Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly termed non-alcoholic fatty liver disease (NAFLD), represents the most prevalent chronic liver condition worldwide, affecting approximately 25%-30% of the global adult population. Endocrine-disrupting chemicals (EDCs)-including phthalates, bisphenols, per- and polyfluoroalkyl substances (PFAS), persistent organic pollutants (POPs) and heavy metals-are ubiquitous environmental contaminants with established metabolic toxicity. However, the quantitative association between EDC exposure and MASLD prevalence remains incompletely characterised. We conducted a systematic review and meta-analysis to synthesise the current epidemiological evidence on this association. We systematically searched PubMed, Embase, Web of Science and the Cochrane Library from inception through January 2026, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines (PROSPERO: CRD420261298624). Studies were eligible if they reported quantitative associations between measured EDC exposures and MASLD/NAFLD/metabolic-associated fatty liver disease (MAFLD) outcomes in human populations. Two investigators independently screened records, extracted data and assessed methodological quality using a customised Newcastle-Ottawa Scale (NOS). Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models. Heterogeneity was assessed via the I2 statistic. Funnel plot asymmetry and Egger's test were used to evaluate publication bias. Sensitivity analyses were performed using leave-one-out methods. Of 427 records identified, 42 studies encompassing diverse global populations met inclusion criteria and were incorporated into the quantitative synthesis. The meta-analysis demonstrated that: Phthalates: mono (2-ethyl-5-carboxypentyl) phthalate (MECPP; weighted mean difference [WMD]: 2.40, 95% CI: 0.71-4.09), mono (2-ethyl-5-hydroxyhexyl) phthalate (MEHHP; WMD: 2.46, 95% CI: 0.81-4.10) and monobenzyl phthalate (MBzP; WMD: 1.84, 95% CI: 0.10-3.59) showed significant positive associations with MASLD prevalence; pooled analysis of phthalate mixtures yielded an overall OR of 1.17 (95% CI: 1.13-1.21; I2 = 41.4%). Bisphenols: pooled analysis demonstrated a significant positive association with MASLD (OR: 1.29, 95% CI: 1.09-1.50; I2 = 73.0%), with bisphenol A (BPA; OR: 1.32, 95% CI: 0.92-1.72), bisphenol S (BPS; OR: 1.47, 95% CI: 0.96-1.98) and bisphenol F (BPF; OR: 1.19, 95% CI: 0.77-1.61) contributing to this effect. PFAS: the overall pooled effect was OR 0.95 (95% CI: 0.91-1.00; I2 = 22.9%). POPs: the overall OR was 1.30 (95% CI: 1.22-1.37; I2 = 29.2%), with organochlorine pesticides (OCPs; OR: 1.30, 95% CI: 1.19-1.42) and polychlorinated biphenyl (PCB)/OCP combinations demonstrating significant associations. Heavy metals/metalloids: mercury (Hg) demonstrated the strongest positive association (OR: 1.60, 95% CI: 1.15-2.04; I2 = 87.3%), followed by lead (Pb; OR: 1.40, 95% CI: 1.02-1.78) and cadmium (Cd; OR: 1.30, 95% CI: 1.09-1.51; I2 = 79.2%); the overall metals pooled OR was 1.26 (95% CI: 1.16-1.37; I2 = 79.9%). Methodological quality assessed by NOS ranged from 6 to 9 points, with the majority of studies scoring ≥ 7. This meta-analysis of observational studies suggests that environmental exposure to several major EDC classes-including phthalates, bisphenols, persistent organic pollutants and certain heavy metals-is associated with a higher prevalence of MASLD, although the magnitude and consistency of associations vary substantially across chemical classes and individual compounds. Findings for PFAS were heterogeneous and compound-specific. Given the predominantly cross-sectional nature of the available evidence and the considerable between-study heterogeneity, causal inference cannot be drawn. These findings should be interpreted as hypothesis-generating and underscore the need for prospective multi-pollutant studies and mechanistic investigations to clarify the role of EDCs in MASLD pathogenesis. Fatty liver disease is now the most common liver problem worldwide, and it is usually linked to obesity, diabetes and unhealthy diets. In this study, we combined the results of 42 previous studies and found that everyday exposure to certain man‐made chemicals—such as plastics‐related compounds (phthalates and bisphenols), long‐lasting industrial pollutants and heavy metals like mercury, lead and cadmium—is associated with a higher chance of having fatty liver disease. These findings suggest that, alongside diet and lifestyle, reducing contact with these common environmental chemicals may be important for protecting liver health.
Hepatocellular carcinoma (HCC) remains a leading cause of cancer-related mortality worldwide despite recent advances in systemic therapy. The introduction of immune checkpoint inhibitors has substantially expanded treatment options for advanced disease; however, durable responses are observed only in a subset of patients. Increasing evidence indicates that this limited efficacy is largely driven by the complex immune landscape of HCC, which is shaped by disease aetiology, tumour microenvironment-mediated immune suppression, and impaired innate immune surveillance. Chronic viral hepatitis and metabolically driven liver diseases represent the principal drivers of HCC and profoundly influence immune regulation within the liver. Persistent antigen exposure, metabolic reprogramming, and stromal remodelling contribute to dysfunctional T- and natural killer (NK) cell responses, while immunosuppressive components of the tumour microenvironment, including tumour-associated macrophages, myeloid-derived suppressor cells, regulatory T cells, and inhibitory ligands such as HLA-G, facilitate immune escape and therapeutic resistance. In this review, we discuss recent advances in HCC immunotherapy, focusing on emerging checkpoint pathways such as TIGIT and Tim-3, glypican-3 targeted cellular therapies and bispecific antibodies, and NK cell-based therapeutic strategies. We further highlight the role of liquid biopsy approaches for treatment monitoring and biomarker development. Together, these insights emphasize the need for biomarker-guided patient stratification and integrated therapeutic strategies to improve the clinical efficacy of immunotherapy in HCC. Liver cancer, particularly hepatocellular carcinoma (HCC), is one of the leading causes of cancer‐related deaths worldwide. Although new immunotherapies have improved treatment options, they only work well for some patients. This is because liver tumours develop in a complex immune environment that often suppresses the body’s natural ability to fight cancer. Chronic liver diseases, such as viral hepatitis and fatty liver disease, further weaken immune responses and help tumours evade detection. This review explains how these immune changes influence treatment outcomes and highlights promising new immunotherapies, including therapies that target immune checkpoints, engineered immune cells, and natural killer cells. It also discusses the growing role of blood‐based biomarkers to help identify which patients are most likely to benefit from these treatments, with the goal of advancing more personalized and effective care for liver cancer.
