematic review and meta-analysis of randomised clinical trials

BACKGROUND AND AIMS

Dehydroepiandrosterone (DHEA) supplementation has been investigated in patients with altered cortisol levels and is proposed to ameliorate the metabolic profile related to adipose tissue. However, further research is warranted and evidence is no compelling for liver safety. Hence, we aimed to meta-analyse the effects of DHEA supplementation on circulating levels of cortisol, liver enzymes, and adipokines.

METHODS

We searched literature published in PubMed, Web of Science, Embase and Scopus, until December 2020. We obtained overall results using the generic inverse of variance method with a random-effects model.

RESULTS

Through 10 arms, serum cortisol levels decreased significantly after DHEA supplementation [weighted mean difference (WMD): -53.581 nmol/L, 95% confidence interval (CI): -88.2, -18.9, P = .002], without significant heterogeneity (I²  = 36%, P = .117). In contrast, any significance was noted for adiponectin (WMD: -0.045 µg/mL, 95% CI: -0.56, 0.47; P = .865), leptin (WMD: -2.55 µg/mL, 95% CI: -6.2, 1.06; P = .166), aspartate transaminase (AST) (WMD: -3.7 U/L, 95% CI: -10.35, 2.95; P = .276), and alanine aminotransferase (ALT) (WMD: -1.7 U/L, 95% CI: -3.45, 0.06; P = .058).

CONCLUSION

DHEA supplementation decreased circulating cortisol but did not alter adiponectin, leptin, AST, and ALT levels. Hence, DHEA supplementation could be considered as an adjunct in the management of hypercortisolaemia and is safe for the liver.

Surgical Resection vs. Percutaneous Ablation for Single Hepatocellular Carcinoma: Exploring the Impact of Li-RADS Classification on Oncological Outcomes

Background: Single hepatocellular carcinoma (HCC) benefits from surgical resection (SR) or US-guided percutaneous ablation (PA), although the best approach is still debated. We evaluated the impact of Li-RADS classification on the oncological outcomes of SR vs. PA as single HCC first-line treatment. Methods: We retrospectively and blindly classified treatment-naïve single HCC that underwent SR or PA between 2010 and 2016 according to Li-RADS protocol. Overall survival (OS), recurrence free survival (RFS) and local recurrence after SR and PA were compared for each Li-RADS subclass before and after propensity-score matching (PS-M). Results: Considering the general population, SR showed better 5-year OS (68.3% vs. 52.2%; p = 0.049) and RFS (42.5% vs. 29.8%; p = 0.002), with lower incidence of local recurrence (8.2% vs. 44.4%; p < 0.001), despite a significantly higher frequency of clinically-relevant complications (12.8% vs. 1.9%; p = 0.002) and a higher Comprehensive Complication Index (12.1 vs. 2.2; p < 0.001). Focusing on different Li-RADS subclasses, we highlighted better 5-year OS (67.1% vs. 46.2%; p = 0.035), RFS (45.0% vs. 27.0% RFS; p < 0.001) and lower incidence of local recurrence (9.7% vs. 48.6%; p < 0.001) after SR for Li-RADS-5 HCCs, while these outcomes did not differ for Li-RADS-3/4 subclasses; such results were confirmed after PS-M. Conclusions: Our analysis suggests a potential prognostic role of Li-RADS classification, supporting SR over PA especially for Li-RADS-5 single HCC.

Heterogeneity of antigenic constellation in human hepatocellular carcinoma

Hepatocellular carcinoma is one of the primary liver malignancies responsible for over a million deaths per year worldwide (approximately 10% of all deaths in the adult age range). The diagnosis of HCC can be difficult and often requires the use of more than one microscopic technique. A retrospective study was performed on a study batch of 42 cases that died of HCC due to metastasis or other secondary complications. Tissue samples were taken in order to investigate the tumour antigenic constellation by means of IHC method using a large variety of antibodies. In situ hybridization was also performed for albumin mRNA to assess the albumin expression in some selected cases. Telomerase activity was investigated using IHC method for the hTERT catalytic subunit. A cocktail of hepatic cytokeratins (CK8, 18) combined with Hep Par-1 and associated to albumin proved to be more powerful than albumin alone in differentiating HCC and increased the value of tumour diagnosis. hTERT expression was proportionally reverse to the tumour degree of differentiation, but was independent from the expression of tumour-proliferating indexes. The heterogeneity of the antigenic constellation in hepatocellular carcinoma suggests an antigenic mosaicism, which can be expressed a synchronous or metachronous manner, depending on the tumour degree of differentiation.