Metabolic dysfunction-associated steatotic liver disease (MASLD) is a progressive liver disease that ranges from simple steatosis to inflammation, fibrosis and cirrhosis. To address the unmet need for new MASLD biomarkers, we aimed to identify candidate biomarkers using publicly available RNA sequencing (RNA-seq) and proteomics data. An approach involving unsupervised gene clustering was performed using homogeneously processed and integrated RNA-seq data of 625 liver specimens to screen for MASLD biomarkers, in combination with public proteomics data from healthy controls and MASLD patients. Additionally, we validated the results in the MASLD and healthy cohorts using enzyme-linked immunosorbent assay (ELISA) of plasma and immunohistochemical staining (IHC) of liver samples. We generated a database (https://dreamapp.biomed.au.dk/NAFLD/) for exploring gene expression changes along MASLD progression to facilitate the identification of genes and pathways involved in the disease's progression. Through cross-analysis of the gene and protein clusters, we identified 38 genes as potential biomarkers for MASLD severity. Up-regulation of Quiescin sulfhydryl oxidase 1 (QSOX1) and down-regulation of Interleukin-1 receptor accessory protein (IL1RAP) were associated with increasing MASLD severity in RNA-seq and proteomics data. Particularly, the QSOX1/IL1RAP ratio in plasma demonstrated effectiveness in diagnosing MASLD, with an area under the receiver operating characteristic (AUROC) of up to 0.95 as quantified by proteomics profiling and an AUROC of 0.82 with ELISA. We discovered a significant association between the levels of QSOX1 and IL1RAP and MASLD severity. Furthermore, the QSOX1/IL1RAP ratio shows promise as a non-invasive biomarker for diagnosing MASLD and assessing its severity. This study aimed to find non‐invasive biomarkers for metabolic dysfunction‐associated steatotic liver disease (MASLD). Researchers utilized a new gene clustering method to analyse RNA‐seq data from 625 liver samples. The identified biomarkers were further validated using plasma proteomics profiling, enzyme‐linked immunosorbent assay (ELISA) and liver immunohistochemical staining (IHC) in three separate groups of healthy controls and MASLD patients. The study revealed that the levels of QSOX1 were elevated while IL1RAP levels were reduced with increasing severity of MASLD. Importantly, the ratio of QSOX1 to IL1RAP expression in plasma showed promise as a non‐invasive diagnostic tool for assessing the severity of MASLD, eliminating the reliance on liver biopsy.
The sympathetic nervous system is involved in the progression and aggressiveness of several cancers, including hepatocellular carcinoma (HCC). However, the specific effects of sympathetic innervation and catecholamines on tumour hepatocyte behaviour remain poorly understood. In this study, we aimed to investigate the role of sympathetic fibres and catecholamines in the progression of HCC. The distribution of sympathetic nerves was mapped in 10 human HCC samples using multiplex immunofluorescence labeling. Adrenergic receptors (ADR) and enzymes involved in catecholamine degradation were assessed in three HCC (HepaRG, BC2, Huh-7) and one hepatoblastoma (HepG2) cell lines. The impact of catecholamines on gene and protein expression and metabolic pathways was assessed in differentiated HepaRG-hepatocytes, and the results were verified in primary human hepatocyte (PHH) cultures. The clinical relevance of the findings was evaluated in two transcriptomics datasets. Abundant and tortuous sympathetic fibres were detected in non-tumour liver tissues adjacent to the HCC invasion front. Differentiated HepaRG-hepatocytes expressed both α1- and β2-ADR and metabolized catecholamines to normetanephrine, metanephrine, and vanillylmandelic acid. In these cells, catecholamine exposure activated inflammation, cell proliferation, and extracellular matrix remodelling pathways associated with retro-differentiation and primed epithelial-to-mesenchymal transition. The catecholamine-induced program was detected in aggressive, ECM/STEM HCC subclasses with poor patient prognosis. Catecholamines induce an aggressive phenotype in differentiated tumour hepatocytes localized at the invasive front, suggesting their involvement in cancer progression. Understanding the interplay between the sympathetic nervous system and HCC may offer novel therapeutic opportunities. Sympathetic nerve fibres that release catecholamines are found in non‐tumour liver samples, adjacent to the invasion front of human HCCs. Catecholamines induce retro‐differentiation of differentiated HepaRG‐hepatocytes, and a transcriptomic program matching aggressive HCCs in a 1133‐HCC transcriptomic meta data set. Repositioning adrenergic receptor antagonists, which are commonly prescribed drugs for the treatment of portal hypertension, warrants further exploration for their therapeutic interest as adjuvant therapies in HCC.
Liver fibrosis is a major determinant of liver-related events (LREs) in patients with metabolic dysfunction-associated steatotic liver disease (MASLD). Effective stratification based on fibrosis severity is essential for accurate prognosis. The Enhanced Liver Fibrosis (ELF) test, a non-invasive test measuring direct fibrosis markers, offers a potential alternative to traditional methods like FIB-4, liver stiffness measurement (LSM) and liver biopsy. This study aims to evaluate the prognostic value of the ELF test in comparison with these established methods. We retrospectively analysed 289 MASLD patients (30.4% female, median age 49 years [IQR 39-58], 28% with type 2 diabetes) from the PROMETEO cohort (NCT04371042). We excluded patients with prior or current evidence of decompensated cirrhosis. At baseline, patients underwent liver biopsy, FIB-4, ELF and LSM assessments. The primary outcome was development of Liver Related Events (LRE), a composite of liver-related death, hepatocellular carcinoma, liver transplantation, ascites, encephalopathy or variceal bleeding. Over a median follow-up of 64 months [IQR 39-81], 41 patients (14.2%) experienced LREs. Event rates increased markedly across ELF categories (1% for ELF < 9.8, 27.8% for ELF ≥ 9.8 to < 11.3 and 72.7% for ELF ≥ 11.3). ELF demonstrated discriminative performance comparable to histological fibrosis stage and LSM, with the highest overall AUC among evaluated tests. In adjusted Cox models, higher ELF categories remained strongly associated with LRE risk, although confidence intervals were wide due to the limited number of events. In this biopsy-proven MASLD cohort, ELF provided prognostic stratification for liver-related events comparable to liver histology and LSM. Given the limited number of outcome events, these findings support the non-inferiority of ELF rather than definitive superiority. Larger prospective studies are needed to confirm these results and refine risk prediction strategies. The Enhanced Liver Fibrosis (ELF) test, a simple blood test, predicts liver‐related complications in patients with MASLD demonstrating discriminative performance comparable to histological fibrosis stage and LSM in the real‐world setting. ELF effectively stratifies patients into low‐, intermediate‐ and high‐risk groups, helping identify those at greatest risk of severe outcomes. This non‐invasive test offers a reliable alternative to invasive procedures, improving patient care and monitoring in real‐world clinical settings.
The predictive ability of histological components in Metabolic Dysfunction Associated Steatotic Liver Disease (MASLD) has not been well studied. Here, we look at the ability of digital pathology through the components of qFIBs (qfibrosis, qInflammation, qBallooning, qSteatosis) in predicting the risk of Major Adverse Liver Outcomes (MALO). 235 liver biopsy images were retrieved, and the composite end point of MALO, including overall death, hepatic encephalopathy (HE), ascites, variceal haemorrhage and hepatocellular carcinoma (HCC), was studied in parallel with the Non-alcoholic Steatohepatitis Clinical Research Network (NASH-CRN) score and qFIBs. The predictive power of qFibrosis for MALOs (qF3/4 vs. qF0/1/2, HR 6.64, 95% CI 1.69-26.06, log rank p-value 0.001) was comparable to NASH-CRN (F3/4 vs. F0/1/2, HR 7.02, 95% CI 2.37-20.84, log rank p-value < 0.001). Interestingly, a lower steatosis grade, rather than being a protective factor, correlated with poorer outcomes for both the qFIBs (qS0/1 vs. qS2/3 HR 17.24, 95% CI 3.12-95.32, log rank p value < 0.001) and NASH-CRN (S0/1 vs. S2/3 HR 6.30, 95% CI 2.14-18.61, log rank p value < 0.001). Lower qSteatosis scores of qS1 and below among the cirrhotic group (n = 35) also showed a six-fold higher risk of MALOs (< 1.50 vs. ≥ 1.50, HR 6.40, 95% CI 1.08-37.92, log rank p value < 0.011), likely due to the reduction of steatosis in the cachectic state of a patient with end stage liver disease. Samples with lower percentages of macro-vesicular vacuoles had a fourfold increased risk of MALOs (HR 4.41, 95% CI 1.06-18.43, log rank p value 0.017). Lower steatosis grades in higher fibrosis stages correlate significantly with the occurrence of MALO. Our findings instigate exploration of the process of fat resorption in MASLD and its relation to outcomes. Our study found that patients with cirrhosis from metabolic dysfunction‐associated steatotic liver disease (MASLD) who had less fat remaining in their liver were more likely to develop serious liver‐related complications. This finding suggests that in advanced disease, a reduction in liver fat may be a warning sign of worsening liver health rather than recovery.
Liver biopsy is the reference standard for the evaluation of inflammation and fibrosis in MASH and is the primary endpoint in steatohepatitis clinical trials. An optimal liver biopsy is generally considered to be obtained with a 16-gauge needle, measure at least 2 cm in length and contain at least 10 complete portal tracts, although these features have not been prospectively validated as mandatory thresholds in MASH trials. Published clinical trials for MASH have not consistently reported sufficient details of liver biopsy quality (needle gauge, length, number of portal tracts) at baseline or post-treatment, and biopsy quality metrics are rarely reported separately by treatment arm. Placebo response rates in clinical trials for MASH varied widely (2% to 34%) and this variation could influence the outcomes of clinical trials. Future MASH trials should report biopsy quality metrics (needle gauge, core length and portal tract count) by treatment arm in supplementary appendices of those publications, treat the 16-gauge/≥ 2 cm/≥ 10 portal tract criteria as preferred acquisition standards rather than required thresholds, and may consider pre-specified sensitivity analyses restricted to biopsies meeting adequacy criteria, recognising that such exclusions may alter the disease spectrum and must be interpreted cautiously. Biopsy quality is a plausible contributor to variability in placebo responses and trial outcomes, but direct evidence that needle gauge, core length, or portal tract number independently affect histologic response rates in randomised MASH trials remains limited. As digital pathology/AI tools mature and NIT-based surrogate endpoints advance toward regulatory qualification, ensuring high quality histologic reference standards remains essential. The liver biopsy (microscopic evaluation of a piece of liver taken with a needle) is the best way to determine if a patient has liver disease. Clinical trials should report the details of the liver biopsy (width of the needle used to get the biopsy, and the length of the liver biopsy) in order to ensure that the groups of patients have similar details. In addition, non‐invasive methods of determining liver disease (blood tests and measurement of liver stiffness) should be compared against liver biopsy results so we can confirm they give similarly reliable information without requiring a needle biopsy.