Evidence of Tri-Exponential Decay for Liver Intravoxel Incoherent Motion MRI: A Review of Published Results and Limitations

Diffusion weighted imaging (DWI) and intravoxel incoherent motion (IVIM) have been explored to assess liver tumors and diffused liver diseases. IVIM reflects the microscopic translational motions that occur in voxels in magnetic resonance (MR) DWI. In biologic tissues, molecular diffusion of water and microcirculation of blood in the capillary network can be assessed using IVIM DWI. The most commonly applied model to describe the DWI signal is a bi-exponential model, with a slow compartment of diffusion linked to pure molecular diffusion (represented by the coefficient D_slow), and a fast compartment of diffusion, related to microperfusion (represented by the coefficient D_fast). However, high variance in D_fast estimates has been consistently shown in literature for liver IVIM, restricting its application in clinical practice. This variation could be explained by the presence of another very fast compartment of diffusion in the liver. Therefore, a tri-exponential model would be more suitable to describe the DWI signal. This article reviews the published evidence of the existence of this additional very fast diffusion compartment and discusses the performance and limitations of the tri-exponential model for liver IVIM in current clinical settings.

Diabetes mellitus affects long-term survival in hepatitis B virus-related hepatocellular carcinoma patients: A propensity score-matched analysis

Diabetes mellitus (DM) increases the risk of developing hepatocellular carcinoma (HCC), and how DM affects the prognosis of HCC have not been elucidated. The aim of this study was to compare clinicopathological characteristics and survival between hepatitis B virus (HBV)-related HCC patients with and without DM and to determine risk factors for overall survival after hepatectomy.Among 474 patients with HBV-related HCC, 119 patients had DM. Patients were divided into the diabetic group and nondiabetic group. The short-term and long-term outcomes were evaluated by using propensity score matching analysis.After 1:2 propensity score matching, there were 107 patients in diabetic group, 214 patients in nondiabetic group. The proportion of vessels invasion were higher in diabetic group. The overall survival rate in the diabetic group was 44.7% at 3 years, which was lower than that in the nondiabetic group (56.1%, P = .025). The multivariate analysis indicated that fasting blood glucose >7.0, capsular invasion, microvascular invasion and satellite were independent risk factor of poor prognosis in HCC.DM dose affect the recurrence-free survival and overall survival in HBV-related HCC patients after hepatectomy. One of the more significant findings to emerge from this study is that DM induced higher proportion of major vessel invasion in HCC patients implied unfavorable prognosis.

The Impact of Vitamin D in Non-Alcoholic Fatty Liver Disease: A Cross-Sectional Study in Patients with Morbid Obesity

PURPOSE

We aimed to evaluate the association between vitamin D status and hepatic function parameters and scores: Fatty Liver Index (FLI, predictor of hepatic steatosis) and BARD (BMI, AST/ALT ratio and DM, predictor of hepatic fibrosis) in patients with morbid obesity.

PATIENTS AND METHODS

Cross-sectional study including patients with morbid obesity followed in our centre between January 2010 and July 2018. Patients with missing vitamin D levels or hepatic profile parameters were excluded. We divided the population according to two cut-offs of vitamin D levels (12ng/mL and 20ng/mL).

RESULTS

The included population (n=1124) had an average age of 43.3±10.7 years and 84.3% were female. Seventy-point eight percent of the population had vitamin D levels lower than 20ng/mL and 34.8% lower than 12ng/dL. Patients with lower vitamin D levels (<12ng/mL) had higher BMI, hip and waist circumferences and higher prevalence of hypertension. Higher FLI scores [OR= 0.77 (0.07), p<0.01] and ALP levels [β= -0.03 (-0.06, -0.01), p<0.01] associated to lower vitamin D levels.

CONCLUSION

Vitamin D deficiency is associated with a higher risk of hepatic steatosis in individuals with morbid obesity. Correction of vitamin D deficiency may have a beneficial role in the management of NAFLD in patients with morbid obesity.

Impact of dehydroepiandrosterone (DHEA) supplementation on testosterone concentrations and BMI in elderly women: A meta-analysis of randomized controlled trials

BACKGROUND

Despite the fact that numerous clinical studies have evaluated the positive effects of dehydroepiandrosterone (DHEA) supplementation on testosterone concentrations and on the body mass index (BMI), more evidence is needed to certify that DHEA is a BMI-reducing agent in the elderly. This meta-analysis aims to clarify the various incompatible results and investigate the impact of DHEA supplementation on serum testosterone levels and lean body mass in elderly women.

METHODS

Four scientific databases (EMBASE, PubMed/MEDLINE, Scopus and Web of Science) were searched from inception until 20 August 2020 for trials comparing DHEA with placebo. Results were presented as weighted mean differences (WMDs) and 95 % confidence intervals (CIs) based on the random effects model (DerSimonian-Laird approach).