Hepatitis E virus (HEV) infection during pregnancy can lead to severe adverse pregnancy outcomes including stillbirth, preterm birth, abortion, maternal death, and vertical transmission. Off-label use of ribavirin or pegylated interferon-α is proved effective for treating HEV infection, but they are both contraindicated for pregnant women. A safe and effective treatment against HEV infection during pregnancy is urgently needed. We used JEG-3 choriocarcinoma cells to investigate the p38-MAPK signalling pathway in HEV replication. The cells were treated with varying concentrations of SB203580, a selective p38-MAPK inhibitor. For in vivo validation, HEV-infected pregnant rabbits were treated with SB203580. HEV replication, cytokine secretion, apoptosis, and pathological changes were measured. The effects on pregnancy outcomes, including vertical transmission, were also monitored. In this study, with a HEV-infected choriocarcinoma cell line, the JEG-3 cell model, we found that HEV infection significantly altered the expression patterns of the p38-MAPK signalling pathway. SB203580 can inhibit HEV replication and reduce the secretion of proinflammatory cytokines and apoptosis in vitro. Further in vivo validation with the HEV-infected pregnant rabbit model also revealed that SB203580 treatment during pregnancy significantly reduced the viral load in faeces and serum, the secretion of proinflammatory cytokines, and apoptosis in placental tissues. Most importantly, SB203580 is not only safe but can also effectively prevent HEV-related adverse pregnancy outcomes in pregnant rabbits and vertical transmission of HEV to pups. These results demonstrate that the p38 inhibitor SB203580 is an effective compound with potential as a therapeutic candidate against HEV infection during pregnancy. Hepatitis E is an acute viral liver disease caused by the hepatitis E virus (HEV), and it is widespread across the globe. For healthy, non‐pregnant people, HEV infection usually causes mild illness and clears up on its own. For pregnant women, however, the infection carries much higher risks. Unfortunately, the drugs currently used to treat HEV infection either have proven foetal risks or lack safety data for use during pregnancy. Our study showed that HEV‐infected pregnant rabbits treated with SB203580 had lower levels of virus in their faeces and blood, and their liver and placental tissues showed less damage. Most importantly, the drug reduced problems such as stillbirth and miscarriage. This study offers a promising new treatment candidate for HEV infection in pregnant people in the future.
Hepatic encephalopathy (HE) is morbid and increases mortality in cirrhosis. Lactulose is first-line therapy for HE treatment and secondary prophylaxis; however, data supporting its role in primary prevention of incident HE is less definitive. We therefore conducted a systematic review and meta-analysis of the most current evidence evaluating lactulose for the prevention and treatment of HE to guide future management. Medline, EMBASE, and Cochrane Library databases were searched for randomized controlled trials comparing lactulose to placebo or non-drug control for the treatment or prevention of HE. 17 studies with 1428 patients were analyzed. Random effects meta-analysis evaluated four main outcomes: overt HE (OHE), mortality, treatment discontinuation, and serious adverse events. Bayesian meta-analysis assessed two main outcomes: risk of overt HE and mortality. We found that lactulose significantly reduces the incidence of OHE compared to no lactulose, with a pooled relative risk (RR) of 0.48 (95% CI 0.37-0.63) and RR of 0.43 (95% CI 0.27-0.69) for those focusing on primary prophylaxis. There was no increased risk of adverse events (RR 0.87, 95% CI 0.64-1.17). Further, using Bayesian statistics, there exists a high probability that lactulose reduces mortality in individuals with HE (pooled posterior RR 0.72-0.88). Lactulose therapy safely contributes to a significant reduction in incident HE and is highly likely to reduce mortality. These results should guide HE prevention and management, as well as inform future investigations regarding the long-term benefits of lactulose.
Vibration-controlled transient elastography (VCTE) predicts liver-related events (LREs), but how serial liver stiffness (LS) changes should be translated into clinical risk-whether by their magnitude, direction or movement across established thresholds-remains uncertain. We tested whether a threshold-defined trajectory framework anchored at the Baveno VII 10 kPa criterion would stratify LRE risk across chronic liver disease aetiologies. From the retrospective V-LINK registry (2006-2020), 6313 event-free patients with baseline and 1-year LS were stratified by the 10 kPa threshold into Stable Low, Improved, Worsened or Persistent High trajectories. A 3-year landmark (LM3) subset (n = 1617) enabled trajectory reassessment over time. Cox models estimated adjusted hazard ratios (HRs). During a median follow-up of 5.5 years, 472 LREs occurred. Compared with Stable Low, adjusted HRs were 1.5 (95% confidence interval [CI], 1.1-2.2) for Improved, 2.5 (1.5-4.3) for Worsened and 4.1 (3.1-5.5) for Persistent High, with 3-year risks of 1.2%, 3.2%, 3.8%, and 15.0%. Persistent High (14.4% of the cohort) accounted for 61.9% of LREs; 65.7% showed a numerical decrease in LS yet remained ≥ 10 kPa. By aetiology, the HR for Persistent High was 6.4 (4.0-10.2) in non-viral aetiologies versus 2.6 (1.8-3.8) in viral aetiologies (p for interaction < 0.001). At LM3, the trajectory-based risk gradient was preserved (Persistent High HR, 3.5; 95% CI, 2.2-5.5). Threshold-defined LS trajectories identified a small subgroup concentrating most LRE risk, with the largest gradient in non-viral aetiologies. Persistent threshold elevation was the most robust prognostic signal, supporting serial LS monitoring pending external validation. For people with chronic liver disease, repeated liver stiffness tests may provide useful information about the risk of future liver‐related complications. We found that patients whose liver stiffness remained above an important clinical threshold had the highest risk, even when their liver stiffness had decreased over time. This simple approach may help clinicians decide how closely patients should be followed and monitored.
Liver fibrosis is a progressive pathological condition characterized by excessive extracellular matrix accumulation, primarily driven by activated hepatic stellate cells (HSCs). While molecular-based strategies have been extensively explored for HSC deactivation, clinically effective therapies remain elusive. Previous studies suggest that epithelial-like features of quiescent HSCs are lost upon activation, implying that mesenchymal-epithelial transition (MET) may be a potential therapeutic mechanism for reversing HSC activation. To identify compounds capable of reprogramming HSCs, we screened a library of 1134 FDA-approved drugs using human HSCs (HHSteCs). Morphological changes were quantified by the axial ratio, and functional assays included proliferation, immunofluorescence, Western blotting, and qPCR. Mechanistic analyses focused on microtubule integrity, focal adhesion signalling, and YAP/TAZ activity. Antifibrotic effects in vivo were evaluated using a carbon tetrachloride (CCl4)-induced mouse fibrosis model treated with febantel, the prodrug of fenbendazole. Five compounds, including taxanes and benzimidazoles, induced epithelial-like morphology and suppressed HSC activation. All shared the ability to disrupt microtubule dynamics. Fenbendazole exerted the strongest effect, reducing mesenchymal markers while restoring E-cadherin expression. Mechanistically, fenbendazole impaired focal adhesion signalling, attenuated YAP/TAZ activity, and promoted reassembly of adherens junctions, consistent with durable MET-like reprogramming. In vivo, febantel administration suppressed α-SMA and collagen1α1 expression and downregulated fibrogenic genes without altering serum markers of hepatocellular injury. Our findings identify microtubule-dynamics inhibitors as potent inducers of MET-like reprogramming in HSCs. Fenbendazole, in particular, promotes HSC inactivation by linking microtubule disruption to focal adhesion and TAZ suppression, while restoring epithelial junction integrity. These insights provide a mechanistic rationale for the antifibrotic potential of microtubule-targeting compounds and highlight benzimidazoles as promising candidates for translational development. Liver fibrosis occurs when scar‐producing cells in the liver become overly active and produce excessive collagen. In this study, we found that several drugs targeting microtubules can shift hepatic stellate cells toward a less fibrogenic state and reduce fibrosis‐related changes. These findings may provide a basis for developing new strategies to control liver fibrosis.
Chronic hepatitis B virus (HBV) infection is endemic in Uzbekistan. Previous data showed a high prevalence of anti-hepatitis D virus (HDV) antibodies in HBsAg-positive individuals. Limited data are available on disease severity, treatment availability and hepatocellular carcinoma (HCC) prevalence in patients with chronic HDV infection in Uzbekistan. The Scientific Research Institute of Virology (SRIoV) is the leading medical and scientific reference centre for viral hepatitis in Uzbekistan. In this retrospective study, epidemiological, clinical and laboratory data were collected and analysed from all HBsAg-positive patients presenting to the SRIoV between June 2023 and May 2024. Data from HDV-coinfected and HBV-monoinfected patients were compared. Data of 1393 individual patients were included. HDV coinfection was more prevalent than HBV-monoinfection (73.9% [n = 1030/1393]) vs. 26.1% [n = 363/1393]. HDV-infected patients were significantly younger (41.9 vs. 45.4, p < 0.001) and showed higher rates of cirrhosis (78.4% vs. 43.9%, p < 0.001) with the majority of patients being classified as Child-Pugh score B (57.8%). Only a minority of HDV-coinfected patients has ever received anti-HDV-directed treatment (0.4%, n = 4/1030). Consecutively, HDV RNA was detectable in 78.9% (812/1023) of patients. Quantitative HDV RNA was independently associated with ALT elevation > upper limit of normal. The HCC detection rate was low in both patient groups due to insufficient screening measures (HDV: n = 7/1030, HBV: n = 11/363). In this retrospective cohort of 1393 individual patients, HDV coinfection exceeds HBV monoinfection in prevalence and disease severity. Most HDV-infected patients present with advanced liver disease and currently lack access to HDV-directed therapy. In this large retrospective cohort from Uzbekistan, HDV coinfection was more prevalent than HBV mono infection and was associated with significantly higher rates of cirrhosis and advanced liver disease. The majority of HDV‐infected patients had detectable HDV RNA and almost no prior exposure to HDV‐directed therapy, indicating a substantial unmet therapeutic need. Improved access to antiviral treatment and strengthened HCC surveillance are urgently required to address the high burden of HDV‐associated liver disease.