RESULTS

Nine arms with 793 subjects reported testosterone as an outcome measure. The overall results demonstrated that testosterone levels increased significantly after DHEA administration in elderly women (WMD: 17.52 ng/dL, 95 % CI: 6.61, 28.43, P = 0.002). In addition, DHEA administration significantly decreased the BMI (WMD:-0.39 kg/m², I² = 0.0 %).

CONCLUSION

The results of the current meta-analysis support the use of DHEA supplementation for increasing testosterone concentrations in elderly women.

Exercise Training and Vitamin C Supplementation Affects Ferritin mRNA in Leukocytes without Affecting Prooxidative/Antioxidative Balance in Elderly Women

Physical training and antioxidant supplementation may influence iron metabolism through reduced oxidative stress and subsequent lowering of mRNA levels of genes that are easily induced by this stress, including those responsible for iron homeostasis. Fifteen elderly women participated in our 12-week experiment, involving six weeks of training without supplementation and six weeks of training supported by oral supplementation of 1000 mg of vitamin C daily. The participants were divided into two groups (n = 7 in group 1 and n = 8 in group 2). In group 1, we applied vitamin C supplementation in the first six weeks of training, while in group 2 during the remaining six weeks of training. In both phases, the health-related training occurred three times per week. Training accompanied by vitamin C supplementation did not affect prooxidative/antioxidative balance but significantly decreased ferritin heavy chain (FTH) and ferritin light chain (FTL) mRNA in leukocytes (for FTH mRNA from 2^64.24 to 2^11.06, p = 0.03 in group 1 and from 2^60.54 to 2^16.03, p = 0.01 in group 2, for FTL mRNA from 2^20.22 to 2^4.53, p = 0.01 in group 2). We concluded that vitamin C supplementation might have caused a decrease in gene expression of two important antioxidative genes (FTH, FTL) and had no effect on plasma prooxidative/antioxidative balance.

Dietary vitamin A, C, and E intake and subsequent fracture risk at various sites: A meta-analysis of prospective cohort studies

BACKGROUND

This study aimed to provide reliable estimates for dietary antioxidant vitamin (vitamins A, C, and E) intake and their effect on fracture risk at various sites.

METHODS

The PubMed, EMBASE, and Cochrane Library databases were searched to identify prospective cohort studies published throughout October 2019. The pooled relative risk (RR) with its 95% confidence interval (CI) was calculated using a random-effects model.

RESULTS

In total, 13 prospective cohort studies involving 384,464 individuals were selected for this meta-analysis. The summary RR indicated that increased antioxidant vitamin intake was associated with a reduced fracture risk (RR: 0.92; 95% CI: 0.86-0.98; P = .015). When stratified by the vitamin types, increased vitamin E intake was found to be associated with a reduced fracture risk (RR: 0.66; 95% CI: 0.46-0.95; P = .025), whereas increased vitamin A and C intake did not affect this risk. Increased antioxidant vitamin intake was associated with a reduced fracture risk, irrespective of fracture sites (HR: 0.90; 95% CI: 0.86-0.94; P < .001); however, it did not affect hip fracture risk. Furthermore, increased antioxidant vitamin intake was associated with a reduced fracture risk in men (RR: 0.81; 95% CI: 0.68-0.96; P = .017) and combined men and women (RR: 0.83; 95%CI: 0.73-0.93; P = .002); however, it did not affect fracture risk in women.

CONCLUSION

Fracture risk at any site is significantly reduced with increased antioxidant vitamin intake, especially vitamin E intake and in men.

The non-invasive assessment of hepatic fibrosis

Hepatic disease accounts for approximately 2 million deaths/year worldwide. Liver fibrosis, as the last stage of numerous chronic liver diseases, is one of the most relevant prognostic factors. The liver biopsy with the histopathological examination is considered to be the "gold standard" for the identification and staging of the hepatic fibrosis. However, liver biopsy is known as an invasive investigation that has multiple limitations. Research studies conducted in the last few years focused on identifying non-invasive type methods for the evaluation of hepatic fibrosis; usually, there are 2 categories of such investigations: serologic tests and imaging techniques. This narrative review presents the non-invasive investigation methods used in the liver fibrosis evaluation. New molecular perspectives on fibrogenesis and fibrosis regression, as well as the appearance of therapeutic antifibrotic agents, justify the necessity of non-invasive tools to detect and grade liver fibrosis.