Prognostic biomarkers that link disease progression and/or responses to therapeutic interventions in patients with primary biliary cholangitis (PBC) remain undefined. In this study, we used a machine learning (ML) approach with whole-blood transcriptomic data to predict clinical outcomes in response to obeticholic acid (OCA) and disease progression. We developed an ML model that incorporated whole-blood RNA-seq analyses using longitudinal samples from the POISE study (discovery cohort) and a prospective group of PBC patients who remained unchanged or progressed to liver transplantation/hepatic decompensation (independent validation cohort). The model identified 1200 candidate genes predictive of outcomes, which were investigated using pathway analysis. A genetic algorithm refined the panel to a 105-gene list that was trained on the POISE end-of-treatment cohort. The algorithm's generalisability was tested by assessing the baseline POISE patients as responders or non-responders to OCA (AUROC 0.93) and independently validated by differentiating liver disease-related survival between progressors and non-progressors (AUROC 0.94). Pathway analysis of the ML candidate genes identified enrichment of FXR regulated genes, autoimmune disease-related inflammation, immune regulation, fibrosis and integrated stress response pathways as prognostically related to PBC. When we compared these ML-derived prognostic pathways with RNA-seq analysis of PBC versus healthy controls, the most relevant transcripts were those involved in the integrated stress response and metabolic remodelling in PBC. The ML-derived score links both prognostic and disease pathogenesis pathways and can be used in future studies to better understand the pathophysiology and management of PBC. Primary Biliary Cholangitis (PBC) is an autoimmune liver disease. The cause of the disease is unknown. We don't know why some patients respond to treatment while others progress to needing liver transplantation. By studying gene expression in blood samples using computer modelling, we found that changes in the immune system response to stress may be linked to the development of worse disease. These findings may help guide future research into understanding PBC and improving treatment for patients.
Autoimmune hepatitis (AIH) remains difficult to study mechanistically in patients because disease initiation is rarely observed directly, the relevant autoantigens differ across subsets, and clinically meaningful outcomes such as chronic inflammation, fibrosis, relapse, and treatment response evolve over time. Animal models therefore remain indispensable. At the same time, the field has become increasingly heterogeneous. Acute immune-mediated hepatitis systems, especially concanavalin A (ConA), dominate the recent literature because they are rapid, inexpensive, and experimentally tractable. However, ConA-induced hepatitis is not an antigen-driven autoimmune response and is better interpreted as acute bystander immune-mediated liver injury than as a stand-alone model of chronic AIH. In contrast, antigen-driven adenoviral models based on cytochrome P450 2D6 (CYP2D6) or formiminotransferase cyclodeaminase (FTCD), as well as genetically predisposed or spontaneous tolerance-defect models, provide stronger insight into loss of hepatic tolerance, chronicity, fibrosis, and the interaction between antigenic context and host susceptibility. This review proposes a pragmatic framework for evaluating AIH models on the basis of face validity, construct validity, predictive validity, chronicity, host susceptibility, and mechanistic fitness for a specific biological question. Using that framework, we classify current models into acute surrogate models, immunization- and xenoantigen-based systems, adenoviral antigen-driven chronic models, spontaneous and genetically predisposed models, transgenic or neoantigen-driven tolerance models, and humanized or microbiota-sensitive hybrid systems. We then synthesize what these systems have taught the field about central and peripheral tolerance, MHC and non-MHC genetic susceptibility, sex- and age-related disease context, CD4+ and CD8+ T-cell biology, B-cell function, regulatory T-cell instability, impaired suppressive function, defective IL-2-dependent regulation, macrophage and innate lymphocyte participation, cell-death programmes, and gut-liver or liver-microbiome interactions. A central conclusion emerges: AIH models are complementary tools with markedly different levels of disease fidelity, and they should not be treated as interchangeable. Acute systems remain useful for effector-phase biology and first-pass intervention studies, but the strongest translational inferences for chronic AIH come from antigen-defined chronic models and selected tolerance-defect systems. Future progress will depend on better benchmarking across models, stronger alignment with human immune profiling and ex vivo validation platforms, and wider use of tolerance-restoring rather than purely anti-inflammatory therapeutic strategies.
It remains unclear whether different factors influence 30- and 90-day readmission rates. We identified predictors of 90-day mortality in a global cohort of hospitalised patients with cirrhosis. Variables associated with 30- and 90-day post-discharge readmission, liver transplantation (LT), and mortality were compared in prospectively enrolled, non-electively hospitalised adult patients with cirrhosis. We enrolled 4208 patients from 125 centres across 37 countries. Alcohol-related liver disease was the most common aetiology of cirrhosis (40%), followed by hepatitis B virus infection (21%); 47% were readmitted, 8% received liver transplantation (LT), and 23% died within 90 days post-discharge. In multivariable analysis, country income was significantly associated with both 30- and 90-day readmission rates, the receipt of LT, and mortality within 30 and 90 days post-discharge (all p-values < 0.001). Independent predictors of higher rates of 30- and 90-day readmissions, respectively, were disease severity (p < 0.001, p = 0.003), prior ascites (p = 0.025, p = 0.016), prior hospitalisation (p < 0.001), hyponatremia (p < 0.001, p = 0.008), and in-hospital vasopressor use (p = 0.002, p = 0.011). Prior variceal bleeding independently predicted higher 90-day readmission rates, whereas age, disease severity, mechanical ventilation, and in-hospital vasopressor use (all, p < 0.001) increased odds of 30- and 90-day post-discharge death. Additionally, admission (p = 0.011) and nosocomial (p = 0.022) infections increased the odds of 90-day post-discharge death. In a global cohort of hospitalised patients with cirrhosis, patients in high-income countries exhibited the highest rates of 30- and 90-day readmission, alongside lower mortality rates and a higher incidence of LT. Variables that predict 30-day readmission also predicted 90-day readmission. Understanding these disparities is essential for achieving health equity. Healthcare disparities in the prevention, diagnosis, and management of cirrhosis may substantially influence patient outcomes. In a prospectively enrolled global cohort study comprising 4,208 inpatients with cirrhosis, nearly half of the patients required readmissions, fewer than one‐tenth underwent liver transplantation, and one‐quarter died within 90 days after hospital discharge. Notably, major outcome differences appear to be independent of disease etiology and instead are more strongly associated with country income.