Overview of the anticancer activity of withaferin A, an active constituent of the Indian ginseng Withania somnifera

Cancer is still considered a "hopeless case", besides all of the advancements in oncology research. On the other hand, the natural products, as effective lead molecules, have gained significant interest for research due to the absence of toxic and harmful side effects usually associated with conventional treatment methods. Medicinal properties of herbal plants are strongly evidenced in traditional medicine from ancient times. In the context above, withaferin A (WA) was identified as the active principle of the plant Withania somnifera, its molecule being reported to have excellent anticancer and tumour inhibition activities in various cell lines. Furthermore, the in silico approaches in the medicinal chemistry of WA revealed the biological targets and gave momentum for the research that leads to many amazing pharmacological activities of WA which are not yet explored. This includes a broad spectrum of anticancer actions manifested in different organs (breast, pancreas, colon), melanoma and B cell lymphoma, etc. This review is an extensive survey of the most recent anticancer studies reported for WA, along with its mechanism of action and details about its in vitro and/or in vivo behaviour.

Patterns and Factors Associated with Self-Medication among the Pediatric Population in Romania

Background and objectives: Self-medication is a global phenomenon in both developed and emerging countries. At present, data regarding the practice, patterns, and factors associated with self-medication in Romanian patient groups of various ages and health are relatively scarce. A pilot study that uses a questionnaire was conducted to observe the attitudes as well as the behaviors of a group of Romanian parents related to self-medication, specifically their beliefs and perceived risks of the administration of medicine to their children without medical advice, frequency of self-medications, symptoms, and types of medications most commonly used without medical advice. Materials and Methods: The questionnaire was sent via e-mail or WhatsApp link on a mobile phone using the existing data at the general practitioner's office together with the protection of data form and the informed consent form; some participants completed the questionnaire when they came for a regular visit at the general practitioner's office. Of 246 applied questionnaires, we had a rate of responses of 98%. Results: We found a high percentage (70%) of parents who self-medicate their children. The data reveals a significant relation between parents' beliefs on self-medication and their tendency to administrate drugs to their children without medical advice. A significant relation was also found between the likelihood of parental self-medication for their children and the number of illnesses experienced by their children over the six-month period prior to the survey. Even when parents have a correct understanding of self-medication risks, these are not aligned with actual behavior; therefore, parents continue to administer drugs to their children without medical advice. Conclusions: Our study helps to describe the patterns of parents' decisions about self-medicating their children and to identify parents who are more predisposed to administering self-medication to their children.

Infection with hepatitis C virus in hemodialysis patients: An overview of the diagnosis and prevention rules within a hemodialysis center (Review)

Increase in the number of patients with chronic kidney disease (CKD) calls for improved management of these patients. In stage 5 CKD, when the initiation of renal replacement therapy (RRT) becomes necessary, there is an increase in the infection risk of the patients and immunological tests for hepatitis C virus (HCV) detection turn positive at an alarmingly higher rate compared to general population. With the introduction into clinical practice of diagnostic tests, the increased prevalence of HCV among CKD patients has been known since the 1990s. Also, the negative impacts of HCV infection on CKD evolution as well as the unfavorable evolution of grafts received by HCV infected patients are known. Chronic hemodialysis patients are a category of patients whose risk of HCV infection is substantial. Currently, in the hemodialysis centers, at the base of the transmission of HCV infection there are a multitude of factors. Infection with HCV has a different impact on patient with end-stage renal disease (ESRD). Comorbidities in this case have significant sources of mortality and morbidity. It was proven that the post transplantations problems were prevented and mortality was reduced for patients who were diagnosed with HCV and in whom the infection was treated before the kidney transplant (KT). Consequently, early detection of the infection and the application of specific treatment has a considerable impact on the outcome of the patients. Another important component of the management of HCV infection in the chronic hemodialysis patients is the prevention of the infection transmission by applying specific methods.

Cytokines in heart failure

The natural history of heart failure (HF) is not linear, because changes in the heart structure and function start long before the disease becomes clinically evident. Many different cytokines originating from intracardiac tissues (cardiomyocytes, cardiac endothelial cells, cardiac fibroblasts, and cardiac infiltrated immune cells) or extracardiac tissues (adipose tissue, gut, and lymphoid organs) have been identified in HF. Because the levels of circulating cytokines correlate with the development and severity of HF, these mediators may have both pathophysiological importance, through their ability to modulate inflammation, myocyte stress/stretch, myocyte injury and apoptosis, fibroblast activation and extracellular matrix remodeling, and utility as clinical predictive biomarkers. A greater understanding of the mechanisms mediated by the multifaceted network of cytokines, leading to distinct HF phenotypes (HF with reduced or preserved ejection fraction), is urgently needed for the development of new treatment strategies. In this chapter, all these issues were thoroughly discussed, pointing on the practical considerations concerning the clinical use of the cytokines as prognostic biomarkers and potential therapeutic targets in HF.