Hepatotoxicity is a common and significant adverse effect associated with adeno-associated virus (AAV) gene therapy; however, the underlying mechanisms remain unknown. In this study, we demonstrated innate immune activation in two patients with spinal muscular atrophy shortly after receiving AAV9 gene therapy with onasemnogene abeparvovec. Both patients developed marked hyperferritinemia accompanied by hepatotoxicity, thrombocytopenia, hypertriglyceridemia, and hypofibrinogenemia, all of which are the diagnostic criteria for macrophage activation syndrome. To evaluate their immune responses, serial analyses of serum cytokines/chemokines and flow cytometry were performed. Surges in macrophage-associated cytokine levels were observed in proportion to the severity of adverse events within 1 week after AAV vector infusion, suggesting that macrophage activation contributed to the pathogenesis of these adverse effects. Our findings clarify the immunological basis underlying hepatotoxicity in patients after AAV gene therapy. Furthermore, these findings provide a rationale for using various immunosuppressants or chemokine blockers in patients exhibiting severe adverse effects.
Metabolic dysfunction-associated steatotic liver disease (MASLD) and its progressive form, metabolic dysfunction-associated steatohepatitis (MASH), are globally prevalent conditions with limited therapeutic options. While macrophage scavenger receptor 1 (MSR1) is implicated in lipid uptake and inflammation, its role in MASLD pathogenesis remains poorly defined. MSR1 expression was analyzed using public databases and diet-induced animal models. Myeloid-specific Msr1 knockout (Msr1ΔMφ) mice were generated to investigate the specific function of MSR1. In vitro, oxidized low-density lipoprotein (ox-LDL)-stimulated primary mouse hepatic macrophages and bone marrow-derived macrophages were analyzed to explore potential mechanisms. Finally, an MSR1 inhibitor was employed to demonstrate therapeutic potential. MSR1 was upregulated in liver tissues and hepatic macrophages of MASLD/MASH patients and mice. Msr1ΔMφ mice exhibited significant attenuation of steatosis, inflammation, and fibrosis in comparison to wild-type littermates. In vitro, ox-LDL induced MSR1 expression, triggering lipid accumulation and pro-inflammatory cytokine release. Mechanistically, Msr1 deficiency upregulated the antioxidant enzyme superoxide dismutase 3 (SOD3) by inhibiting the PI3K/AKT/FoxO3a pathway, and these protective effects were blunted by Sod3 knockdown. Conversely, Sod3 overexpression ameliorated metabolic inflammation. Notably, pharmacological inhibition of MSR1 by fucoidan markedly attenuated the progression of diet-induced MASLD in mice. MSR1 promotes MASLD progression by mediating ox-LDL uptake in hepatic macrophages, which in turn exacerbates hepatic inflammation and fibrosis via PI3K/AKT/FoxO3a-dependent suppression of SOD3. Targeting MSR1 or its downstream pathway represents a promising novel therapeutic strategy for treating MASLD and MASH. MSR1 expression is significantly increased in the livers of diet‐induced MASLD/MASH mice and human MASH patients. Ablation of Msr1 in macrophages alleviates the progression of diet‐induced MASLD/MASH in mice. MSR1 promotes lipid accumulation and inflammatory responses by disrupting FoxO3a‐SOD3 mediated redox balance. Pharmacologic inhibition targeting MSR1 mitigates the severity of diet‐induced MASLD in mice.
We compared multibipolar radiofrequency ablation (mbpRFA) with open liver resection (OLR) or laparoscopic liver resection (LLR) in patients with HCCs within Milan. This multicenter cohort study included patients treated by mbpRFA, OLR or LLR for HCC within the Milan Criteria, developed on advanced fibrosis in nine French centres between 2008 and 2018. Adjustments on HCC size/number, gender, age, ASA, HCV, HBV, metabolic syndrome, chronic alcohol intake, MELD score, serum AFP level, APRI score, cirrhosis, significant portal hypertension and HCC localization were performed using multivariable regressions with centre-robust variance and propensity score-based matching (3:1 nearest-neighbour with calliper < 0.1; effective ratios 2.18:1 and 2.43:1). 1040 patients were included (median age: 64 years; male 82.9%), with 606, 266 and 168 treated by mbpRFA, LLR and OLR. Most HCCs were solitary (84.8%) and on cirrhosis (89.2%). In months, the follow-up was 50.2 (95% CI: 45.3, 54.3), 43.3 (95% CI: 40.0, 48.6) and 47.4 (95% CI: 40.8, 58.7) for mbpRFA, LLR and OLR patients. After matching, OLR patients had similar overall survival (OS) (HR = 1.05 [CI 95% = 0.65, 1.69], p = 0.853), transplant-free survival (TFS) (HR = 0.91 [CI 95% = 0.56, 1.47]; p = 0.690) or recurrence-free survival (RFS) (HR = 0.99 [CI 95% = 0.69, 1.43]; p = 0.968) compared to mbpRFA patients but with more severe adverse events (RR = 2.58 [CI 95% = 1.16, 5.71]; p = 0.02) and mortality (RR = 4.51 [CI 95% = 1.16, 17.59]; p = 0.03). After matching, LLR patients had better OS (HR = 0.57 [CI 95% = 0.38, 0.88], p = 0.01) but similar TFS (HR = 0.77 [CI 95% = 0.55, 1.1]; p = 0.152) and more severe adverse events (RR = 2.61 [CI 95% = 1.15, 5.96]; p = 0.022) compared to mbpRFA patients. LLR patients had a better RFS (HR = 0.7 [CI 95% = 0.53, 0.91]; p = 0.009) than mbpRFA patients. When distant-only recurrences were considered in the mbpRFA patients, there was no significant difference in RFS (p = 0.087). The LLR survival benefit was consistent across pre-specified subgroups, with no interaction surviving correction for multiple testing. Minimally invasive modalities (LLR or mbpRFA) should be prioritized when treating early HCC. LLR maximizes oncological outcomes, but mbpRFA maintains optimal TFS with less morbidity. In this large multicenter cohort of patients with early hepatocellular carcinoma developed on advanced fibrosis or cirrhosis, three first‐line curative treatments were compared: multibipolar radiofrequency ablation (mbpRFA), laparoscopic liver resection (LLR), and open liver resection (OLR). Laparoscopic resection achieved better survival than ablation, with similar transplant‐free survival but more severe complications. Open resection had oncological outcomes comparable to ablation but higher severe adverse events and mortality, without survival benefit. These findings support prioritizing minimally invasive approaches over open surgery, with the choice guided by the trade‐off between oncological control and morbidity.
Metabolic dysfunction-associated steatotic liver disease (MASLD) is increasingly recognized in patients with primary biliary cholangitis (PBC). While metabolic comorbidities are expected to worsen outcomes, the clinical impact of MASLD in PBC remains uncertain. We investigated whether concomitant MASLD modifies hepatic and cardiovascular outcomes in patients with PBC. We conducted a retrospective international cohort study using de-identified electronic health records from the TriNetX global research network, including 172 healthcare organizations between 2010 and 2025. Adult patients with PBC with and without MASLD were matched using propensity score matching (1:1) to balance baseline characteristics. The primary outcomes were all-cause mortality. Major adverse cardiovascular events (MACE) and hepatic decompensation were evaluated as secondary outcomes. Additional outcomes included hepatocellular carcinoma, liver transplantation, and one-year biochemical response (ALP normalization). Among 30 934 patients with PBC (78.9% female; mean age 68 years), 5955 (19.2%) had concomitant MASLD. After matching, 10 856 patients (5428 per group) were included. Over a mean follow-up of 4 years, patients with PBC-MASLD had a lower risk of all-cause mortality (HR 0.60; 95% CI 0.54-0.67) and hepatic decompensation (HR 0.82; 95% CI 0.71-0.93), but higher risk of MACE (hazard ratio [HR] 1.30; 95% CI 1.14-1.48). One-year biochemical response rates were comparable between groups. Findings remained consistent across multiple sensitivity analyses. MASLD identifies a distinct metabolic phenotype of PBC characterized by increased cardiovascular risk but paradoxically lower mortality and hepatic decompensation. These findings highlight the need to integrate cardiovascular risk assessment into the management of patients with PBC. Patients with primary biliary cholangitis who also have metabolic fatty liver disease face a higher risk of serious heart problems. In this large study of 30,934 patients, this added hepatic steatosis was linked to more cardiovascular events, but not worse liver outcomes or survival. These findings highlight the need to actively screen for and manage heart risk in patients with both conditions.
Volatile organic compound (VOC) exposure is an environmental health concern and could, through the liver exposome, be associated with metabolic dysfunction associated steatotic liver disease (MASLD) progression. We analysed NHANES 2017-2020, a U.S. population-based cohort with controlled attenuation parameter (CAP), liver stiffness measurement (LSM) and urinary VOC metabolites. Participants with viral hepatitis, excess alcohol use or missing urine creatinine were excluded. MASLD was defined as CAP ≥ 275 dB/m with metabolic dysfunction, at-risk MASH as FAST ≥ 0.35 and increased LSM as ≥ 8 kPa. Weighted quantile sum (WQS) regression assessed associations between VOC metabolites and outcomes, adjusting for age, sex, smoking and alcohol. Phenylglyoxylic acid (PGA) and mandelic acid (MA) were further examined using logistic regression for the MA/(MA and PGA) ratio and human liver organoids. The cohort comprised 2004 participants (41.4% MASLD, 5.4% at-risk MASH, 9.7% LSM ≥ 8 kPa). Higher VOC metabolite levels were associated with increased risk of MASLD (aOR 1.47 per quartile, 95% CI 1.06-2.04) and at-risk MASH (aOR 2.69 per quartile, 95% CI 1.23-5.87), primarily driven by N-Acetyl-S-(2-carboxyethyl)-L-cysteine (CEMA) and N-Acetyl-S-(3-hydroxy-1-methylpropyl)-L-cysteine (HMPMA), with inverse associations driven by PGA. No significant associations were found for increased LSM, yet a higher MA/(MA + PGA) ratio was associated with increased risk for at-risk MASH and LSM ≥ 8 kPa. In human liver organoids, PGA exposure increased lipid droplet number and size. Urinary VOC metabolites show distinct associations with MASLD and at-risk MASH in the general population. CEMA and HMPMA were associated with increased risk, consistent with prior links to metabolic dysfunction. PGA induced steatosis in liver organoids, suggesting poor metabolising of styrene and ethylbenzene and intracellular PGA accumulation. Volatile organic compounds are chemicals that enter the human body through inhalation, ingestion and dermal contact. Urine analysis revealed that exposure to these compounds was associated with MASLD and at‐risk MASH in the general population. Furthermore, when tested in a laboratory setting, these compounds were shown to cause fat buildup in artificial human liver models.